Vashitz Geva, Meyer Joachim, Parmet Yisrael, Henkin Yaakov, Peleg Roni, Liebermann Nicky, Gilutz Harel
Department of Industrial Engineering and Management, Ben-Gurion University of the Negev, Beer Sheva, Israel.
Isr Med Assoc J. 2011 Nov;13(11):657-62.
There is a wide treatment gap between evidence-based guidelines and their implementation in primary care.
To evaluate the extent to which physicians "literally" follow guidelines for secondary prevention of dyslipidemia and the extent to which they practice "substitute" therapeutic measures.
We performed a post hoc analysis of data collected in a prospective cluster randomized trial. The participants were 130 primary care physicians treating 7745 patients requiring secondary prevention of dyslipidemia. The outcome measure was physician literal adherence or substitute adherence. We used logistic regressions to evaluate the effect of various clinical situations on literal and substitute adherence.
Literal adherence was modest for ordering a lipoprotein profile (35.1%) and for pharmacotherapy initiations (26.0%), but rather poor for drug up-titrations (16.1%) and for referrals for specialist consultation (3.8%). In contrast, many physicians opted for substitute adherence for up-titrations (75.9%) and referrals for consultation (78.7%). Physicians tended to follow the guidelines literally in simple clinical situations (such as the need for lipid screening) but to use substitute measures in more complex cases (when dose up-titration or metabolic consultation was required). Most substitute actions were less intense than the actions recommended by the guidelines.
Physicians often do not blindly follow guidelines, but rather evaluate their adequacy for a particular patient and adjust the treatment according to their assessment. We suggest that clinical management be evaluated in a broader sense than strict guideline adherence, which may underestimate physicians' efforts.
循证指南与其在初级保健中的实施之间存在很大的治疗差距。
评估医生“严格”遵循血脂异常二级预防指南的程度以及他们采取“替代”治疗措施的程度。
我们对一项前瞻性整群随机试验收集的数据进行了事后分析。参与者为130名初级保健医生，他们治疗7745名需要进行血脂异常二级预防的患者。结局指标为医生的严格依从性或替代依从性。我们使用逻辑回归来评估各种临床情况对严格依从性和替代依从性的影响。
在开具脂蛋白谱检查单（35.1%）和启动药物治疗（26.0%）方面，严格依从性一般，但在药物剂量上调（16.1%）和转介至专科会诊（3.8%）方面较差。相比之下，许多医生在剂量上调（75.9%）和会诊转介（78.7%）方面选择了替代依从性。医生在简单临床情况（如需要进行血脂筛查）下倾向于严格遵循指南，但在更复杂的病例（需要剂量上调或代谢会诊时）会采用替代措施。大多数替代措施的强度低于指南推荐的措施。
医生通常不会盲目遵循指南，而是会评估其对特定患者的适用性，并根据自己的评估调整治疗。我们建议，临床管理的评估应比严格遵循指南更具宽泛性，因为严格遵循指南可能会低估医生的努力。
