Laprise Réjean, Thivierge Robert, Gosselin Gilbert, Bujas-Bobanovic Maja, Vandal Sylvie, Paquette Daniel, Luneau Micheline, Julien Pierre, Goulet Serge, Desaulniers Jean, Maltais Paule
Division of Continuing Professional Development, Faculty of Medicine, Université de Montréal, Montreal QC, Canada.
J Contin Educ Health Prof. 2009 Winter;29(1):16-31. doi: 10.1002/chp.20002.
It was hypothesized that after a continuing medical education (CME) event, practice enablers and reinforcers addressing main clinical barriers to preventive care would be more effective in improving general practitioners' (GPs) adherence to cardiovascular guidelines than a CME event only.
A cluster-randomized trial was conducted on a convenience sample of 122 GPs who were randomly assigned to either CME only (control group) or CME with practice enablers and reinforcers (PER group). In the PER group, nurses visited GPs' offices once a month to implement the clinical intervention on patients > or = 55 years old with a scheduled visit in the month following the nurse visit: (1) screening medical records for potentially undermanaged high-risk patients; (2) prompting physicians to reassess preventive care in these patients; (3) enclosing a checklist reporting most recent information relevant to guidelines' implementation; and (4) enclosing a summary of experts' recommendations in the form of a follow-up and treatment algorithm.
A retrospective chart audit of 2344 consenting patients, potentially undermanaged at baseline, demonstrated that the PER intervention following CME significantly improved adherence to guidelines compared to CME alone (OR: 1.78, 95% CI: 1.32-2.41).
The intervention was designed for self-implementation in primary care practices that have their own nursing staff. PER GPs were highly satisfied with the intervention; the majority said that they would implement it in their practice if someone trained their nurse, thus suggesting support for development of a multiprofessional CME program to disseminate this clinical approach to primary care practice groups.
研究假设，在继续医学教育（CME）活动之后，针对预防保健主要临床障碍的实践促进因素和强化因素，相较于单纯的CME活动，在提高全科医生（GPs）对心血管指南的依从性方面会更有效。
对122名全科医生的便利样本进行了整群随机试验，这些医生被随机分配到仅接受CME（对照组）或接受带有实践促进因素和强化因素的CME（PER组）。在PER组中，护士每月访问全科医生办公室一次，对年龄≥55岁且在护士访问后的次月有预约就诊的患者实施临床干预：（1）筛查病历以找出可能管理不足的高危患者；（2）促使医生重新评估这些患者的预防保健情况；（3）附上一份报告与指南实施相关最新信息的清单；（4）附上以随访和治疗算法形式呈现的专家建议摘要。
对2344名基线时可能管理不足的同意参与研究的患者进行回顾性病历审核，结果表明，与单纯的CME相比，CME后的PER干预显著提高了对指南的依从性（比值比：1.78，95%置信区间：1.32 - 2.41）。
该干预旨在供有自身护理人员的基层医疗实践自行实施。接受PER干预的全科医生对该干预高度满意；大多数人表示，如果有人培训他们的护士，他们会在自己的实践中实施该干预，这表明支持开展多专业CME项目，以将这种临床方法推广到基层医疗实践群体中。
