Parchman Michael L, Pugh Jacqueline A, Romero Raquel L, Bowers Krista W
VERDICT Health Services Research Center, South Texas Veterans Health Care System, San Antonio, Tex 78229-4404, USA.
Ann Fam Med. 2007 May-Jun;5(3):196-201. doi: 10.1370/afm.679.
This study aimed to examine the contribution of competing demands to changes in hypoglycemic medications and to return appointment intervals for patients with type 2 diabetes and an elevated glycosylated hemoglobin (A1c) level.
We observed 211 primary care encounters by adult patients with type 2 diabetes in 20 primary care clinics and documented changes in hypoglycemic medications. Competing demands were assessed from length of encounter, number of concerns patients raised, and number of topics brought up by the clinician. Days to the next scheduled appointment were obtained at patient checkout. Recent A1c values and dates were determined from the chart.
Among patients with an A(1c) level greater than 7%, each additional patient concern was associated with a 49% (95% confidence interval, 35%-60%) reduction in the likelihood of a change in medication, independent of length of the encounter and most recent level of A1c. Among patients with an A(1c) level greater than 7% and no change in medication, for every additional minute of encounter length, the time to the next scheduled appointment decreased by 2.8 days (P = .001). Similarly, for each additional 1% increase in A1c level, the time to the next scheduled appointment decreased by 8.6 days (P=.001).
The concept of clinical inertia is limited and does not fully characterize the complexity of primary care encounters. Competing demands is a principle for constructing models of primary care encounters that are more congruent with reality and should be considered in the design of interventions to improve chronic disease outcomes in primary care settings.
本研究旨在探讨相互竞争的需求对2型糖尿病且糖化血红蛋白（A1c）水平升高患者降糖药物变化及复诊间隔时间的影响。
我们在20家基层医疗诊所观察了211例成年2型糖尿病患者的基层医疗诊疗过程，并记录了降糖药物的变化。从诊疗时长、患者提出的问题数量以及临床医生提及的话题数量来评估相互竞争的需求。在患者结账时获取下次预约就诊的天数。从病历中确定近期的A1c值和日期。
在A1c水平大于7%的患者中，患者每多提出一个问题，药物变更可能性降低49%（95%置信区间，35%-60%），这与诊疗时长和最近的A1c水平无关。在A1c水平大于7%且药物未变更的患者中，诊疗时长每增加一分钟，下次预约就诊时间减少2.8天（P = .001）。同样，A1c水平每增加1%，下次预约就诊时间减少8.6天（P = .001）。
临床惰性的概念具有局限性，不能完全描述基层医疗诊疗过程的复杂性。相互竞争的需求是构建更符合实际的基层医疗诊疗模型的一项原则，在设计改善基层医疗环境中慢性病治疗效果的干预措施时应予以考虑。
