Eccles Martin P, Whitty Paula M, Speed Chris, Steen Ian N, Vanoli Alessandra, Hawthorne Gillian C, Grimshaw Jeremy M, Wood Linda J, McDowell David
Centre for Health Services Research, University of Newcastle, Newcastle upon Tyne, UK.
Implement Sci. 2007 Feb 16;2:6. doi: 10.1186/1748-5908-2-6.
Following the introduction of a computerised diabetes register in part of the northeast of England, care initially improved but then plateaued. We therefore enhanced the existing diabetes register to address these problems. The aim of the trial was to evaluate the effectiveness and efficiency of an area wide 'extended,' computerised diabetes register incorporating a full structured recall and management system, including individualised patient management prompts to primary care clinicians based on locally-adapted, evidence-based guidelines.
The study design was a pragmatic, cluster randomised controlled trial, with the general practice as the unit of randomisation. Set in 58 general practices in three Primary Care Trusts in the northeast of England, the study outcomes were the clinical process and outcome variables held on the diabetes register, patient-reported outcomes, and service and patient costs. The effect of the intervention was estimated using generalised linear models with an appropriate error structure. To allow for the clustering of patients within practices, population averaged models were estimated using generalized estimating equations.
Patients in intervention practices were more likely to have at least one diabetes appointment recorded (OR 2.00, 95% CI 1.02, 3.91), to have a recording of a foot check (OR 1.87, 95% CI 1.09, 3.21), have a recording of receiving dietary advice (OR 2.77, 95% CI 1.22, 6.29), and have a recording of blood pressure (BP) (OR 2.14, 95% CI 1.06, 4.36). There was no difference in mean HbA1c or BP levels, but the mean cholesterol level in patients from intervention practices was significantly lower (-0.15 mmol/l, 95% CI -0.25, -0.06). There were no differences in patient-reported outcomes or in patient-reported use of drugs, or uptake of health services. The average cost per patient was not significantly different between the intervention and control groups. Costs incurred in administering the system at the register and in general practice were in addition to these.
This study has shown benefits from an area-wide, computerised diabetes register incorporating a full structured recall and individualised patient management system. However, these benefits were achieved at a cost. In future, these costs may fall as electronic data exchange becomes a reliable reality.
International Standard Randomised Controlled Trial Number (ISRCTN) Register, ISRCTN32042030.
在英格兰东北部部分地区引入计算机化糖尿病登记系统后，护理水平最初有所改善，但随后趋于平稳。因此，我们对现有的糖尿病登记系统进行了改进以解决这些问题。该试验的目的是评估一个涵盖全面结构化召回和管理系统的区域范围“扩展型”计算机化糖尿病登记系统的有效性和效率，该系统包括根据当地适用的循证指南向基层医疗临床医生提供个性化患者管理提示。
本研究设计为实用的整群随机对照试验，以全科医疗作为随机分组单位。研究在英格兰东北部三个初级医疗信托基金的58家全科医疗中进行，研究结局为糖尿病登记系统中记录的临床过程和结局变量、患者报告的结局以及服务和患者成本。使用具有适当误差结构的广义线性模型估计干预效果。为了考虑患者在医疗机构内的聚集情况，使用广义估计方程估计总体平均模型。
干预组的患者更有可能至少有一次糖尿病就诊记录（比值比2.00，95%置信区间1.02，3.91）、足部检查记录（比值比1.87，95%置信区间1.09，3.21）、接受饮食建议记录（比值比2.77，95%置信区间1.22，6.29）以及血压（BP）记录（比值比2.14，95%置信区间1.06，4.36）。糖化血红蛋白（HbA1c）或血压水平的均值无差异，但干预组患者的平均胆固醇水平显著更低（-0.15毫摩尔/升，95%置信区间-0.25，-0.06）。患者报告的结局、患者报告的药物使用情况或医疗服务利用情况均无差异。干预组和对照组的每位患者平均成本无显著差异。登记系统和全科医疗管理该系统产生的成本不包括在内。
本研究表明，一个涵盖全面结构化召回和个性化患者管理系统的区域范围计算机化糖尿病登记系统具有益处。然而，这些益处是有成本的。未来，随着电子数据交换成为可靠现实，这些成本可能会降低。
国际标准随机对照试验编号（ISRCTN）登记册，ISRCTN32042030。
