Determinanten der Krankenhausaufnahme - eine Untersuchung mit Fallvignetten

Abstract

Unexplained differences in the density of in-patient management in one federal state in Germany led to a regional survey of physicians in independent and hospital practice, which aimed to describe more precisely the determinants of referral and admission behaviour. Brief typical case descriptions (vignettes) were designed, as an instrument of data collection, dealing with two examples of management problems: upper and lower abdominal pain. The urgency of inpatient treatment was ranked using clinical scores and guidelines. Social characteristics for the patient (age, gender, social situation, preference for/against hospitalisation, day of the week on which the patient presented) were randomly assigned to the case vignettes. Each physician was asked by mail to decide on the management of 10 upper and 10 lower abdominal vignettes each. The physicians were also asked to provide additional information on the characteristics of their practice or hospital. The data were analysed using multivariate hierarchical models. A 28 % response rate meant that vignettes were available from 455 general practitioners and internal medicine specialists in independent practice, as well as 261 hospital surgeons and internal medicine specialists, together with responses from 31 physicians from the medical service of the German statutory health insurance (MDK). 7376 upper abdominal and 7335 lower abdominal vignettes were analysed. Admission rates reflected the graded severity of the symptoms built into the vignettes. Hospital physicians wanted to admit the vignette patients much more frequently than physicians in independent practice wished to refer them. Older patients, independent of symptoms, were more frequently referred or admitted than younger patients. In the case of acute symptoms it is the day of the week when the patient consulted the physician and in the case of elective surgery the patient's preference that are important for hospitalisation. The results show that medical decisions on case management are made using reasonable problem-specific preferences. The probability of actually instigating admission was, other things being equal, much higher in hospital physicians than in office-based physicians. As an instrument of comparative research into medical care, case vignettes have practical advantages in relation to medical audits and standardised patients. They can also be used for teaching, examining, documenting and quality assurance purposes.

Diagnostic Certainty as a Source of Medical Practice Variation in Coronary Heart Disease: Results from a Cross-National Experiment of Clinical Decision Making

“…For present purposes, vignettes offer several key advantages over alternative methods: (1) they allow for the manipulation of several variables at once and the measurement of unconfounded effects, thereby “isolating physicians’ decision making from other factors in the environment” (50); (2) standardization of case mix; (3) vignette-based studies allow for the collection of a large amount of information simultaneously from a large number of subjects; (4) make efficient use of time; and (5) are cost-effective (for example, standardized patients would have been prohibitively expensive in this context). In a direct comparison of vignettes, standardized patients, and chart abstraction, Peabody and colleagues (51) validated the use of vignettes for studying quality of outpatient care, and studies comparing vignettes with standardized patients and other methods corroborate the result that vignettes are ecologically valid for studies of medical decision making (50, 52, 53). …”

Hausärztliche Arzneimittelpriorisierung bei stationär entlassenen, multimorbiden, älteren Patienten – Ein Vignetten-Ansatz aus der Hausarzt-Perspektive

“…Wie schon bei anderen ärztlichen Entscheidungssituationen [ 26 ] konnte die Vignettenmethode genutzt werden für typische fallbezogene Entscheidungen bei der Priorisierung medikamentöser Therapien. Fallvignetten haben sich als ähnlich aussagefä-hig für das ärztliche Handeln erwiesen wie eine systematische Dokumentenanalyse und der Einsatz von Standardpatienten [ 36 ] .…”

Decision-Making in Implantology – A Vignette-Based Study to Determine Clinical Treatment Routines for the Edentulous Atrophic Mandible

“…Such case vignettes are typi ed case descriptions and are used in comparative health care research for the experimental investigation of health care decisions. 16,17 In terms of methodology, they are between theory and real patient cases. A prospective study has shown that case vignettes have comparable informative value in terms of medical practice as a systematic evaluation of medical records and standardized medical patients.…”