成功实施鼓励急性心肌梗死后患者使用β受体阻滞剂的指南。

Successful implementation of guidelines for encouraging the use of beta blockers in patients after acute myocardial infarction.

作者信息

Sarasin F P, Maschiangelo M L, Schaller M D, Héliot C, Mischler S, Gaspoz J M

机构信息

Medical Clinic 1, Department of Internal Medicine, Hôpital Cantonal, University of Geneva Medical School, Switzerland.

出版信息

Am J Med. 1999 May;106(5):499-505. doi: 10.1016/s0002-9343(99)00065-0.

DOI:10.1016/s0002-9343(99)00065-0

PMID:10335720

Abstract

PURPOSE

To assess whether implementation of guidelines increases the prescription of drugs, particularly beta blockers, recommended for secondary prevention after acute myocardial infarction.

SUBJECTS AND METHODS

Prescription patterns among 355 patients discharged from a public teaching hospital after recovery from myocardial infarction were prospectively monitored in a before-after trial. The implementation strategies included educational interventions (large group meetings), placement of guidelines in patients' records, and bimonthly general reminders sent to physicians.

RESULTS

Beta blockers were prescribed in 93 (38%) of 243 survivors of acute myocardial infarction before guideline implementation (12-month control period), as compared with 71 (63%) of 112 patients (P <0.001) after their implementation (6-month period). During the entire study period, the prescription of beta blockers at a neighboring public teaching hospital, used as a comparison, was unchanged. After adjusting for potential confounders, implementation of the guidelines remained significantly associated with prescription of beta blockers at discharge [odds ratio (OR) = 10; 95% confidence interval (CI), 3.2 to 33; P <0.001]. Other independent predictors of prescription of beta blockers were previous coronary artery bypass grafting (OR = 8.7; 95% CI, 2.5 to 31; P = 0.001), hypertension (OR = 2.5; 95% CI, 1.4 to 4.5; P = 0.003), age per 10-year increase (OR = 0.82; 95% CI, 0.67 to 0.99; P = 0.04), secular trend in prescription patterns expressed in months (OR = 0.9; 95% CI, 0.8 to 1.0; P = 0.02), a left ventricular ejection fraction < or = 40% (OR = 0.2; 95% CI, 0.1 to 0.4; P <0.001), the presence of atrioventricular block (OR = 0.1; 95% CI, 0.02 to 0.7; P = 0.02), and concomitant prescription of digoxin (OR = 0.2; 95% CI, 0.05 to 0.8; P = 0.02) or calcium antagonists (OR = 0.06; 95% CI, 0.01 to 0.3; P = 0.001).

CONCLUSION

When appropriately developed and implemented by local experts, literature-based guidelines may be effective in modifying use of recommended drugs for secondary prevention of coronary artery disease, such as prescription of beta blockers.

摘要

目的

评估指南的实施是否会增加急性心肌梗死后二级预防推荐药物（尤其是β受体阻滞剂）的处方量。

对象与方法

在一项前后对照试验中，对一家公立教学医院355例心肌梗死康复出院患者的处方模式进行前瞻性监测。实施策略包括教育干预（大型集体会议）、将指南放入患者病历以及每两个月向医生发送一次一般性提醒。

结果

在指南实施前（12个月对照期），243例急性心肌梗死幸存者中有93例（38%）开具了β受体阻滞剂，而在实施后（6个月期间），112例患者中有71例（63%）开具了β受体阻滞剂（P<0.001）。在整个研究期间，作为对照的邻近公立教学医院β受体阻滞剂的处方量没有变化。在对潜在混杂因素进行调整后，指南的实施与出院时β受体阻滞剂的处方仍显著相关[比值比（OR）=10；95%置信区间（CI），3.2至33；P<0.001]。β受体阻滞剂处方的其他独立预测因素包括既往冠状动脉旁路移植术（OR = 8.7；95% CI，2.5至31；P = 0.001）、高血压（OR = 2.5；95% CI，1.4至4.5；P = 0.003）、年龄每增加10岁（OR = 0.82；95% CI，0.67至0.99；P = 0.04）、以月表示的处方模式的长期趋势（OR = 0.9；95% CI，0.8至1.0；P = 0.02）、左心室射血分数≤40%（OR = 0.2；95% CI，0.1至0.4；P<0.001）、存在房室传导阻滞（OR = 0.1；95% CI，0.02至0.7；P = 0.02）以及同时开具地高辛（OR = 0.2；95% CI，0.05至0.8；P = 0.02）或钙拮抗剂（OR = 0.06；95% CI，0.01至0.3；P = 0.001）。