Ohtera Shosuke, Kanazawa Natsuko, Ozasa Neiko, Ueshima Kenji, Nakayama Takeo
Department of Health Informatics, Graduate School of Medicine/School of Public Health, Kyoto University, Kyoto, Japan.
Clinical Research Center, National Hospital Organization, Tokyo, Japan.
BMJ Open. 2017 Jan 27;7(1):e013036. doi: 10.1136/bmjopen-2016-013036.
Cardiac rehabilitation is underused and its quality in practice is unclear. A quality indicator is a measurable element of clinical practice performance. This study aimed to propose a set of quality indicators for cardiac rehabilitation following an acute coronary event in the Japanese population and conduct a small-size practice test to confirm feasibility and applicability of the indicators in real-world clinical practice.
This study used a modified Delphi technique (the RAND/UCLA appropriateness method), a consensus method which involves an evidence review, a face-to-face multidisciplinary panel meeting and repeated anonymous rating. Evidence to be reviewed included clinical practice guidelines available in English or Japanese and existing quality indicators. Performance of each indicator was assessed retrospectively using medical records at a university hospital in Japan.
10 professionals in cardiac rehabilitation for the consensus panel.
In the literature review, 23 clinical practice guidelines and 16 existing indicators were identified to generate potential indicators. Through the consensus-building process, a total of 30 indicators were assessed and finally 13 indicators were accepted. The practice test (n=39) revealed that 74% of patients underwent cardiac rehabilitation. Median performance of process measures was 93% (IQR 46-100%). 'Communication with the doctor who referred the patient to cardiac rehabilitation' and 'continuous participation in cardiac rehabilitation' had low performance (32% and 38%, respectively).
A modified Delphi technique identified a comprehensive set of quality indicators for cardiac rehabilitation. The single-site, small-size practice test confirmed that most of the proposed indicators were measurable in real-world clinical practice. However, some clinical processes which are not covered by national health insurance in Japan had low performance. Further studies will be needed to clarify and improve the quality of care in cardiac rehabilitation.
心脏康复的使用率较低，其实际质量尚不清楚。质量指标是临床实践表现的可衡量要素。本研究旨在提出一套针对日本人群急性冠状动脉事件后心脏康复的质量指标，并进行小规模实践测试，以确认这些指标在实际临床实践中的可行性和适用性。
本研究采用改良的德尔菲技术（兰德/加州大学洛杉矶分校适宜性方法），这是一种共识方法，包括证据审查、面对面的多学科小组会议和反复匿名评分。要审查的证据包括英文或日文的临床实践指南以及现有的质量指标。使用日本一家大学医院的病历对每个指标的表现进行回顾性评估。
10名心脏康复专业人员组成共识小组。
在文献综述中，确定了23份临床实践指南和16项现有指标以生成潜在指标。通过达成共识的过程，共评估了30项指标，最终接受了13项指标。实践测试（n = 39）显示，74%的患者接受了心脏康复。过程指标的中位表现为93%（四分位间距46 - 100%）。“与将患者转诊至心脏康复的医生沟通”和“持续参与心脏康复”的表现较低（分别为32%和38%）。
改良的德尔菲技术确定了一套全面的心脏康复质量指标。单中心、小规模的实践测试证实，大多数提议的指标在实际临床实践中是可衡量的。然而，日本国民健康保险未涵盖的一些临床过程表现较低。需要进一步研究以阐明并提高心脏康复的护理质量。
