Finkelstein Jonathan A, Lozano Paula, Fuhlbrigge Anne L, Carey Vincent J, Inui Thomas S, Soumerai Stephen B, Sullivan Sean D, Wagner Edward H, Weiss Scott T, Weiss Kevin B
Department of Ambulatory Care and Prevention, Harvard Medical School, Boston, MA, USA.
Health Serv Res. 2005 Dec;40(6 Pt 1):1737-57. doi: 10.1111/j.1475-6773.2005.00451.x.
To assess the practice-level effects of (1) a physician peer leader intervention and (2) peer leaders in combination with the introduction of asthma education nurses to facilitate care improvement. And, to compare findings with previously reported patient-level outcomes of trial enrollees.
Data were included on children 5-17 years old with asthma in 40 primary care practices, affiliated with managed health care plans enrolled in the Pediatric Asthma Care Patient Outcomes Research Team (PORT) randomized trial.
Primary care practices were randomly assigned to one of two care improvement arms or to usual care. Automated claims data were analyzed for 12-month periods using a repeated cross-sectional design. The primary outcome was evidence of at least one controller medication dispensed among patients with persistent asthma. Secondary outcomes included controller dispensing among all identified asthmatics, evidence of chronic controller use, and the dispensing of oral steroids. Health service utilization outcomes included numbers of ambulatory visits and hospital-based events.
The proportion of children with persistent asthma prescribed controllers increased in all study arms. No effect of the interventions on the proportion receiving controllers was detected (peer leader intervention effect 0.01, 95 percent confidence interval [CI]: -0.07, 0.08; planned care intervention effect -0.03, 95 percent CI: -0.09, 0.02). A statistical trend was seen toward an increased number of oral corticosteroid bursts dispensed in intervention practices. Significant adjusted increases in ambulatory visits of 0.08-0.10 visits per child per year were seen in the first intervention year, but only a statistical trend in these outcomes persisted into the second year of follow-up. No differences in hospital-based events were detected.
This analysis showed a slight increase in ambulatory asthma visits as a result of asthma care improvement interventions, using automated data. The absence of detectable impact on medication use at the practice level differs from the positive intervention effect observed in patient self-reported data from trial enrollees. Analysis of automated data on nonenrollees adds information about practice-level impact of care improvement strategies. Benefits of practice-level interventions may accrue disproportionately to the subgroup of trial enrollees. The effect of such interventions may be less apparent at the level of practices or health plans.
评估（1）医生同行领导者干预措施以及（2）同行领导者与引入哮喘教育护士相结合以促进护理改善在实践层面的效果。并且，将研究结果与之前报道的试验参与者患者层面的结果进行比较。
数据纳入了40家初级保健机构中5 - 17岁患哮喘的儿童，这些机构隶属于参与儿科哮喘护理患者结局研究团队（PORT）随机试验的管理式医疗保健计划。
初级保健机构被随机分配到两个护理改善组之一或常规护理组。使用重复横断面设计对12个月期间的自动理赔数据进行分析。主要结局是在持续性哮喘患者中至少配给一种控制药物的证据。次要结局包括在所有确诊哮喘患者中的控制药物配给情况、长期使用控制药物的证据以及口服类固醇药物的配给情况。卫生服务利用结局包括门诊就诊次数和住院事件数量。
所有研究组中，开具控制药物的持续性哮喘儿童比例均有所增加。未检测到干预措施对接受控制药物治疗比例的影响（同行领导者干预效果为0.01，95%置信区间[CI]： - 0.07，0.08；计划护理干预效果为 - 0.03，95%CI： - 0.09，0.02）。在干预机构中，口服糖皮质激素突发给药次数有增加的统计趋势。在干预的第一年，每名儿童每年门诊就诊次数显著调整增加0.08 - 0.10次，但这些结局仅在随访的第二年存在统计趋势。未检测到住院事件方面的差异。
本分析表明哮喘护理改善干预措施使哮喘门诊就诊次数略有增加，使用的是自动数据。在实践层面未检测到对药物使用的明显影响，这与试验参与者患者自我报告数据中观察到的积极干预效果不同。对非参与者自动数据的分析增加了关于护理改善策略实践层面影响的信息。实践层面干预措施的益处可能在试验参与者亚组中不成比例地积累。此类干预措施的效果在实践或健康计划层面可能不太明显。
