M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Mail Stop 409, Houston, TX 77030, USA.
Anesth Analg. 2010 Aug;111(2):515-9. doi: 10.1213/ANE.0b013e3181dd5899. Epub 2010 Jun 7.
Clinical practice guidelines summarize evidence from science and attempt to translate those findings into clinical practice. Pervasive and consistent adoption of these guidelines into daily provider practice has proven slow.
Using postoperative nausea and vomiting (PONV) prophylaxis guideline compliance as our metric, we compared the effects of continuing medical education (CME) alone (I), CME with a single snapshot of provider compliance (II), and ongoing reporting of provider compliance data without further CME (III). We retrospectively analyzed guideline compliance of 23,279 anesthetics at the University of Texas M.D. Anderson Cancer Center. Compliance was defined as a patient with 1 risk factor for PONV receiving at least 1 antiemetic, 2 risk factors receiving at least 2 antiemetics, and 3 risk factors receiving at least 3 antiemetics. Drugs of the same class were counted as single antiemetic administration. Propofol-based anesthetic techniques were counted as receiving 1 antiemetic. Patients with 0 risk factors for PONV were not included. We estimated the compliance rates for each of the 4 time periods of the study adjusting for multiple observations on the same clinician. Individual performance feedback was given once at 6 months after intervention I coincident with a refresher presentation on PONV (start of intervention II) and on an ongoing quarterly basis during intervention III.
Compliance rates were not significantly influenced with CME (intervention I) compared with baseline behavior (54.5% vs 54.4%, P = 0.9140). Significant improvement occurred during the time period when CME was paired with performance data (intervention II) compared with intervention I (59.2% vs 54.4%, P = 0.0002). Further significant improvement occurred when data alone were presented (intervention III) compared with intervention II (65.1% vs 59.2%, P < 0.0001). For patients with 3 risk factors, we saw significant improvement in compliance rates during intervention III (P = 0.0002). In post hoc analysis of overtreatment, the percentage differences between the baseline and time period III decreased as the number of risk factors increased.
We observed the greatest improvement in guideline compliance with ongoing personal performance feedback. Provider feedback can be an effective tool to modify clinical practice but can have unanticipated consequences.
临床实践指南总结了科学证据，并试图将这些发现转化为临床实践。然而，这些指南在日常医疗实践中的广泛和持续应用一直进展缓慢。
我们以术后恶心呕吐（PONV）预防指南的依从性为指标，比较了继续教育（CME）单独应用（I 组）、CME 联合单次医生依从性评估（II 组）以及仅报告医生依从性数据而不进行进一步 CME（III 组）的效果。我们回顾性分析了德克萨斯大学 MD 安德森癌症中心 23279 例麻醉患者的指南依从性。依从性定义为：有 1 个 PONV 风险因素的患者至少接受 1 种止吐药，有 2 个风险因素的患者至少接受 2 种止吐药，有 3 个风险因素的患者至少接受 3 种止吐药。同一类药物被视为单次止吐药给药。基于丙泊酚的麻醉技术被视为接受 1 种止吐药。无 PONV 风险因素的患者不包括在内。我们对研究的 4 个时间段中的每一个时间段都进行了估计，对同一医生的多次观察进行了调整。在 I 组干预后 6 个月（即 II 组的重新评估时）和 III 组的每季度报告时，对个人绩效反馈进行了一次评估。
与基线行为相比（54.4%对 54.5%，P = 0.9140），CME（I 组）并未显著影响依从率。在 CME 与绩效数据相结合的时间段（II 组），与 I 组相比，依从率显著提高（59.2%对 54.4%，P = 0.0002）。当仅呈现数据时（III 组），与 II 组相比，依从率进一步显著提高（65.1%对 59.2%，P < 0.0001）。对于有 3 个风险因素的患者，我们发现 III 组的依从率显著提高（P = 0.0002）。在事后分析中，随着风险因素数量的增加，基线与 III 组之间的差异百分比减少。
我们观察到，通过持续的个人绩效反馈，指南的依从性得到了最大的提高。医生反馈可以是一种有效的工具来改变临床实践，但可能会产生意想不到的后果。
