Gill James M, DiPrinzio Marie J
Department of Family and Community Medicine at Christiana Care Health Services in Wilmington, Delaware, USA.
Del Med J. 2004 Mar;76(3):111-22.
In 2001, the Diabetes Physician Committee of the Medical Society of Delaware developed Uniform Clinical Guidelines (UCGs) for diabetes mellitus. These guidelines were intended to provide a standard for the diabetes quality indicators that could be used by all providers and all major insurers in Delaware. The guidelines were sent to Delaware physicians in December 2001. This study examines whether implementation of the diabetes UCG had a positive impact on the quality of diabetes care in primary care offices.
A chart review was conducted for 258 diabetic patients of 28 primary care physicians in all three counties in Delaware. Quality of care was compared from the year prior to guideline implementation (2001) to the year after implementation (2002). Quality was determined by process measures, including receipt of recommended monitoring tests (glycosylated hemoglobin, blood pressure, lipids, microalbumin, foot exams, eye exams) and immunizations (influenza and pneumococcal), as well as by outcome measures, including adequate glycemic control, blood pressure control, and lipid control.
There was no significant change in most quality indicators from the year before to the year after implementation of the UCG. The only improvements seen were in influenza immunizations and, to some extent, lipid and blood pressure control. However, none of these reached optimal levels, and for some process measures (microalbumin testing and eye exams) there was a decrease in adherence to guidelines. In a second analysis, physicians who used diabetes flow sheets had better quality of care for most measures, although these differences were relatively small and not consistent across all measures.
The Medical Society of Delaware's Uniform Clinical Guidelines are intended to standardize care for diabetes and other conditions. While the guidelines may help to reduce unnecessary duplication and confusion caused by multiple guidelines, this study showed that they have not yet resulted in substantial improvements in quality of care for diabetes. Since the study does suggest that using flow sheets is associated with somewhat better care, it could be that quality will improve as more physicians incorporate these tools into their practices.
2001年，特拉华州医学协会糖尿病医师委员会制定了糖尿病统一临床指南（UCGs）。这些指南旨在为糖尿病质量指标提供一个标准，供特拉华州所有医疗服务提供者和所有主要保险公司使用。该指南于2001年12月发送给特拉华州的医生。本研究调查了糖尿病UCG的实施是否对初级保健诊所的糖尿病护理质量产生了积极影响。
对特拉华州所有三个县的28名初级保健医生的258名糖尿病患者进行了病历审查。将指南实施前一年（2001年）和实施后一年（2002年）的护理质量进行了比较。质量通过过程指标来确定，包括接受推荐的监测测试（糖化血红蛋白、血压、血脂、微量白蛋白、足部检查、眼部检查）和免疫接种（流感和肺炎球菌），以及通过结果指标来确定，包括血糖控制良好、血压控制和血脂控制。
UCG实施前一年到实施后一年，大多数质量指标没有显著变化。唯一的改善是在流感免疫接种方面，以及在一定程度上的血脂和血压控制方面。然而，这些都没有达到最佳水平，对于一些过程指标（微量白蛋白检测和眼部检查），遵循指南的情况有所下降。在第二项分析中，使用糖尿病流程图的医生在大多数指标上的护理质量更好，尽管这些差异相对较小，且并非在所有指标上都一致。
特拉华州医学协会的统一临床指南旨在规范糖尿病和其他疾病的护理。虽然这些指南可能有助于减少多个指南造成的不必要重复和混乱，但本研究表明，它们尚未在糖尿病护理质量方面带来实质性改善。由于该研究确实表明使用流程图与更好的护理相关，随着更多医生将这些工具纳入他们的实践中，护理质量可能会提高。
