通过为期两年的互联网干预改善心肌梗死后护理：退伍军人事务部心肌梗死加集群随机试验
Improving care after myocardial infarction using a 2-year internet-delivered intervention: the Department of Veterans Affairs myocardial infarction-plus cluster-randomized trial.
作者信息
Levine Deborah A, Funkhouser Ellen M, Houston Thomas K, Gerald Joe K, Johnson-Roe Nancy, Allison Jeroan J, Richman Joshua, Kiefe Catarina I
机构信息
Department of Medicine, University of Michigan, Ann Arbor, 48109, USA.
出版信息
Arch Intern Med. 2011 Nov 28;171(21):1910-7. doi: 10.1001/archinternmed.2011.498.
BACKGROUND
Cardiovascular risk reduction in ambulatory patients who survive myocardial infarction (MI) is effective but underused. We sought to evaluate a provider-directed, Internet-delivered intervention to improve cardiovascular management for post-MI outpatients.
METHODS
The Department of Veterans Affairs (VA) MI-Plus study was a cluster-randomized trial involving 168 community-based primary care clinics and 847 providers in 26 states, the Virgin Islands, and Puerto Rico, from January 1, 2002, through December 31, 2008, with the clinic as the randomization unit. We collected administrative data for 15,847 post-MI patients and medical record data for 10,452 of these. A multicomponent, Internet-delivered intervention included quarterly educational modules, practice guidelines, monthly literature summaries, and automated e-mail reminders delivered to providers for 27 months. Main outcome measures included percentage of patients who achieved each of 7 clinical indicators, a composite score of the 7 clinical indicators, and mean low-density lipoprotein cholesterol and hemoglobin A(1c) levels.
RESULTS
Clinics had a median of 3 providers (interquartile range, 2-6), with a median of 50.0% of providers (33.3%-66.7%) participating in the study. Patients in intervention clinics had greater improvements (from 70.0% to 85.5%) in the percentages prescribed β-blockers than patients in control clinics (71.9% to 84.0%; adjusted improvement gain for intervention vs control, 2.6%; 95% CI, 0.1%-4.1%). We found nonsignificant differences in improvements favoring patients in intervention clinics for 5 of 6 remaining clinical indicators and levels of low-density lipoprotein cholesterol and hemoglobin A(1c).
CONCLUSION
A longitudinal, Internet-delivered intervention improved only 1 of 7 clinical indicators of cardiovascular management in ambulatory post-MI patients.
背景
心肌梗死（MI）存活的门诊患者心血管风险降低有效，但未得到充分利用。我们试图评估一种由医疗服务提供者主导、通过互联网提供的干预措施，以改善心肌梗死后门诊患者的心血管管理。
方法
退伍军人事务部（VA）的MI-Plus研究是一项整群随机试验，从2002年1月1日至2008年12月31日，涉及26个州、美属维尔京群岛和波多黎各的168家社区基层医疗诊所和847名医疗服务提供者，以诊所作为随机分组单位。我们收集了15847名心肌梗死后患者的管理数据以及其中10452名患者的病历数据。一项多成分的、通过互联网提供的干预措施包括每季度的教育模块、实践指南、每月的文献摘要以及向医疗服务提供者发送27个月的自动电子邮件提醒。主要结局指标包括达到7项临床指标中每项指标的患者百分比、7项临床指标的综合评分以及平均低密度脂蛋白胆固醇和糖化血红蛋白A1c水平。
结果
诊所的医疗服务提供者中位数为3名（四分位间距，2 - 6名），参与研究的医疗服务提供者中位数为50.0%（33.3% - 66.7%）。与对照诊所的患者相比，干预诊所的患者使用β受体阻滞剂的处方百分比有更大改善（从70.0%提高到85.5%），而对照诊所从71.9%提高到84.0%；干预组与对照组相比的调整改善增益为2.6%；95%置信区间，0.1% - 4.1%）。对于其余6项临床指标以及低密度脂蛋白胆固醇和糖化血红蛋白A1c水平中的5项，我们发现干预诊所患者的改善情况虽有差异，但无统计学意义。
结论
一项纵向的、通过互联网提供的干预措施仅改善了心肌梗死后门诊患者心血管管理7项临床指标中的1项。
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