多组分综合护理的各个方面促进了替代临床结局的持续改善：系统评价和荟萃分析。
Aspects of Multicomponent Integrated Care Promote Sustained Improvement in Surrogate Clinical Outcomes: A Systematic Review and Meta-analysis.
机构信息
Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China.
Asia Diabetes Foundation, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China.
出版信息
Diabetes Care. 2018 Jun;41(6):1312-1320. doi: 10.2337/dc17-2010.
OBJECTIVE
The implementation of the Chronic Care Model (CCM) improves health care quality. We examined the sustained effectiveness of multicomponent integrated care in type 2 diabetes.
RESEARCH DESIGN AND METHODS
We searched PubMed and Ovid MEDLINE (January 2000-August 2016) and identified randomized controlled trials comprising two or more quality improvement strategies from two or more domains (health system, health care providers, or patients) lasting ≥12 months with one or more clinical outcomes. Two reviewers extracted data and appraised the reporting quality.
RESULTS
In a meta-analysis of 181 trials ( = 135,112), random-effects modeling revealed pooled mean differences in HbA of -0.28% (95% CI -0.35 to -0.21) (-3.1 mmol/mol [-3.9 to -2.3]), in systolic blood pressure (SBP) of -2.3 mmHg (-3.1 to -1.4), in diastolic blood pressure (DBP) of -1.1 mmHg (-1.5 to -0.6), and in LDL cholesterol (LDL-C) of -0.14 mmol/L (-0.21 to -0.07), with greater effects in patients with LDL-C ≥3.4 mmol/L (-0.31 vs. -0.10 mmol/L for <3.4 mmol/L; = 0.013), studies from Asia (HbA -0.51% vs. -0.23% for North America [-5.5 vs. -2.5 mmol/mol]; = 0.046), and studies lasting >12 months (SBP -3.4 vs. -1.4 mmHg, = 0.034; DBP -1.7 vs. -0.7 mmHg, = 0.047; LDL-C -0.21 vs. -0.07 mmol/L for 12-month studies, = 0.049). Patients with median age <60 years had greater HbA reduction (-0.35% vs. -0.18% for ≥60 years [-3.8 vs. -2.0 mmol/mol]; = 0.029). Team change, patient education/self-management, and improved patient-provider communication had the largest effect sizes (0.28-0.36% [3.0-3.9 mmol/mol]).
CONCLUSIONS
Despite the small effect size of multicomponent integrated care (in part attenuated by good background care), team-based care with better information flow may improve patient-provider communication and self-management in patients who are young, with suboptimal control, and in low-resource settings.
目的
实施慢性病管理模式（CCM）可提高医疗质量。我们研究了 2 型糖尿病多组分综合护理的持续有效性。
研究设计和方法
我们检索了 PubMed 和 Ovid MEDLINE（2000 年 1 月至 2016 年 8 月），并确定了持续时间至少 12 个月、包含 2 种或以上来自 2 个或以上领域（卫生系统、医疗保健提供者或患者）的质量改进策略、且至少有 1 项临床结局的随机对照试验。2 名审核员提取数据并评估报告质量。
结果
在对 181 项试验（n = 135112）的荟萃分析中，随机效应模型显示 HbA 的平均差值为 -0.28%（95%CI -0.35 至 -0.21）（-3.1 mmol/mol [-3.9 至 -2.3]），收缩压（SBP）为 -2.3 mmHg（-3.1 至 -1.4），舒张压（DBP）为 -1.1 mmHg（-1.5 至 -0.6），LDL 胆固醇（LDL-C）为 -0.14 mmol/L（-0.21 至 -0.07），LDL-C≥3.4 mmol/L 的患者效果更明显（-0.31 与 <3.4 mmol/L 的 -0.10 mmol/L； = 0.013），亚洲的研究（HbA -0.51% 与北美的 -0.23%[-5.5 与 -2.5 mmol/mol]； = 0.046）和持续时间>12 个月的研究（SBP -3.4 与 -1.4 mmHg， = 0.034；DBP -1.7 与 -0.7 mmHg， = 0.047；LDL-C -0.21 与 12 个月研究的 -0.07 mmol/L， = 0.049）。年龄中位数<60 岁的患者 HbA 降低更明显（-0.35% 与 ≥60 岁的 -0.18%[-3.8 与 -2.0 mmol/mol]； = 0.029）。团队变化、患者教育/自我管理和改善医患沟通的效果最大（0.28-0.36%[3.0-3.9 mmol/mol]）。
结论
尽管多组分综合护理的效果较小（部分原因是基础护理较好），但以团队为基础的护理可改善年轻、控制效果欠佳和资源匮乏环境下患者的医患沟通和自我管理。
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