Ornstein Steven, Jenkins Ruth G, Nietert Paul J, Feifer Chris, Roylance Loraine F, Nemeth Lynne, Corley Sarah, Dickerson Lori, Bradford W David, Litvin Cara
Department of Family Medicine, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
Ann Intern Med. 2004 Oct 5;141(7):523-32. doi: 10.7326/0003-4819-141-7-200410050-00008.
Research is needed to validate effective and practical strategies for improving the provision of evidence-based medicine in primary care.
To determine whether a multimethod quality improvement intervention was more effective than a less intensive intervention for improving adherence to 21 quality indicators for primary and secondary prevention of cardiovascular disease and stroke.
2-year randomized, controlled clinical trial with the practice as the unit of randomization.
20 community-based family or general internal medicine practices in 14 states. All used the same electronic medical record.
44 physicians, 17 midlevel providers, and approximately 200 staff members; data from the electronic medical records of 87,291 patients.
All practices received copies of practice guidelines and quarterly performance reports. Intervention practices also hosted quarterly site visits to help them adopt quality improvement approaches and participated in 2 network meetings to share "best practice" approaches.
The percentage of indicators at or above predefined targets and the percentage of patients who had achieved each clinical indicator.
Intervention practices improved 22.4 percentage points (from 11.3% to 33.7%) in the percentage of indicators at or above the target; control practices improved 16.4 percentage points (from 6.3% to 22.7%). The 6.0-percentage point absolute difference between the intervention and control group was not statistically significant (P > 0.2). Patients in intervention practices had greater improvements than those in control practices for diagnoses of hypertension (improvement difference, 15.7 percentage points [95% CI, 5.2 to 26.3 percentage points]) and blood pressure control in patients with hypertension (improvement difference, 8.0 percentage points [CI, 0.0 to 16.0 percentage points]).
The study involved a small number of practices and lacked a pure control group.
Primary care practices that use electronic medical records and receive regular performance reports can improve their adherence to clinical practice guidelines for cardiovascular disease and stroke prevention.
需要开展研究以验证改善基层医疗中循证医学应用的有效且实用的策略。
确定多方法质量改进干预措施在提高心血管疾病和中风一级及二级预防的21项质量指标的依从性方面是否比强度较低的干预措施更有效。
以医疗机构为随机分组单位的为期2年的随机对照临床试验。
14个州的20个社区家庭或普通内科医疗机构。所有机构都使用相同的电子病历。
44名医生、17名中级医疗人员和约200名工作人员；来自87291名患者的电子病历数据。
所有医疗机构均收到了实践指南副本和季度绩效报告。干预组医疗机构还接受了季度实地考察以帮助他们采用质量改进方法，并参加了2次网络会议以分享“最佳实践”方法。
达到或高于预定义目标的指标百分比以及达到每项临床指标的患者百分比。
干预组医疗机构达到或高于目标的指标百分比提高了22.4个百分点（从11.3%提高到33.7%）；对照组医疗机构提高了16.4个百分点（从6.3%提高到22.7%）。干预组和对照组之间6.0个百分点的绝对差异无统计学意义（P>0.2）。干预组医疗机构的患者在高血压诊断（改善差异为15.7个百分点[95%CI，5.2至26.3个百分点]）和高血压患者血压控制（改善差异为8.0个百分点[CI，0.0至16.0个百分点]）方面比对照组患者有更大改善。
该研究涉及的医疗机构数量较少且缺乏纯对照组。
使用电子病历并定期收到绩效报告的基层医疗实践可以提高其对心血管疾病和中风预防临床实践指南的依从性。
