Harvey Gill, Oliver Kathryn, Humphreys John, Rothwell Katy, Hegarty Janet
Manchester Business School, University of Manchester, Booth Street West, Manchester M15 6PB, UK School of Nursing, University of Adelaide, Eleanor Harrald Building, Frome Road, Adelaide SA5005, Australia.
School of Social Sciences, University of Manchester, Arthur Lewis Building, Oxford Road, Manchester M13 9PL, UK Department for Science, Technology, Engineering and Public Policy (UCL STEaPP), University College London, 36-38 Fitzroy Square (2nd Floor), London W1T 6EY, UK.
Int J Qual Health Care. 2015 Feb;27(1):10-6. doi: 10.1093/intqhc/mzu097. Epub 2014 Dec 18.
Undiagnosed chronic kidney disease (CKD) contributes to a high cost and care burden in secondary care. Uptake of evidence-based guidelines in primary care is inconsistent, resulting in variation in the detection and management of CKD.
Routinely collected general practice data in one UK region suggested a CKD prevalence of 4.1%, compared with an estimated national prevalence of 8.5%. Of patients on CKD registers, ∼ 30% were estimated to have suboptimal management according to Public Health Observatory analyses.
An evidence-based framework for implementation was developed. This informed the design of an improvement collaborative to work with a sample of 30 general practices.
A two-phase collaborative was implemented between September 2009 and March 2012. Key elements of the intervention included learning events, improvement targets, Plan-Do-Study-Act cycles, benchmarking of audit data, facilitator support and staff time reimbursement.
Outcomes were evaluated against two indicators: number of patients with CKD on practice registers; percentage of patients achieving evidence-based blood pressure (BP) targets, as a marker for CKD care. In Phase 1, recorded prevalence of CKD in collaborative practices increased ∼ 2-fold more than that in comparator local practices; in Phase 2, this increased to 4-fold, indicating improved case identification. Management of BP according to guideline recommendations also improved.
An improvement collaborative with tailored facilitation support appears to promote the uptake of evidence-based guidance on the identification and management of CKD in primary care. A controlled evaluation study is needed to rigorously evaluate the impact of this promising improvement intervention.
未确诊的慢性肾脏病（CKD）导致二级医疗保健成本高昂且护理负担沉重。基层医疗中基于证据的指南采用情况不一致，导致CKD检测和管理存在差异。
英国一个地区常规收集的全科医疗数据显示CKD患病率为4.1%，而全国估计患病率为8.5%。根据公共卫生观察站的分析，在CKD登记册上的患者中，约30%的患者管理欠佳。
制定了一个基于证据的实施框架。这为与30家全科医疗机构样本合作开展改进协作提供了依据。
2009年9月至2012年3月实施了两阶段协作。干预的关键要素包括学习活动、改进目标、计划-执行-研究-行动循环、审核数据基准、促进者支持和员工时间补偿。
根据两个指标评估结果：全科医疗登记册上CKD患者数量；达到基于证据的血压（BP）目标的患者百分比，作为CKD护理的一个指标。在第一阶段，协作医疗机构中记录的CKD患病率比对照地区医疗机构增加了约2倍；在第二阶段，增加到4倍，表明病例识别得到改善。按照指南建议进行的血压管理也有所改善。
有针对性的促进者支持的改进协作似乎能促进基层医疗中基于证据的CKD识别和管理指南的采用。需要进行对照评估研究，以严格评估这种有前景的改进干预措施的影响。
