THE PROBLEM OF DIAGNOSTIC VARIABILITY IN GENERAL-PRACTICE
THE PROBLEM OF DIAGNOSTIC VARIABILITY IN GENERAL-PRACTICE
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DOI：
10.1136/jech.46.4.447
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发表时间：
1992-08-01
影响因子：
6.3
通讯作者：
FLEMING, DM
中科院分区：
文献类型：
--
作者：
CROMBIE, DL;CROSS, KW;FLEMING, DM
研究目的-目的是检查的规模，来源和相关性的变化与患者咨询的疾病在每个几个诊断groups. Design-本研究涉及一个一般的做法进行了两年，1970年至1972年的发病率调查之间的一般做法的利率。确定了所有咨询全科医生的患者，并计算了根据《国际疾病分类》18个主要章节中的每一章进行诊断的患者人数。在一个章节内咨询一个以上诊断的患者仅计数一次;在几个章节中的每一个章节中咨询一个或多个诊断的人，每个章节计数一次。设置-这是一项涉及英格兰和威尔士全科医生的全国性调查。对象-这项研究涉及来自53个选定的全科诊所的214524名患者1970- 1971年全年在全科医生处登记的115名医生，他们的发病率数据与1971年人口普查的社会数据相联系。计算了每种实践和每一ICD章节的实践患者咨询率（PPCR）。通过计算变异系数以及考虑随机变异后的残差变异系数，检查了第PPCR章中的变异性。在所有章节的费率中有很大的执业（医生）差异。这些变化只是轻微归因于：机会;不同年龄，性别和社会阶层的实践人口的混合;地理位置;和实践组织。然而，任何一种做法的比率从一年到下一年都是一致的。大约一半的实践（医生）诊断变异性与整体患者咨询行为。当这种行为的影响被打折，任何主要的残留诊断变异主要局限于ICD第一，第五，第十六，和第十七章，即那些章节的病因形成的基础classification. Conclusion的变化，在记录的诊断率主要是由于一致的，但特异质和选择性排除从业者的一些组件，从总的一套往往共存于一个新的诊断。由于相互实践诊断的可变性的规模，算法和信息技术的使用在很大程度上被排除在结果研究，审计程序和实践工作量的研究一般。然而，（1）任何个别医生的诊断记录模式从一年到另一年的一致性允许趋势的研究;（2）给定合理数量的记录实践，人口平均实践咨询率可以估计与许多流行病学研究和行政用途足够的准确性。
Study objective-The aim was to examine the scale, source, and relevance of variation between general practices in respect of the rates with which patients consulted with illnesses falling in each of several diagnostic groups.Design-This study involved a general practice morbidity survey conducted over two years, 1970-72. All patients who consulted their general practitioners were identified and the number of these who consulted with diagnoses attributable to each of the 18 main chapters of the International classification of diseases were counted. Patients who consulted for more than one diagnosis within a chapter were counted once only; those who consulted for one or more diagnoses in each of several chapters were counted once for each chapter.Setting-This was a national survey involving general practitioners in England and Wales.Subjects-The study involved 214 524 patients from 53 selected general practices (115 doctors) who were registered with their general practitioners for the whole of the year 1970-71 and for whom their morbidity data had been linked with their social data from the 1971 census.Measurements and main results-Using the numbers of patients on the practice lists as denominators, practice patient consulting rates (PPCR) were calculated for each practice and for each ICD chapter. Variability in chapter PPCR was examined by calculating coefficients of variation and, after allowance for random variation, coefficients of residual variation. There were large interpractice (doctor) variations in all chapter rates. These variations were only marginally attributable to: chance; different age, sex and social class mixes of practice populations; geographical locations; and practice organisation. The rates were, however, consistent from one year to the next for any one practice. Approximately half of the interpractice (doctor) diagnostic variability was associated with overall patient consulting behaviour. When the effects of this behaviour were discounted, any major residual diagnostic variability was confined largely to ICD chapters I-V, XVI, and XVII, ie, those chapters where aetiology forms the basis of classification.Conclusion-Variations in recorded diagnostic rates are mainly due to the consistent but idiosyncratic and selective exclusion by practitioners of some components from the total set which often coexist in a new diagnosis. Because of the scale of interpractice diagnostic variability, the use of algorithms and information technology is largely precluded from outcome studies, auditing procedures, and studies of practice work loads in general. However, (1) the consistency of any individual doctor's pattern of diagnostic recording from one year to another permits studies of trends; and (2) given a reasonable number of recording practices, the population mean practice consulting rates can be estimated with sufficient accuracy for many epidemiological research and administrative uses.