Dealing with geographic variations in the use of hospitals. The experience of the Maine Medical Assessment Foundation Orthopaedic Study Group.
ABSTRACT Orthopaedists and other physicians in Maine organized the Maine Medical Assessment Foundation to deal with the problem of variations in the rates of hospitalization for orthopaedic conditions. Five musculoskeletal injuries and five orthopaedic procedures were selected for study. The variation in decision-making by orthopaedists was least for fractures of the ankle and fractures of the hip and was greatest for fractures of the forearm, derangement of the knee, and lumbosacral sprain. The rates in an area tended to be consistently high or low for the same treatments. The major reasons for the variations appeared to be related to lack of agreement about optimum treatment. Feedback of data to physicians on variations in patterns of practice reduced the variations.
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ABSTRACT: Fundamento Los resultados de estudios previos muestran una amplia variabilidad en los medios diagnósticos y terapéuticos en artritis reumatoide (AR) en España. La calidad asistencial se beneficiaría al aplicar estándares de práctica apropiados; se presenta un estudio sobre variabilidad en el manejo de la AR en España. Métodos Estudio descriptivo de revisión de historias clínicas (HC) de pacientes con AR de edad mayor de 16 años, seleccionados por muestreo estratificado por comunidades autónomas y bietápico por centro hospitalario y paciente. Se recogió datos sociodemográficos, evolución, seguimiento, recuento articular, reactantes, función, vida laboral, escalas visuales analógicas (EVA) y otros. Resultados Se obtuvo información válida de 1.272 pacientes con AR. Se empleó mayoritariamente la VSG, PCR y factor reumatoide (FR). Los porcentajes de ausencia de datos en los recuentos de articulaciones dolorosas (NAD) y tumefactas (NAT) son el 8,2 y el 9,6%; se utilizaron poco las EVA. Conclusiones A pesar de tener una guía de práctica clínica sobre la AR, existe variabilidad en su manejo.Reumatología Clínica 09/2012; 8(5):236-242. DOI:10.1016/j.reuma.2012.03.009
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ABSTRACT: OBJECTIVE: to determine the surgical decision making variation in five degenerative lumbar spine clinical situations. Determine whether factor related to spinal surgeon training program, experience and age are determinants in surgical decision making for each case. METHODS: ten orthopedists and ten neurosurgeons from different ages were questioned about surgery indication, approach options, need for decompression, need for fusion with instrumentation or not for five degenerative lumbar spinal clinical scenarios. Information about history, examination and image studies (all examiners had the same information and oriented to answer thinking in their own experience). Cases presented: instability and disc disease in a Young patient; extruded lumbar hérnia in a young patient; multiple level spinal stenosis without deformity; multiple spinal stenosis with degenerative kyphoscoliosis; lumbar hernia with facet degeneration. Effects on training background and surgeon mean age on surgical decision making were analyzed using Student "t" test (p<0.05). RESULTS: mean age was 42.15 years (varying 29 to 56 years). Twelve (60%) participants were from Sao Paulo while resting eight (40%) were from other states. Significative variation was not observed. In a general manner, orthopedists recommend fusion and instrumentation more often then neurosurgeons, reaching significance for degenerative scoliosis with spinal stenosis (p=0.04) and for lumbar hernia (p=0.01). Experienced surgeons were more likely to recommend instrumentations than younger for spinal stenosis and instability without deformity (p=0.001). CONCLUSION: there is a great agreement about surgeon's preferences, resting differences in orthopedists preference for instrumentation for lumbar disc herniation cases and treatment of the deformity for degenerative scoliosis with spinal stenosis case. Surgeon's age and experience were not determinant in surgical decision making. Actually there is a growing uniformization in spinal surgeon training programs with a few differences inherent to basic training for orthopedists and neurosurgeons.Coluna/ Columna 03/2009; 8(1):13-18.