Explaining variations in medical practice between government primary care health centres in Trinidad and Tobago

ABSTRACT

OBJECTIVE: We evaluated variations in care among government health centres in Trinidad and Tobago. DESIGN AND METHODS: We studied processes of care and drug prescribing for diabetes in 23 government health centres in Trinidad and Tobago. Data were abstracted from the records of 1579 subjects with clinical diabetes, related to 12 processes of care and the prescription of five hypoglycaemic drugs and six cases of anti-hypertensive drug. Health centre level variances were estimated using multilevel statistical models. RESULTS: At different health centres, the proportion of patients receiving dietary advice ranged from 6 percent ot 95 percent; blood glucose estimations ranged from 14 percent to 88 percent; and foot inspection from 3 percent to 43 percent. Using a process of care summary score ranging from zero to 12, the lowest scoring health centre achieved a mean score of 1.55 and the highest 7.45. Regression analyses showed that health centres with only one nurse or doctor at each session provided fewer processes of care. More processes of care were provided when there were more patients attending each session, or when the health centre had more items of equipment. The proportion of patients prescribed insulin ranged from 3 percent to 29 percent. Prescription of insulin was associated with younger age and male gender but not with health centre characteristics. CONCLUSIONS: Larger health centres with more staff and equipment, or with higher patient attendance rates, appeared to provide better quality care. Variations in drug utilisation were less and tended to be explained by individual patient characteristics.(Au)