Kirkman M Sue, Williams Susanna R, Caffrey Helena H, Marrero David G
Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.
Diabetes Care. 2002 Nov;25(11):1946-51. doi: 10.2337/diacare.25.11.1946.
Previous studies have shown that primary care physician (PCP) adherence to diabetes guidelines is suboptimal. We sought to determine the state of diabetes care given by independently practicing PCPs in a rural county in Indiana and whether a multifaceted intervention targeting PCPs, patients, and the health care system would improve adherence to diabetes guidelines.
Baseline audits to assess adherence to diabetes guidelines were done on charts of the seven PCPs in the county. Audits were repeated after development of local consensus guidelines and feedback of baseline performance and after implementation of various interventions (practice aids, physician detailing, patient education sessions, and implementation of computerized individual meal planning).
Before any intervention, rates of adherence to guidelines were low (15% for foot exams, 20% for HbA(1c) measurement, 23% for eye exam referrals, 33% for urine protein screening, 44% for lipid profiles, 73% for home glucose monitoring, and 78% for blood pressure measurements). One year after development of local consensus guidelines and feedback of baseline performance, significant improvements were seen in blood pressure measurements (71 vs. 83%; P = 0.002), foot exams (19 vs. 42%; P < 0.001), HbA(1c) measurements (26 vs. 37%; P = 0.012), and PCP eye exams (38 vs. 46%; P = 0.043); a trend toward improvement was seen in referral to eye specialists (25 vs. 33%; P = 0.059). After a second year of multiple interventions, only blood pressure measurements (70 vs. 92%; P < 0.001) and foot exams (22 vs. 47%; P < 0.001) remained significantly improved; all other areas returned to rates indistinguishable from baseline.
In busy primary care practices lacking organizational support and computerized tracking systems, sustained improvements in diabetes care are difficult to attain using traditional physician-targeted approaches.
既往研究表明，初级保健医生（PCP）对糖尿病指南的遵循情况并不理想。我们试图确定印第安纳州一个乡村县独立执业的初级保健医生提供糖尿病护理的状况，以及针对初级保健医生、患者和医疗保健系统的多方面干预措施是否会提高对糖尿病指南的遵循率。
对该县7名初级保健医生的病历进行基线审核，以评估对糖尿病指南的遵循情况。在制定当地共识指南并反馈基线表现后，以及在实施各种干预措施（实践辅助工具、医生详细说明、患者教育课程以及实施计算机化个人饮食计划）后，重复进行审核。
在进行任何干预之前，指南遵循率较低（足部检查为15%，糖化血红蛋白（HbA1c）测量为20%，眼科检查转诊为23%，尿蛋白筛查为33%，血脂谱检查为44%，家庭血糖监测为73%，血压测量为78%）。在制定当地共识指南并反馈基线表现一年后，血压测量（71%对83%；P = 0.002）、足部检查（19%对42%；P < 0.001）、糖化血红蛋白（HbA1c）测量（26%对37%；P = 0.012）以及初级保健医生眼科检查（38%对46%；P = 0.043）有显著改善；转诊至眼科专家有改善趋势（25%对33%；P = 0.059）。在进行了第二年的多项干预后，只有血压测量（70%对92%；P < 0.001）和足部检查（22%对47%；P < 0.001）仍有显著改善；所有其他领域的比率恢复到与基线无显著差异的水平。
在缺乏组织支持和计算机化跟踪系统的繁忙初级保健实践中，使用传统的以医生为目标的方法难以实现糖尿病护理的持续改善。
