Division of Nephrology and.
Division of Nephrology, Stanford University School of Medicine, Palo Alto, California.
Clin J Am Soc Nephrol. 2017 Oct 6;12(10):1601-1614. doi: 10.2215/CJN.02490317. Epub 2017 Sep 6.
Quality improvement interventions have enhanced care for other chronic illnesses, but their effectiveness for patients with CKD is unknown. We sought to determine the effects of quality improvement strategies on clinical outcomes in adult patients with nondialysis-requiring CKD.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a systematic review of randomized trials, searching Medline and the Cochrane Effective Practice and Organization of Care database from January of 2003 to April of 2015. Eligible studies evaluated one or more of 11 prespecified quality improvement strategies, and prespecified study outcomes included at least one process of care measure, surrogate outcome, or hard clinical outcome. We used a random effects model to estimate the pooled risk ratio (RR; dichotomous data) or the mean difference (continuous data).
We reviewed 15 patient-level randomized trials (=3298 patients), and six cluster-randomized trials (=30,042 patients). Quality improvement strategies reduced dialysis incidence (seven trials; RR, 0.85; 95% confidence interval [95% CI], 0.74 to 0.97) and LDL cholesterol concentrations (four trials; mean difference, -17.6 mg/dl; 95% CI, -28.7 to -6.5), and increased the likelihood that patients received renin-angiotensin-aldosterone system inhibitors (nine trials; RR, 1.16; 95% CI, 1.06 to 1.27). We did not observe statistically significant effects on mortality, cardiovascular events, eGFR, glycated hemoglobin, and systolic or diastolic BP.
Quality improvement interventions yielded significant beneficial effects on three elements of CKD care. Estimates of the effectiveness of quality improvement strategies were limited by study number and adherence to quality improvement principles.
This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_09_06_CJASNPodcast_17_10.mp3.
质量改进干预措施已经提高了对其他慢性疾病的治疗效果，但它们对非透析慢性肾脏病（CKD）患者的疗效尚不清楚。我们旨在确定质量改进策略对非透析需求的 CKD 成年患者临床结局的影响。
设计、地点、参与者和测量：我们对随机试验进行了系统回顾，检索了 2003 年 1 月至 2015 年 4 月期间的 Medline 和 Cochrane 有效实践与医疗保健组织数据库。合格的研究评估了 11 种预设质量改进策略中的一种或多种，并且预设的研究结果包括至少一项护理过程测量、替代结果或临床硬终点。我们使用随机效应模型来估计汇总风险比（RR；二项数据）或平均差异（连续数据）。
我们回顾了 15 项患者水平的随机试验（=3298 名患者）和 6 项群组随机试验（=30042 名患者）。质量改进策略降低了透析发生率（7 项试验；RR，0.85；95%置信区间[95%CI]，0.74 至 0.97）和 LDL 胆固醇浓度（4 项试验；平均差异，-17.6mg/dl；95%CI，-28.7 至-6.5），并增加了患者接受肾素-血管紧张素-醛固酮系统抑制剂的可能性（9 项试验；RR，1.16；95%CI，1.06 至 1.27）。我们未观察到死亡率、心血管事件、eGFR、糖化血红蛋白和收缩压或舒张压的统计学显著影响。
质量改进干预措施对 CKD 治疗的三个方面产生了显著的有益效果。质量改进策略有效性的估计受到研究数量和对质量改进原则的遵守的限制。
本文包含一个播客，网址为 https://www.asn-online.org/media/podcast/CJASN/2017_09_06_CJASNPodcast_17_10.mp3。
