McGill University Health Centre, McGill University, Montréal, Quebec.
CMAJ. 2013 Feb 19;185(3):E156-66. doi: 10.1503/cmaj.120095. Epub 2013 Jan 14.
International guidelines for the management of nonvariceal upper gastrointestinal bleeding have not been widely adopted in clinical practice. We sought to determine whether a national, multifaceted intervention could improve adherence to guidelines, especially for patients at high risk of nonvariceal upper gastrointestinal bleeding.
In this randomized trial, we stratified hospitals by region and size and allocated sites to either the control or experimental group. Health care workers in the experimental group were given published guidelines, generic algorithms, stratification scoring systems and written reminders and attended multidisciplinary guideline education groups and case-based workshops. These interventions were implemented over a 12-month period after randomization, with performance feedback and benchmarking. The primary outcome of adherence rates to key guidelines in endoscopic and pharmacologic management, determined by chart review, was adjusted according to site characteristics and possible within-site dependencies. We also report the rates of adherence to other recommendations.
Forty-three sites were randomized to the experimental (n=21) or control (n=22) groups. In our primary analysis, we compared patients before (experimental group: n=402 patients; control group: n=424 patients) and after (experimental group: n=361 patients; control group: n=389 patients) intervention. Patient-level analysis revealed no significant difference in adherence rates to the guidelines after the intervention (experimental group: 9.8%; control group: 4.8%; p=0.99) after adjustment for the rate of adherence before the intervention (experimental group: 13.2%; control group: 7.1%). The adherence rates to other guidelines were similar and decreased over time, varying between 5% and 93%.
This national knowledge translation-based trial suggests poor adherence to guidelines on nonvariceal upper gastrointestinal bleeding. Adherence was not improved by an educational intervention, which highlights both the complexity and poor predictability of attempting to alter the behaviour of health care providers (Trial registration: ClinicalTrials.gov, no. MCT-88113).
国际上针对非静脉曲张性上消化道出血的管理指南尚未在临床实践中得到广泛应用。我们旨在确定一种全国性的、多方面的干预措施是否能够提高对指南的遵循程度，尤其是针对那些存在非静脉曲张性上消化道出血高风险的患者。
在这项随机试验中，我们根据地域和规模对医院进行分层，并将研究地点分配到对照组或实验组。实验组的医护人员接受了已发表的指南、通用算法、分层评分系统和书面提醒，并参加了多学科指南教育小组和基于案例的研讨会。这些干预措施在随机分组后的 12 个月内实施，同时提供绩效反馈和基准测试。通过病历回顾确定的内镜和药物治疗关键指南的遵循率是主要结局，根据地点特征和可能的内部依赖关系进行了调整。我们还报告了其他建议的遵循率。
43 个研究地点被随机分配到实验组（n=21）或对照组（n=22）。在我们的主要分析中，我们比较了干预前（实验组：n=402 例患者；对照组：n=424 例患者）和干预后（实验组：n=361 例患者；对照组：n=389 例患者）患者的情况。患者水平的分析显示，干预后指南遵循率没有显著差异（实验组：9.8%；对照组：4.8%；p=0.99），在调整了干预前的遵循率后（实验组：13.2%；对照组：7.1%）。其他指南的遵循率也相似，且随着时间的推移逐渐下降，范围在 5%至 93%之间。
这项基于全国性知识转化的试验表明，非静脉曲张性上消化道出血的指南遵循情况较差。教育干预并没有提高遵循率，这突出了试图改变医疗保健提供者行为的复杂性和不可预测性（试验注册：ClinicalTrials.gov，编号 MCT-88113）。
