Fretheim Atle, Oxman Andrew D, Håvelsrud Kari, Treweek Shaun, Kristoffersen Doris T, Bjørndal Arild
Norwegian Knowledge Centre for Health Services, Oslo, Norway.
PLoS Med. 2006 Jun;3(6):e134. doi: 10.1371/journal.pmed.0030134.
A gap exists between evidence and practice regarding the management of cardiovascular risk factors. This gap could be narrowed if systematically developed clinical practice guidelines were effectively implemented in clinical practice. We evaluated the effects of a tailored intervention to support the implementation of systematically developed guidelines for the use of antihypertensive and cholesterol-lowering drugs for the primary prevention of cardiovascular disease.
We conducted a cluster-randomized trial comparing a tailored intervention to passive dissemination of guidelines in 146 general practices in two geographical areas in Norway. Each practice was randomized to either the tailored intervention (70 practices; 257 physicians) or control group (69 practices; 244 physicians). Patients started on medication for hypertension or hypercholesterolemia during the study period and all patients already on treatment that consulted their physician during the trial were included. A multifaceted intervention was tailored to address identified barriers to change. Key components were an educational outreach visit with audit and feedback, and computerized reminders linked to the medical record system. Pharmacists conducted the visits. Outcomes were measured for all eligible patients seen in the participating practices during 1 y before and after the intervention. The main outcomes were the proportions of (1) first-time prescriptions for hypertension where thiazides were prescribed, (2) patients assessed for cardiovascular risk before prescribing antihypertensive or cholesterol-lowering drugs, and (3) patients treated for hypertension or hypercholesterolemia for 3 mo or more who had achieved recommended treatment goals. The intervention led to an increase in adherence to guideline recommendations on choice of antihypertensive drug. Thiazides were prescribed to 17% of patients in the intervention group versus 11% in the control group (relative risk 1.94; 95% confidence interval 1.49-2.49, adjusted for baseline differences and clustering effect). Little or no differences were found for risk assessment prior to prescribing and for achievement of treatment goals.
Our tailored intervention had a significant impact on prescribing of antihypertensive drugs, but was ineffective in improving the quality of other aspects of managing hypertension and hypercholesterolemia in primary care.
在心血管危险因素管理方面，证据与实践之间存在差距。如果系统制定的临床实践指南能在临床实践中得到有效实施，这一差距可能会缩小。我们评估了一项针对性干预措施的效果，该措施旨在支持实施系统制定的关于使用抗高血压和降胆固醇药物进行心血管疾病一级预防的指南。
我们在挪威两个地理区域的146家普通诊所进行了一项整群随机试验，比较了针对性干预与被动传播指南的效果。每家诊所被随机分配到针对性干预组（70家诊所；257名医生）或对照组（69家诊所；244名医生）。在研究期间开始服用高血压或高胆固醇血症药物的患者，以及在试验期间咨询医生的所有已接受治疗的患者均被纳入。针对已确定的变革障碍制定了多方面的干预措施。关键组成部分包括一次带有审核和反馈的教育外展访问，以及与病历系统相关联的计算机提醒。药剂师进行访问。在干预前后的1年时间里，对参与诊所中所有符合条件的患者进行了结果测量。主要结果包括：（1）首次开具噻嗪类药物治疗高血压的处方比例；（2）在开具抗高血压或降胆固醇药物之前评估心血管风险的患者比例；（3）接受高血压或高胆固醇血症治疗3个月或更长时间且达到推荐治疗目标的患者比例。干预导致对指南中抗高血压药物选择建议的依从性增加。干预组17%的患者开具了噻嗪类药物，而对照组为11%（相对风险1.94；95%置信区间1.49 - 2.49，对基线差异和聚类效应进行了调整）。在开具处方前的风险评估和治疗目标的达成方面，几乎没有发现差异。
我们的针对性干预对抗高血压药物的处方有显著影响，但在改善初级保健中高血压和高胆固醇血症管理其他方面的质量方面无效。
