Bordley W C, Margolis P A, Stuart J, Lannon C, Keyes L
Children's Primary Care Research Group, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7225, USA.
Pediatrics. 2001 Sep;108(3):E41. doi: 10.1542/peds.108.3.e41.
Rates of childhood immunizations and other preventive services are lower in many practices than national goals and providers' own estimates. Office systems have been used in adult settings to improve the delivery of preventive care, but their effectiveness in pediatric practices is unknown. This study was designed to determine whether a group of primary care practices in 1 community could implement office-based quality improvement systems that would significantly improve their delivery of childhood preventive services. The study was part of a larger community-wide intervention study reported in a preceding study.
All the major providers of primary care to children in 1 community were recruited and agreed to participate (N = 8 practices). Project staff worked on-site with improvement teams in each practice to develop tailored systems to assess and improve the delivery of immunizations and screening for anemia, tuberculosis, and lead exposure. Office-based quality improvement systems typically involved some combination of chart prescreening, risk assessment forms, Post-it prompts, flow-sheets, reminder/recall systems, and patient education materials. Office systems also often involved redistributing responsibilities among office staff.
All 8 participating practices created improvement teams. Project staff met with the practices 10 to 15 times over 12 months. After the period of office assistance, the overall rates for all preventive services except tuberculosis screening increased by amounts that were both clinically and statistically significant. Absolute percent improvements included: complete immunizations at 12 months, 7%; complete immunizations at 24 months, 12%; anemia screening, 30%; lead screening, 36%. The amount of improvement achieved varied considerably between practices.
Office systems and the principles of quality improvement that underlie them seem to be effective in improving the delivery of childhood preventive services. Important predisposing factors may exist within practices that affect the likelihood that an individual practice will make significant improvements. prevention, immunizations, improvement, office systems, primary care.
在许多医疗机构中，儿童免疫接种率和其他预防服务水平低于国家目标以及医疗服务提供者自己的预期。办公系统已在成人医疗环境中用于改善预防保健服务的提供，但它们在儿科医疗机构中的效果尚不清楚。本研究旨在确定一个社区中的一组初级保健机构能否实施基于办公场所的质量改进系统，从而显著改善儿童预防服务的提供情况。该研究是之前一项研究中所报告的一项更大规模的全社区干预研究的一部分。
招募了该社区所有主要的儿童初级保健服务提供者并获得其参与同意（共8家医疗机构）。项目工作人员在每家医疗机构现场与改进团队合作，开发量身定制的系统，以评估和改善免疫接种以及贫血、结核病和铅暴露筛查服务的提供情况。基于办公场所的质量改进系统通常涉及某种组合的图表预筛查、风险评估表、便利贴提示、流程图、提醒/召回系统以及患者教育材料。办公系统还常常涉及在办公人员之间重新分配职责。
所有8家参与的医疗机构都组建了改进团队。项目工作人员在12个月内与这些医疗机构会面了10至15次。在办公协助期之后，除结核病筛查外，所有预防服务的总体比率均有提高，且在临床和统计学上均具有显著意义。绝对百分比提高包括：12个月时的全程免疫接种率提高7%；24个月时的全程免疫接种率提高12%；贫血筛查率提高30%；铅筛查率提高36%。不同医疗机构所实现的改进幅度差异很大。
办公系统及其所依据的质量改进原则似乎在改善儿童预防服务提供方面是有效的。医疗机构内部可能存在重要的诱发因素，影响个别医疗机构实现显著改进的可能性。预防、免疫接种、改进、办公系统、初级保健。
