质量改进小组在优化抗生素处方策略中扮演着什么角色？一项在初级医疗保健机构开展的实用整群随机对照试验。
What is the role of quality circles in strategies to optimise antibiotic prescribing? A pragmatic cluster-randomised controlled trial in primary care.
作者信息
van Driel M L, Coenen S, Dirven K, Lobbestael J, Janssens I, Van Royen P, Haaijer-Ruskamp F M, De Meyere M, De Maeseneer J, Christiaens T
机构信息
Department of General Practice and Primary Health Care, Ghent University, Ghent, Belgium.
出版信息
Qual Saf Health Care. 2007 Jun;16(3):197-202. doi: 10.1136/qshc.2006.018663.
OBJECTIVE
To evaluate the effect on antibiotic prescribing of an intervention in existing local quality circles promoting an evidence-based guideline for acute rhinosinusitis.
DESIGN
A pragmatic cluster-randomised controlled trial comparing standard dissemination of the guideline by mail with an additional strategy using quality circles.
SETTING
General practice in Flanders, Belgium.
PARTICIPANTS
General practitioners (GPs) in 18 local quality circles were randomly allocated to two study arms. All GPs received the guideline by mail. GPs in the nine quality circles allocated to the intervention arm received an additional group intervention, which consisted of one self-led meeting using material introduced to the group moderator by a member of the research team.
MAIN OUTCOME MEASURES
Adherence to the guideline was measured as differences in the proportion of antibiotic prescriptions, including the choice of antibiotic, between the two study arms after the intervention period. GPs registered their encounters with patients presenting with signs and symptoms of acute rhinosinusitis in a booklet designed for the study.
RESULTS
A total of 75 doctors (29% of GPs in the participating quality circles) registered 408 consultations. In the intervention group, 56.9% of patients received an antibiotic compared with 58.3% in the control group. First-choice antibiotics were issued in 34.5% of antibiotic prescriptions in the intervention group compared with 29.4% in the control group. After adjusting for patient and GP characteristics, the ORadj for antibiotics prescribed in the intervention arm compared with the control arm was 0.63 (95% CI 0.29 to 1.37). There was no effect on the choice of antibiotic (ORadj 1.07, 95% CI 0.34 to 3.37).
CONCLUSION
A single intervention in quality circles of GPs integrated in the group's normal working procedure did not have a significant effect on the quality of antibiotic prescribing. More attention to the context and structure of primary care practice, and insight into the process of self-reflective learning may provide clues to optimise the effectiveness of quality circles.
目的
评估在现有的地方质量改进小组中推行基于证据的急性鼻窦炎指南干预措施对抗生素处方开具的影响。
设计
一项实用的整群随机对照试验，比较通过邮件进行指南的标准传播与使用质量改进小组的额外策略。
地点
比利时弗拉芒地区的全科医疗。
参与者
18个地方质量改进小组中的全科医生（GPs）被随机分配到两个研究组。所有全科医生都通过邮件收到了指南。分配到干预组的9个质量改进小组中的全科医生还接受了额外的小组干预，该干预包括一次由研究团队成员向小组主持人介绍材料后进行的自主会议。
主要观察指标
在干预期后，通过比较两个研究组之间抗生素处方比例（包括抗生素的选择）的差异来衡量对指南的依从性。全科医生在为该研究设计的手册中记录他们对出现急性鼻窦炎体征和症状患者的诊疗情况。
结果
共有75名医生（参与质量改进小组的全科医生中的29%）记录了408次诊疗。干预组中56.9%的患者接受了抗生素治疗，而对照组为58.3%。干预组34.5%的抗生素处方开具了首选抗生素，而对照组为29.4%。在调整患者和全科医生特征后，干预组与对照组相比开具抗生素的校正比值比（ORadj）为0.63（95%可信区间0.29至1.37）。对抗生素的选择没有影响（ORadj 1.07，95%可信区间0.34至3.37）。
结论
在全科医生质量改进小组中融入小组正常工作流程的单一干预措施，对抗生素处方开具质量没有显著影响。更多关注初级医疗实践的背景和结构，以及深入了解自我反思学习过程，可能为优化质量改进小组的有效性提供线索。
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