Peters-Klimm Frank, Müller-Tasch Thomas, Remppis Andrew, Szecsenyi Joachim, Schellberg Dieter
Department of Genral Practice and Health Services Research, University Hospital Heidelberg, Germany.
J Eval Clin Pract. 2008 Oct;14(5):823-9. doi: 10.1111/j.1365-2753.2008.01060.x.
Clinical practice guidelines (CPG) reflect the evidence of effective pharmacotherapy of chronic (systolic) heart failure (CHF) which needs to be implemented. This study aimed to evaluate the effect of a new, multifaceted intervention (educational train-the-trainer course plus pharmacotherapy feedback = TTT) compared with standard education on guideline adherence (GA) in general practice.
Thirty-seven participating general practitioners (GPs) were randomized (18 vs. 19) and included 168 patients with ascertained symptomatic CHF [New York Heart Association (NYHA) II-IV]. Groups received CPG, the TTT intervention consisted of four interactive educational meetings and a pharmacotherapy feedback, while the control group received a usual lecture (Standard). Outcome measure was GA assessed by prescription rates and target dosing of angiotensin converting enzyme (ACE) inhibitors (ACE-I) or angiotensin receptor blockers (ARB), beta-blockers (BB) and aldosterone antagonists (AA) at baseline and 7-month follow-up. Group comparisons at follow-up were adjusted to GA, sex, age and NYHA stage at baseline.
Prescription rates at baseline (n = 168) were high (ACE-I/ARB 90, BB 79 and AA 29%) in both groups. At follow up (n = 146), TTT improved compared with Standard regarding AA (43% vs. 23%, P = 0.04) and the rates of reached target doses of ACE-I/ARB (28% vs. 15%, P = 0.04). TTT group achieved significantly higher mean percentages of daily target dose (52% vs. 42%, mean difference 10.3%, 95% CI 0.84-19.8, P = 0.03).
Despite of pre-existing high GA in both groups and an active control group, the multifaceted intervention was effective in quality of care measured by GA. Further research is needed on the choice of interventions in different provider populations.
临床实践指南（CPG）反映了慢性（收缩性）心力衰竭（CHF）有效药物治疗的证据，需要予以实施。本研究旨在评估一种新的多方面干预措施（教育培训师课程加药物治疗反馈 = TTT）与标准教育相比，对全科医疗中指南依从性（GA）的影响。
37名参与的全科医生（GP）被随机分组（18名对19名），纳入168例确诊为有症状CHF的患者[纽约心脏协会（NYHA）II-IV级]。两组均接受CPG，TTT干预包括四次互动教育会议和一次药物治疗反馈，而对照组接受常规讲座（标准组）。结局指标是通过基线和7个月随访时血管紧张素转换酶（ACE）抑制剂（ACE-I）或血管紧张素受体阻滞剂（ARB）、β受体阻滞剂（BB）和醛固酮拮抗剂（AA）的处方率和目标剂量来评估GA。随访时的组间比较根据基线时的GA、性别、年龄和NYHA分级进行了调整。
两组在基线时（n = 168）的处方率都很高（ACE-I/ARB为90%，BB为79%，AA为29%）。在随访时（n = 146），与标准组相比，TTT组在AA方面有所改善（43%对23%，P = 0.04），以及ACE-I/ARB达到目标剂量的比例（28%对15%，P = 0.04）。TTT组实现的每日目标剂量平均百分比显著更高（52%对42%，平均差异10.3%，95%CI 0.84 - 19.8，P = 0.03）。
尽管两组以及积极对照组中预先存在较高的GA，但多方面干预在以GA衡量的医疗质量方面是有效的。需要对不同医疗服务提供者群体的干预措施选择进行进一步研究。
