Stc Hamilton Karen E, Sullivan Frank M, Donnan Peter T, Taylor Rex, Ikenwilo Divine, Scott Anthony, Baker Chris, Wyke Sally
Tayside Centre for General Practice, University of Dundee, Kirsty Semple Way, Dundee, DD2 4BF Scotland.
Int J Integr Care. 2005;5:e10. doi: 10.5334/ijic.135. Epub 2005 Sep 9.
To investigate the set up and operation of a Managed Clinical Network for cardiac services and assess its impact on patient care.
This single case study used process evaluation with observational before and after comparison of indicators of quality of care and costs. The study was conducted in Dumfries and Galloway, Scotland and used a three-level framework. Process evaluation of the network set-up and operation through a documentary review of minutes; guidelines and protocols; transcripts of fourteen semi-structured interviews with health service personnel including senior managers, general practitioners, nurses, cardiologists and members of the public. Outcome evaluation of the impact of the network through interrupted time series analysis of clinical data of 202 patients aged less than 76 years admitted to hospital with a confirmed myocardial infarction one-year pre and one-year post, the establishment of the network. The main outcome measures were differences between indicators of quality of care targeted by network protocols. Economic evaluation of the transaction costs of the set-up and operation of the network and the resource costs of the clinical care of the 202 myocardial infarction patients from the time of hospital admission to 6 months post discharge through interrupted time series analysis. The outcome measure was different in National Health Service resource use.
Despite early difficulties, the network was successful in bringing together clinicians, patients and managers to redesign services, exhibiting most features of good network management. The role of the energetic lead clinician was crucial, but the network took time to develop and 'bed down'. Its primary "modus operand" was the development of a myocardial infarction pathway and associated protocols. Of sixteen clinical care indicators, two improved significantly following the launch of the network and nine showed improvements, which were not statistically significant. There was no difference in resource use.
The Managed Clinical Network made a difference to ways of working, particularly in breaching traditional boundaries and involving the public, and made modest changes in patient care. However, it required a two-year "set-up" period. Managed clinical networks are complex initiatives with an increasing profile in health care policy. This study suggests that they require energetic leadership and improvements are likely to be slow and incremental.
调查心脏服务管理临床网络的建立与运行情况，并评估其对患者护理的影响。
本单案例研究采用过程评估，对护理质量指标和成本进行前后观察比较。该研究在苏格兰的邓弗里斯和加洛韦进行，采用了三级框架。通过对会议记录、指南和协议的文献回顾；对包括高级管理人员、全科医生、护士、心脏病专家和公众在内的14名卫生服务人员进行的半结构化访谈记录，对网络的建立和运行进行过程评估。通过对网络建立前一年和建立后一年确诊为心肌梗死入院的202名76岁以下患者的临床数据进行中断时间序列分析，评估网络的影响。主要结果指标是网络协议所针对的护理质量指标之间的差异。通过中断时间序列分析，对网络建立和运行的交易成本以及202名心肌梗死患者从入院到出院后6个月临床护理的资源成本进行经济评估。结果指标是国民保健服务资源使用情况的差异。
尽管早期遇到困难，但该网络成功地将临床医生、患者和管理人员聚集在一起重新设计服务，展现出良好网络管理的大多数特征。精力充沛的首席临床医生的作用至关重要，但网络的发展和稳固需要时间。其主要“运作方式”是制定心肌梗死路径及相关协议。在16项临床护理指标中，网络启动后有2项显著改善，9项有改善但无统计学意义。资源使用情况没有差异。
管理临床网络改变了工作方式，特别是在打破传统界限和让公众参与方面，并在患者护理方面做出了适度改变。然而，它需要两年的“建立”期。管理临床网络是复杂的举措，在医疗保健政策中的地位日益重要。本研究表明，它们需要精力充沛地领导，改进可能缓慢且渐进。
