Differences in the diagnosis and management of type 2 diabetes in 3 countries (US, UK, and Germany): results from a factorial experiment.
OBJECTIVE
This article examines the diagnosis and management of type-2 diabetes when exactly the same "patient" is encountered by 192 randomly selected primary care doctors in 3 different health care systems--the United States, United Kingdom, and Germany.


METHODS
We conducted a factorial experiment, employing 2 clinically authentic filmed scenarios, to examine country differences in the treatment of diabetes, while controlling the effects of selected characteristics of patients and physicians. The patient in the first scenario presented with (undiagnosed) signs and symptoms strongly suggestive of diabetes, while the second scenario presented an already diagnosed patient with an emerging foot neuropathy. Physicians were asked how they would diagnose and manage the patients after watching the video vignettes using a questionnaire with standardized and open-ended questions.


RESULTS
Regarding the first (undiagnosed) case, US doctors would ask significantly more questions than physicians from the UK and Germany (P < 0.001). German physicians would give less advice but would want to see the patient again much sooner (P < 0.001). Regarding the diagnosed case with an emerging foot neuropathy, US physicians would be most active in terms of questioning, testing, prescribing, and advice giving. Again, physicians from Germany would be less active in terms of therapeutic strategies but they would like to see the patient again sooner (P = 0.005).


CONCLUSIONS
Although physicians in the 3 countries encountered exactly the same patient, differences in diagnostic and management decisions were evident. The experimental design provides unconfounded estimates of health system differences while simultaneously controlling for the effects of selected patient attributes and physician characteristics.
von dem Knesebeck
Olaf
O
Department of Medical Sociology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, Germany. o.knesebeck@uke.uni-hamburg.de
Gerstenberger
Eric
E
Link
Carol
C
Marceau
Lisa
L
Roland
Martin
M
Campbell
Stephen
S
Siegrist
Johannes
J
de Cruppé
Werner
W
McKinlay
John
J
D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D003657:Decision Making; D003924:Diabetes Mellitus, Type 2 / Q000175:diagnosis* / Q000188:drug therapy* / Q000503:physiopathology; D017719:Diabetic Foot / Q000175:diagnosis / Q000188:drug therapy; D005260:Female; D005858:Germany; D006801:Humans; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D011795:Surveys and Questionnaires; D006113:United Kingdom; D014481:United States; D014743:Videotape Recording