McClellan William M, Hodgin Emily, Pastan Stephen, McAdams Lisa, Soucie Michael
Georgia Medical Care Foundation, Atlanta, GA 30329, USA.
J Am Soc Nephrol. 2004 Mar;15(3):754-60. doi: 10.1097/01.asn.0000115701.51613.d7.
End-stage renal disease (ESRD) Networks are quality improvement organizations that collect, analyze, and report information to clinicians and allied health providers about discrepancies between observed patterns of care of ESRD patients and what has been recommended by clinical practice guidelines. The Networks facilitate response to this information by assisting ESRD treatment centers to develop quality improvement programs to redress inadequate care. The authors evaluated this process of quality improvement by selecting 42 treatment centers in a single ESRD Network with the lowest facility-specific mean urea reduction ratio (URR). The treatment centers were randomly assigned to two intervention strategies: (1) feedback alone; (2) an intensive intervention that included feedback, workshops, distribution of educational materials and clinical practice guidelines, technical assistance with the development of quality improvement plans, and continued monitoring. The intensive intervention had greater improvement in the increased proportions of patients dialyzed with prescribed blood flow (P = 0.02) and documented review of prescription (P = 0.01). Furthermore, the mean center URR increased nearly 3% among intensive intervention centers (from 68.1 to 70.9) but only 0.09% among the feedback centers (68.2 to 69.1) (P = 0.002). Similarly, time on dialysis increased 7.5 min on average among patients in intervention centers but decreased 2 min for patients in comparison centers (P = 0.03). These results demonstrate that Network feedback, coupled with the intensive intervention, resulted in improvement in care that would otherwise not have occurred.
终末期肾病（ESRD）网络是质量改进组织，负责收集、分析并向临床医生及相关健康服务提供者报告有关ESRD患者实际护理模式与临床实践指南推荐内容之间差异的信息。这些网络通过协助ESRD治疗中心制定质量改进计划以纠正护理不足的情况，促进对这些信息的反馈。作者通过在单个ESRD网络中选择42个特定机构平均尿素清除率（URR）最低的治疗中心，对这一质量改进过程进行了评估。这些治疗中心被随机分配到两种干预策略中：（1）仅提供反馈；（2）强化干预，包括反馈、研讨会、分发教育材料和临床实践指南、在制定质量改进计划方面提供技术援助以及持续监测。强化干预在按规定血流量进行透析的患者比例增加（P = 0.02）和有记录的处方审查方面（P = 0.01）有更大改善。此外，强化干预中心的平均中心URR增加了近3%（从68.1升至70.9），而反馈中心仅增加了0.09%（从68.2升至69.1）（P = 0.002）。同样，干预中心患者的透析时间平均增加了7.5分钟，而对照中心患者的透析时间减少了2分钟（P = 0.03）。这些结果表明，网络反馈与强化干预相结合，带来了原本不会出现的护理改善。
