Curtis Jeffrey R, Olivieri Jason, Allison Jeroan J, Gaffo Angelo, Juarez Lucia, Kovac Stacey H, Person Sharina, Saag Kenneth G
Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA.
Am J Manag Care. 2005 Sep;11(9):537-43.
To determine whether audit/feedback and educational materials improve adherence to recommendations for laboratory monitoring and cytoprotective agents to detect and prevent adverse events caused by nonsteroidal anti-inflammatory agents (NSAIDs).
Controlled, cluster-randomized trial.
Physicians commonly prescribing NSAIDs were identified within a large managed care organization and randomized to a control or an intervention group (audit/feedback with peer-derived benchmarks and continuing medical education). Medical records were examined 10 months before and after the intervention for clinical data and receipt of complete blood count (CBC), creatinine testing, and cytoprotective agents (process measures). Primary analysis compared intervention versus control physicians among those who initially performed below a peer-derived benchmark. General estimating equations accounted for patient clustering.
Of 101 physicians initially randomized, 85 remained eligible (38 internists, 36 family physicians, 11 rheumatologists) postintervention. Mean percent change in performance between intervention and control physicians for CBC monitoring was 16% versus 10%; for creatinine monitoring, 0% versus 17%; and use of cytoprotective agents, -3% versus -1%. None of these changes were significant. Rheumatology specialty, number of NSAID prescriptions and physician visits, and patient risk factors for NSAID-related toxicity were more strongly associated with improved safety practices than the intervention.
Audit/feedback and educational materials had no observed effect on improving NSAID-related safety practices. Potentially contributing factors include high baseline performance (ceiling effect), dilution of the intervention effect by case mix and provider factors, nonreceipt of intervention materials, and diverse indications for lab tests.
确定审核/反馈及教育材料是否能提高对实验室监测及细胞保护剂相关建议的依从性，以检测和预防非甾体抗炎药（NSAIDs）所致不良事件。
对照、整群随机试验。
在一个大型管理式医疗组织中识别出经常开具NSAIDs的医生，并将其随机分为对照组或干预组（基于同行基准的审核/反馈及继续医学教育）。在干预前后10个月检查医疗记录，以获取临床数据以及全血细胞计数（CBC）、肌酐检测和细胞保护剂的使用情况（过程指标）。主要分析在最初表现低于同行基准的医生中比较干预组和对照组医生。广义估计方程考虑了患者聚类情况。
最初随机分组的101名医生中，85名在干预后仍符合条件（38名内科医生、36名家庭医生、11名风湿病学家）。干预组和对照组医生在CBC监测方面的平均表现变化百分比分别为16%和10%；肌酐监测方面分别为0%和17%；细胞保护剂使用方面分别为-3%和-1%。这些变化均无统计学意义。与干预措施相比，风湿病专科、NSAIDs处方数量和医生诊疗次数以及患者NSAID相关毒性的危险因素与改善安全实践的关联更强。
审核/反馈及教育材料对改善NSAID相关安全实践未观察到效果。潜在的影响因素包括高基线表现（天花板效应）、病例组合和提供者因素对干预效果的稀释、未收到干预材料以及实验室检查的多种适应证。
