Family Practice Vol. 19, No. 5, 452-460
© Oxford University Press 2002
Variations in asthma treatment in five European countries—judgement analysis of case simulations
Division of International Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, SE-171 76 Stockholm, Sweden,
a Department of General Practice, University of Göttingen, Germany,
b Faculty of Pharmacy, Comenius University, Bratislava, Slovak Republic
c Department of Pharmacotherapeutics, University of Oslo, Norway,
d Northern Centre for Healthcare Research, University of Groningen, The Netherlands,
e National Board of Health and Welfare, Stockholm, Sweden and
f Clinical Skills Centre, The Robin Brook Centre, St Bartholomew’s Hospital, London, UK.
g Members of the Drug Education Project are listed within the Acknowledgements section.
Dr Rolf Wahlström; E-mail: rolf.wahlstrom{at}phs.ki.se
Objective. The aim of this study was to explore and compare treatment decisions and the influence of specific patient characteristics on asthma management in five European countries, and to relate this to existing guidelines.
Methods. Using the technique of clinical judgement analysis, doctors in The Netherlands, Norway, Germany, Sweden and the Slovak Republic (40–100 doctors per country) were presented with sets of written simulated cases on asthma treatment. Patient characteristics were varied to determine their influence on the doctors’ decisions. Decisions indicating over- and under-prescribing in relation to a gold standard derived from guidelines were also determined.
Results. Doctors in The Netherlands prescribed more oral steroid courses and fewer antibiotics than doctors in Norway and Sweden, whereas doctors in Germany and the Slovak Republic prescribed the least oral steroids and the most antibiotics. Partially, this variation could be explained by differences in the underlying propensity to prescribe, but differences in the use of patient characteristics also contributed to the variation. Norwegian doctors were most inclined to increase the maintenance treatment of inhaled corticosteroids, which could best be explained by their relatively high focus on the patient’s peak expiratory flow value. Compared with the gold standard, there was 25–56% under-prescribing of oral steroids, and 21–45% over-prescribing of antibiotics.
Conclusions. The variation in treatment of asthma patients between doctors in different countries may, in part, be attributed to variations in the underlying propensity to prescribe, and in part to different use of clinical patient characteristics. These findings can be used in tailoring educational programmes to improve treatment practices.
Keywords. Asthma, case simulations, clinical judgement analysis, decision making, drug use.
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