Sociological model for understanding medical practice variation.

Primary care practice varies hugely from place to place. This chapter starts with establishing the existence of medical practice variation in primary care presenting some remarkable examples from the abundance of existing literature, which demonstrates variation in primary care practice at all levels: between countries, within countries across regions, and between practices. The chapter will discuss how the visibility and transparency of clinical behavior in combination with shared resources is an important stepping-stone to understand how a “local practice style” evolves. We will explore whether or not these factors influence decisions on prescription, referrals, diagnostics, treatment, and advice. It is suggested that when clinical behavior is made transparent to colleagues and decision making is shared with patients or when shared resources are used, GPs working in the same practice behave more alike. Finally, it is hypothesized that gatekeeping by GP’s helps (or should help) to reduce unwarranted variation in secondary care. The evidence in the literature that actually supports this is scarce and disappointing. Despite the crucial and pivotal role of GPs in many Western countries, substantial variation in the utilization of unnecessary or unwarranted elective surgery and/or hospital treatments is observed that could be avoidable if professional guidance was adhered to by GPs. At present Dutch GPs do not seem to be capable of avoiding unnecessary hospital care if they feel that it does not add to a patient’s value. (aut. ref.