Ben-Gurion University of the Negev.
Fam Pract. 2011 Oct;28(5):524-31. doi: 10.1093/fampra/cmr025. Epub 2011 May 12.
A wide therapeutic gap exists between evidence-based guidelines and their practice in the primary care, which is primarily attributed to physician and patient adherence.
This study aims to differentiate physician and patient adherence to dyslipidemia secondary prevention guidelines and various factors affecting it.
A post hoc analysis of data collected by a prospective cluster randomized trial with 7041 patients diagnosed with clinical atherosclerosis requiring secondary prevention of dyslipidemia and 127 primary care physicians over an 18-month period. Adherence was measured by physicians' and patients' actions taken according to the guidelines and correlated using multivariate logistic regressions.
Physician adherence was 36.9% for lipid profile screening, 27.6% for pharmacotherapy up-titration and 21.0% for pharmacotherapy initiation. Physician adherence was positively correlated with frequent patient visits [odds ratios (OR = 1.304)], having more dyslipidemic patients (OR = 1.304) and treating immigrants (OR = 1.268). Patient adherence was 83.8%, 71.9% and 62.6% for medication up-titration, lipid profile screening and pharmacotherapy initiation, respectively. Patient adherence was affected by attending clinics with many dyslipidemic patients (OR = 1.542), being older (OR = 1.271) and being treated by a male physician (OR = 0.870).
We learn from this study that (i) physician non-adherence was a major cause for the failure to follow guidelines, (ii) pharmacotherapy initiation was the most challenging issue to tackle and (iii) greater adherence occurred mainly in high volume conditions (patients and visits). Practical implications are designated focus on metabolic condition prevention in primary care by cardiologists or primary care clinics specializing in metabolic conditions and the need to facilitate more frequent follow-up visits.
在初级保健中，基于证据的指南与其实践之间存在广泛的治疗差距，这主要归因于医生和患者的依从性。
本研究旨在区分医生和患者对血脂异常二级预防指南的依从性，以及影响其依从性的各种因素。
对一项前瞻性聚类随机试验的数据进行事后分析，该试验纳入了 7041 名患有临床动脉粥样硬化、需要血脂异常二级预防的患者和 127 名初级保健医生，随访时间为 18 个月。依从性通过医生和患者根据指南采取的行动来衡量，并使用多变量逻辑回归进行相关性分析。
医生的依从性为血脂谱筛查 36.9%、药物治疗滴定 27.6%和药物治疗起始 21.0%。医生的依从性与患者就诊频率较高（比值比[OR] = 1.304）、患有更多血脂异常患者（OR = 1.304）和治疗移民（OR = 1.268）呈正相关。患者的依从性分别为药物治疗滴定、血脂谱筛查和药物治疗起始的 83.8%、71.9%和 62.6%。患者的依从性受到就诊诊所血脂异常患者较多（OR = 1.542）、年龄较大（OR = 1.271）和由男性医生治疗（OR = 0.870）的影响。
本研究表明，（i）医生不依从是未能遵循指南的主要原因，（ii）药物治疗起始是最具挑战性的问题，（iii）更高的依从性主要发生在高容量条件下（患者和就诊次数）。实践意义在于指定由心脏病专家或专门从事代谢疾病的初级保健诊所关注初级保健中的代谢疾病预防，并需要促进更频繁的随访就诊。
