Ziemer David C, Doyle Joyce P, Barnes Catherine S, Branch William T, Cook Curtiss B, El-Kebbi Imad M, Gallina Daniel L, Kolm Paul, Rhee Mary K, Phillips Lawrence S
Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine and Grady Health Systems, Atlanta, GA 30322, USA.
Arch Intern Med. 2006 Mar 13;166(5):507-13. doi: 10.1001/archinte.166.5.507.
Although clinical trials have shown that proper management of diabetes can improve outcomes, and treatment guidelines are widespread, glycated hemoglobin (HbA1c) levels in the United States are rising. Since process measures are improving, poor glycemic control may reflect the failure of health care providers to intensify diabetes therapy when indicated--clinical inertia. We asked whether interventions aimed at health care provider behavior could overcome this barrier and improve glycemic control.
In a 3-year trial, 345 internal medicine residents were randomized to be controls or to receive computerized reminders providing patient-specific recommendations at each visit and/or feedback on performance every 2 weeks. When glucose levels exceeded 150 mg/dL (8.33 mmol/L) during visits of 4038 patients, health care provider behavior was characterized as did nothing, did anything (any intensification of therapy), or did enough (if intensification met recommendations).
At baseline, residents did anything for 35% of visits and did enough for 21% of visits when changes in therapy were indicated, and there were no differences among intervention groups. During the trial, intensification increased most during the first year and then declined. However, intensification increased more in the feedback alone and feedback plus reminders groups than for reminders alone and control groups (P<.001). After 3 years, health care provider behavior in the reminders alone and control groups returned to baseline, whereas improvement with feedback alone and feedback plus reminders groups was sustained: 52% did anything, and 30% did enough (P<.001 for both vs the reminders alone and control groups). Multivariable analysis showed that feedback on performance contributed independently to intensification and that intensification contributed independently to fall in HbA1c (P<.001 for both).
Feedback on performance given to medical resident primary care providers improved provider behavior and lowered HbA1c levels. Similar approaches may aid health care provider behavior and improve diabetes outcomes in other primary care settings.
尽管临床试验表明，糖尿病的合理管理可改善预后，且治疗指南广泛应用，但美国糖化血红蛋白（HbA1c）水平仍在上升。由于过程指标正在改善，血糖控制不佳可能反映出医疗服务提供者在有指征时未能加强糖尿病治疗——即临床惰性。我们探讨了针对医疗服务提供者行为的干预措施是否能克服这一障碍并改善血糖控制。
在一项为期3年的试验中，345名内科住院医师被随机分为对照组或接受计算机提醒，每次就诊时提供针对患者的建议和/或每2周提供一次绩效反馈。在4038例患者就诊期间，当血糖水平超过150 mg/dL（8.33 mmol/L）时，医疗服务提供者的行为被描述为未采取任何措施、采取了任何措施（任何治疗强化）或采取了足够措施（如果强化符合建议）。
在基线时，当需要改变治疗时，住院医师在35%的就诊中采取了任何措施，在21%的就诊中采取了足够措施，各干预组之间无差异。在试验期间，强化措施在第一年增加最多，然后下降。然而，仅反馈组和反馈加提醒组的强化增加幅度大于仅提醒组和对照组（P<0.001）。3年后，仅提醒组和对照组的医疗服务提供者行为恢复到基线水平，而仅反馈组和反馈加提醒组的改善得以持续：52%采取了任何措施，30%采取了足够措施（与仅提醒组和对照组相比，两者P<0.001）。多变量分析表明，绩效反馈独立促进了强化措施的实施，而强化措施独立导致了HbA1c水平的下降（两者P<0.001）。
向内科住院医师初级保健提供者提供绩效反馈可改善提供者行为并降低HbA1c水平。类似方法可能有助于其他初级保健环境中的医疗服务提供者行为并改善糖尿病预后。
