Advertisement

Evaluating variations in medical practice between government primary care health centres

  • M.C Gulliford
    Correspondence
    Corresponding author. E-mail address:(M.C. Gulliford)
    Affiliations
    Department of Public Health Sciences, GKT School of Medicine, Kings College London, Capital House, 42 Weston St, London SE1 3QD UK
    Search for articles by this author
  • D Mahabir
    Affiliations
    Nutrition and Metabolism Division, Ministry of Health, Laventille, Trinidad and Tobago , Imperial College School of Medicine, The Hammersmith Hospital, Du Cane Rd London W12 0NN UK
    Search for articles by this author
  • O.C Ukoumunne
    Affiliations
    Department of Medical Statistics and Evaluation, Imperial College School of Medicine, The Hammersmith Hospital, Du Cane Rd London W12 0NN UK
    Search for articles by this author

      Abstract

      We evaluated variations in medical care for diabetes among government health centres in Trinidad and Tobago. Data were analysed for 1579 subjects with clinical diabetes attending 23 health centres concerning 12 processes of care and six case-mix or outcome variables. Random effects models were used for analysis. Health centre level variation was appreciable. Intraclass correlations ranged from 0.025 to 0.316 for process of care variables and 0.000 to 0.056 for case-mix variables. Compared with health centres with only one nurse, patients attending those with three or more nurses received 1.18 (95% confidence interval 0.27 to 2.09) more processes of care. Delivery of medical care varied among the health centres and those with higher staffing levels provided more processes of care.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Clinical Epidemiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Wennberg J.E.
        Understanding geographic variations in health care delivery.
        N Engl J Med. 1999; 340: 52-53
        • McPherson K.
        • Wennberg J.E.
        • Hovind O.B.
        • Clifford P.
        Small-area variations in the use of common surgical procedures.
        N Engl J Med. 1982; 307: 1310-1314
        • Ashton C.M.
        • Peterson N.J.
        • Souchek J.
        • Menke T.J.
        • Yu H.J.
        • Pietz K.
        • Eigenbrodt M.L.
        • Barbour G.
        • Kizer K.W.
        • Wray N.P.
        Geographic variations in utilisation rates in Veterans Affairs hospitals and clinics.
        N Engl J Med. 1999; 340: 32-39
        • Wennberg J.E.
        • Barnes B.A.
        • Zubkoff M.
        Professional uncertainty and the problem of supplier induced demand.
        Soc Sci Med. 1982; 16: 811-824
        • O'Connor G.T.
        • Quinton H.B.
        • Traven N.D.
        • Rammunno L.D.
        • Dodds T.A.
        • Marciniak T.A.
        • Wennberg J.E.
        Geographic variation in the treatment of acute myocardial infarction.
        The Cooperative Cardiovascular Project. JAMA. 1999; 281: 627-633
        • Leyland A.H.
        • Boddy F.A.
        League tables and acute myocardial infarction.
        Lancet. 1998; 351: 555-558
        • Goldstein H.
        • Speigelhalter D.J.
        League tables and their limitations.
        J R Stat Soc A. 1996; 159: 505-513
        • Goldstein H.
        • Rasbash J.
        • Plewis I.
        • Draper D.
        • Browne W.
        • Yang M.
        • Woodhouse G.
        • Healy M.
        A user's guide to MLwiN. Institute of Education, London1998
        • Donner A.
        Some aspects of the design and analysis of cluster randomization trials.
        J R Stat Soc C. 1998; 47: 95-113
        • Murray D.M.
        • Rooney B.L.
        • Hannan P.J.
        • Peterson A.V.
        • Ary D.V.
        • Bigland A.
        • et al.
        Intraclass correlations among common measures of adolescent smoking.
        Am J Epidemiol. 1994; 140: 1038-1050
        • Hannan P.J.
        • Murray D.M.
        • Jacobs D.R.
        • McGovern P.G.
        Parameters to aid the design and analysis of community trials.
        Epidemiology. 1994; 5: 88-95
        • Gulliford M.C.
        • Ukoumunne O.C.
        • Chinn S.
        Components of variance and intraclass correlations for the design of community-based surveys and intervention studies.
        Data from the Health Survey for England. 1994; 149: 876-883
        • Campbell M.
        • Grimshaw J.
        • Steen N.
        • for the Changing Professional practice in Europe Group
        Sample size calculations for cluster randomised trials.
        J Health Serv Res Policy. 2000; 5: 12-16
        • Ukoumunne O.C.
        • Gulliford M.C.
        • Chinn S.
        • Sterne J.A.C.
        • Burney P.G.J.
        Methods for evaluating area-wide and organisation-based interventions in health and health care.
        Health Technol Assess. 1999; 3
        • Miller G.J.
        • Beckles G.L.A.
        • Maude G.H.
        • Carson D.C.
        • Alexis S.D.
        • Price S.G.L.
        Ethnicity and other characteristics predictive of coronary heart disease in a developing community.
        Int J Epidemiol. 1989; 18: 808-817
        • Gulliford M.C.
        • Mahabir D.
        A five year evaluation of intervention on diabetes care in Trinidad and Tobago.
        Diabet Med. 1999; 16: 939-945
        • Stata Corporation
        Stata reference manual. Stata Press, Release 6. Volume 2 H-O. College Station, TX1999 (pp. 240–5.)
        • Stata Corporation
        Stata reference manual. Stata Press, Release 6. Volume 4 Su-Z. College Station, TX1999 (pp. 420–40.)
        • Begg C.B.
        • Cramer L.D.
        • Hoskins W.J.
        • Brennan M.F.
        Impact of hospital volume on operative mortality for major cancer surgery.
        JAMA. 1998; 280: 1747-1751
        • Hartley R.M.
        • Charlton J.R.
        • Harris C.M.
        • Jarman B.
        Patterns of physicians' use of medical resources in ambulatory settings.
        Am J Public Health. 1987; 77: 565-567
        • Coulter A.
        • Noone A.
        • Goldacre M.
        General practitioners' referrals to specialist outpatient clinics. II. Locations of specialist outpatient clinics to which general practitioners refer patients.
        BMJ. 1989; 299: 306-308
        • Shelley M.
        • Croft P.
        • Chapman S.
        • Pantin C.
        Is the ratio of inhaled corticosteroid to bronchodilator a good indicator of the quality of asthma prescribing? Cross sectional study linking prescribing data to data on admissions.
        BMJ. 1996; 313: 1124-1126
        • Thakker Y.
        • Sheldon T.A.
        • Long R.
        • MacFaul R.
        Paediatric inpatient utilisation in a district general hospital.
        Arch Dis Child. 1994; 70: 488-492
        • Greenhalgh P.M.
        Shared care for diabetes–a systematic review (Occasional Paper number 67). Royal College of General Practitioners, London1994
        • Griffiths C.
        • Sturdy P.
        • Naish J.
        • Omar R.
        • Dolan S.
        • Feder G.
        Hospital admissions for asthma in East London.
        BMJ. 1997; 303: 437-440
        • European Diabetes Policy Group
        A desktop guide to type 2 diabetes mellitus.
        Diabet Med. 1999; 16: 716-730
        • American Diabetes Association
        Standards of medical care for patients with diabetes mellitus.
        Diabet Care. 2000; 23: S32-S42
        • Health and Life Sciences Partnership
        Towards a Healthy Nation. Health and Life Sciences Partnership, London and Port of Spain1993