一项关于教育、提示及意见领袖对基层医疗医生为缺血性心脏病患者开具调脂治疗药物处方进行改善的试验。
A trial of education, prompts, and opinion leaders to improve prescription of lipid modifying therapy by primary care physicians for patients with ischemic heart disease.
作者信息
Bloomfield H E, Nelson D B, van Ryn M, Neil B J, Koets N J, Basile J N, Samaha F F, Kaul R, Mehta J L, Bouland D
机构信息
Center for Chronic Disease Outcomes Research, VA Medical Center, Minneapolis, Minnesota, USA.
出版信息
Qual Saf Health Care. 2005 Aug;14(4):258-63. doi: 10.1136/qshc.2004.012617.
BACKGROUND
Recent clinical trials indicate that treatment with lipid modifying therapy improves outcomes in patients with ischemic heart disease (IHD) and low levels of high density lipoprotein (HDL) cholesterol. The results of these trials, however, have not been widely implemented in clinical practice.
OBJECTIVES
To develop and test an intervention designed to increase the rate of prescription of lipid modifying therapy and to determine the relative effectiveness of three different prompts (progress notes, patient letters, or computer chart reminders).
METHODS
The study was conducted in 11 US Department of Veterans Affairs Medical Centers. The effect of the intervention on the proportion of eligible patients receiving lipid modifying therapy was compared between five intervention sites and six matched control sites using a controlled before and after study design. Additionally, 92 providers within the intervention clinics were randomized to receive one of the three prompts. Data were analyzed using logistic regression modeling which incorporated terms to account for the clustered nature of the data.
RESULTS
At the intervention sites the prescription rate increased from 8.3% during the pre-intervention period to 39.1% during the intervention (OR = 6.5, 95% CI 5.2 to 8.2, p<0.0001) but remained unchanged at the control sites. The interaction between group (control v intervention) and time period was highly significant (p<0.0001). The adjusted odds of receiving a prescription during the intervention period was 3.1 times higher at the intervention sites than at the control sites (95% CI 2.1 to 4.7). Overall, there was no significant difference in prescription rates among the three prompt groups. However, there was a significant interaction between prompt group and site, indicating that the efficacy of the prompts differed by site.
CONCLUSION
An intervention for primary care providers consisting of an educational workshop, opinion leader influence, and prompts substantially increased the prescription rate of lipid modifying therapy.
背景
近期临床试验表明，采用调脂治疗可改善缺血性心脏病（IHD）且高密度脂蛋白（HDL）胆固醇水平较低患者的预后。然而，这些试验结果在临床实践中尚未得到广泛应用。
目的
制定并测试一种干预措施，旨在提高调脂治疗的处方率，并确定三种不同提示方式（病程记录、患者信函或电脑图表提醒）的相对有效性。
方法
该研究在美国11家退伍军人事务部医疗中心进行。采用前后对照研究设计，比较了五个干预点和六个匹配对照点之间干预措施对接受调脂治疗的合格患者比例的影响。此外，干预诊所内的92名医护人员被随机分配接受三种提示方式之一。使用逻辑回归模型分析数据，该模型纳入了考虑数据聚类性质的项。
结果
在干预点，处方率从干预前期的8.3%增至干预期间的39.1%（比值比=6.5，95%可信区间5.2至8.2，p<0.0001），而对照点保持不变。组（对照与干预）和时间段之间的交互作用非常显著（p<0.0001）。干预期间接受处方的调整后比值在干预点比对照点高3.1倍（95%可信区间2.1至4.7）。总体而言，三个提示组之间的处方率无显著差异。然而，提示组与地点之间存在显著交互作用，表明提示的效果因地点而异。
结论
由教育研讨会、意见领袖影响和提示组成的针对初级保健提供者的干预措施显著提高了调脂治疗的处方率。
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