Katz David A, Aufderheide Tom P, Bogner Mark, Rahko Peter R, Brown Roger L, Brown Lisa M, Prekker Matthew E, Selker Harry P
Department of Medicine, Population Health Sciences, University of Wisconsin - Madison, USA.
Med Decis Making. 2006 Nov-Dec;26(6):606-16. doi: 10.1177/0272989X06295358.
The primary aim of this study is to determine whether implementing the Agency for Health Care Policy and Research (AHCPR) Unstable Angina Practice Guideline improves emergency physician's decision making in patients with symptoms of possible acute coronary syndrome (ACS), including those for whom the diagnosis of unstable angina is uncertain.
The authors conducted a prospective guideline implementation trial with pre-post design in the emergency departments of 1 university hospital and 1 university-affiliated community teaching hospital from January 2000 to May 2001. They enrolled 1140 adults who presented with chest pain or other symptoms of possible ACS. The intervention included the following: 1) physician training in use of the AHCPR risk groups, 2) algorithm for risk stratification, and 3) group feedback. To determine how accurately physicians interpreted the guideline algorithm, the authors compared their risk ratings with actual guideline risk groups.
No significant difference in physician triage decisions was observed between baseline and intervention periods. Analysis of physician's risk ratings during the intervention period revealed low overall concordance with actual guideline risk groups (kappa = 0.31); however, physician's risk ratings showed superior discrimination in identifying patients with confirmed ACS (receiver operating characteristic [ROC] area .81 v. .74, P = 0.008). Strict adherence to guideline recommendations would have resulted in hospitalizing 9% more non-ACS patients without lowering the rate of missed ACS.
Implementation of the AHCPR guideline did not improve triage decisions in emergency department patients with possible ACS. Assessing physician triage solely based on concordance with the AHCPR guideline may not accurately reflect the quality of patient care.
本研究的主要目的是确定实施医疗保健政策与研究机构（AHCPR）不稳定型心绞痛实践指南是否能改善急诊医生对可能患有急性冠状动脉综合征（ACS）患者的决策，包括那些不稳定型心绞痛诊断不明确的患者。
作者于2000年1月至2001年5月在1所大学医院和1所大学附属社区教学医院的急诊科进行了一项采用前后设计的前瞻性指南实施试验。他们纳入了1140名出现胸痛或其他可能ACS症状的成年人。干预措施包括：1）医生使用AHCPR风险分组的培训，2）风险分层算法，以及3）小组反馈。为了确定医生对指南算法的解读准确性，作者将他们的风险评级与实际指南风险分组进行了比较。
在基线期和干预期之间，未观察到医生分诊决策有显著差异。对干预期医生风险评级的分析显示，与实际指南风险分组的总体一致性较低（kappa = 0.31）；然而，医生的风险评级在识别确诊ACS患者方面具有更好的辨别力（受试者操作特征曲线下面积[ROC]为0.81对0.74，P = 0.008）。严格遵循指南建议会导致多9%的非ACS患者住院，同时又不会降低漏诊ACS的发生率。
实施AHCPR指南并未改善急诊科可能患有ACS患者的分诊决策。仅根据与AHCPR指南的一致性来评估医生分诊可能无法准确反映患者护理质量。
