Wheeler Amanda
Clinical Research and Resource Centre, Mental Health and Addiction Services, Waitakere Hospital, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
J Eval Clin Pract. 2009 Aug;15(4):685-91. doi: 10.1111/j.1365-2753.2008.01084.x.
To use structured implicit review following large-scale explicit audit of antipsychotic polyprescribing to: (1) determine the true rate of antipsychotic polytherapy that deviated from best practice for schizophrenia treatment; and (2) assess whether explicit antipsychotic polytherapy criterion was appropriate for identifying patients at risk for medication problems and assessing quality of care.
Antipsychotic prescribing was reviewed for outpatients in four public health services in Auckland, New Zealand on 31 October 2004 (T1). Schizophrenia patients in one service (n = 794) prescribed antipsychotic polytherapy (n = 84, 10.6%) were followed up 10 months later (T2). Historical medication summaries were prepared for those remaining on polytherapy, including diagnosis, clinical problems and treatment plan. Criteria for structured implicit review and rating form for quality of antipsychotic management were piloted. All medication summaries were independently rated by two reviewers, and a third independent rater reviewed summaries where disagreement was found.
Forty-nine patients remained on long-term polytherapy at T2 (6.2% of original population). All but two cases included a second-generation antipsychotic. At T2, average polytherapy duration was 35.8 months, and average antipsychotic dose was 699 mg day(-1) chlorpromazine equivalents. Two raters achieved agreement for 24/49 summaries, and the remaining 25 were rated independently by a third reviewer. Consensus agreement of antipsychotic management (by two raters) was reached for 44/49 cases (89.8%). Polytherapy was rated 'well-justified' in 32.7%, 'some justification' in 10.2% and 'lacked justification' in 46.9% cases. The final rate of polytherapy deviating from best practice reduced from 10.6% to 3.5% when short-term polytherapy was excluded, and details of the clinical situation and care plan were included in implicit review.
Audit of prescribing in routine practice using explicit guideline-based criteria may be a useful baseline performance indicator. It does not provide an accurate measurement of quality of care because it overestimates the deviation rate from good practice. It may also identify complex patients at risk for poor treatment outcomes who may benefit from structured treatment review.
在对精神分裂症治疗中抗精神病药物联合处方进行大规模明确审核后，采用结构化隐性审核来：（1）确定偏离精神分裂症最佳治疗实践的抗精神病药物联合治疗的实际发生率；（2）评估明确的抗精神病药物联合治疗标准是否适用于识别有用药问题风险的患者以及评估医疗质量。
对2004年10月31日（T1）新西兰奥克兰四家公共卫生服务机构的门诊患者抗精神病药物处方进行审核。对其中一家机构中接受抗精神病药物联合治疗（n = 84，占10.6%）的794例精神分裂症患者在10个月后（T2）进行随访。为继续接受联合治疗的患者准备历史用药总结，包括诊断、临床问题和治疗计划。对结构化隐性审核标准和抗精神病药物管理质量评分表进行了试点。所有用药总结由两名审核员独立评分，如果发现分歧，则由第三名独立审核员对总结进行审核。
在T2时，49例患者仍在接受长期联合治疗（占原患者群体的6.2%）。除两例病例外，所有病例均包括一种第二代抗精神病药物。在T2时，联合治疗的平均持续时间为35.8个月，抗精神病药物的平均剂量为699毫克/天（氯丙嗪等效剂量）。两名审核员对49份总结中的24份达成了一致意见，其余25份由第三名审核员独立评分。49例病例中有44例（89.8%）在抗精神病药物管理方面达成了共识（由两名审核员评定）。联合治疗在32.7%的病例中被评为“理由充分”，在10.2%的病例中被评为“有一定理由”，在46.9%的病例中被评为“缺乏理由”。当排除短期联合治疗并在隐性审核中纳入临床情况和护理计划的详细信息时，偏离最佳实践的联合治疗最终发生率从10.6%降至3.5%。
使用基于明确指南的标准对常规实践中的处方进行审核可能是一个有用的基线绩效指标。但它不能准确衡量医疗质量，因为它高估了与良好实践行为的偏差率。它还可能识别出有治疗效果不佳风险的复杂患者，这些患者可能受益于结构化治疗审核。
