Deyo R A, Schall M, Berwick D M, Nolan T, Carver P
Center for Cost and Outcomes Research, Department of Medicine, and Department of Health Services, University of Washington, Seattle, WA 98103-8652, USA.
J Gen Intern Med. 2000 Sep;15(9):647-55. doi: 10.1046/j.1525-1497.2000.90717.x.
Recent evidence has changed traditional approaches to low back pain, suggesting minimal bed rest, highly selective imaging, and early return to normal activities. However, there are wide geographical variations in care, and substantial gaps between practice and evidence. This project sought to merge scientific evidence about back pain and knowledge about behavior change to help organizations improve care for back pain. Participating insurance plans, HMOs, and group practices focused on problems they themselves identified. The year-long program included quarterly meetings, coaching for rapid cycles of change, a menu of potential interventions, and recommendations for monitoring outcomes. Participants interacted through meetings, e-mail, and conference calls. Of the 22 participating organizations, 6 (27%) made major progress. Typical changes were reduced imaging, bed rest, and work loss, and increased patient education and satisfaction. Specific examples were a 30% decrease in plain x-rays, a 100% increase in use of patient education materials, and an 81% drop in prescribed bed rest. Despite the complexity of care for back pain, rapid improvements appear feasible. Several organizations had major improvements, and most experienced at least modest improvements. Key elements of successful programs included focus on a small number of clinical goals, frequent measurement of outcomes among small samples of patients, vigilance in maintaining gains; involvement of office staffs as well as physicians, and changes in standard protocols for imaging, physical therapy, and referral.
近期的证据改变了传统的腰痛治疗方法，建议尽量减少卧床休息、进行高度选择性的影像学检查，并尽早恢复正常活动。然而，各地的医疗护理存在很大差异，实际做法与证据之间也存在巨大差距。该项目旨在将有关背痛的科学证据与行为改变知识相结合，以帮助各机构改善背痛护理。参与项目的保险计划、健康维护组织（HMO）和团体诊所专注于它们自己确定的问题。为期一年的项目包括季度会议、针对快速变革周期的指导、一系列潜在干预措施以及监测结果的建议。参与者通过会议、电子邮件和电话会议进行互动。在22个参与组织中，有6个（27%）取得了重大进展。典型的变化包括减少影像学检查、卧床休息和工作损失，增加患者教育和满意度。具体例子包括普通X光检查减少30%、患者教育材料使用量增加100%以及规定的卧床休息减少81%。尽管背痛护理很复杂，但快速改善似乎是可行的。几个组织取得了重大改善，大多数组织至少有适度改善。成功项目的关键要素包括专注于少数临床目标、对小样本患者的结果进行频繁测量、保持成果的警惕性；办公室工作人员和医生的参与，以及影像学、物理治疗和转诊标准方案的改变。
