在基层医疗就诊前提示血糖控制不佳的患者确定就诊重点：一项实用的聚类随机试验。
Prompting Patients with Poorly Controlled Diabetes to Identify Visit Priorities Before Primary Care Visits: a Pragmatic Cluster Randomized Trial.
机构信息
Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
Department of Medicine, Oakland Medical Center, Kaiser Permanente Northern California, Oakland, CA, USA.
出版信息
J Gen Intern Med. 2019 Jun;34(6):831-838. doi: 10.1007/s11606-018-4756-4. Epub 2019 Feb 11.
BACKGROUND
Most patients with diabetes do not meet all evidence-based goals of care, and many patients report poor communication and lack of involvement in decision-making during primary care visits.
OBJECTIVE
To test the hypothesis that a "Pre-Visit Prioritization" secure email message could improve visit communication and glycemic control among patients with type 2 diabetes.
DESIGN
We conducted a pragmatic, provider-randomized, multi-site clinical trial from March 2015 to October 2016 across 30 primary care practices within Kaiser Permanente Northern California (KPNC), a large integrated care delivery system.
PARTICIPANTS
Eligible patients had at least 1 year of KPNC membership, type 2 diabetes with most recently measured hemoglobin A1c (HbA1c) > = 8.0%, and were registered users of the KPNC online patient portal.
INTERVENTIONS
Patients in the intervention arm, upon booking an appointment, received a secure email through the KPNC online portal with a link to the EHR allowing them to submit their top one or two priorities prior to the visit. Control patients received usual care.
MAIN MEASURES
Glycemic control; change in HbA1c 6 and 12 months after the initial visit; patient-reported outcomes related to patient-provider communication and patient care experiences.
KEY RESULTS
During the study period, 1276 patients had at least one eligible visit. In post-visit surveys (n = 457), more intervention arm patients reported preparing questions for their visit (72% vs 63%, p = 0.048) and being given treatment choices to consider (81% vs 73%, p = 0.041). Patients in both arms had similar reductions in HbA1c over the 12-month study period (0.56% ± 1.45%), with no significant differences between arms.
CONCLUSIONS
A "light touch" email-based pre-visit intervention resulted in improved measures of visit interaction but did not significantly improve glycemic control relative to usual care. Improving diabetes clinical outcomes through more effective primary care visits may require more intensive approaches to patient visit preparation.
TRIAL REGISTRY
NCT02375932.
背景
大多数糖尿病患者无法达到所有基于证据的护理目标，许多患者在初级保健就诊时报告沟通不佳且缺乏参与决策的机会。
目的
检验“就诊前优先级排序”安全电子邮件能否改善 2 型糖尿病患者的就诊沟通和血糖控制。
设计
我们在 2015 年 3 月至 2016 年 10 月间，在 Kaiser Permanente Northern California（KPNC）的 30 个初级保健机构开展了一项实用、由医生主导、多地点的临床试验，KPNC 是一个大型综合医疗服务提供系统。
参与者
符合条件的患者至少在 KPNC 登记注册 1 年，患有 2 型糖尿病，且其最近的糖化血红蛋白（HbA1c）测量值≥8.0%，并注册了 KPNC 在线患者门户。
干预措施
干预组患者在预约就诊时，通过 KPNC 在线门户收到一封安全电子邮件，其中包含一个链接，可链接到电子病历，以便他们在就诊前提交自己的一到两个优先级事项。对照组患者接受常规护理。
主要观察指标
血糖控制；首次就诊后 6 个月和 12 个月时的 HbA1c 变化；与医患沟通和患者护理体验相关的患者报告结局。
主要结果
在研究期间，有 1276 名患者至少有一次符合条件的就诊。在就诊后调查中（n=457），干预组患者报告自己准备就诊问题的比例（72% vs. 63%，p=0.048）和收到治疗选择方案供其考虑的比例（81% vs. 73%，p=0.041）均更高。两组患者在 12 个月的研究期间内，HbA1c 均有相似程度的下降（0.56%±1.45%），两组间无显著差异。
结论
基于电子邮件的“轻触式”就诊前干预改善了就诊互动的评估指标，但与常规护理相比，对血糖控制无显著改善。通过更有效的初级保健就诊来改善糖尿病临床结局，可能需要采取更积极的患者就诊准备措施。
试验注册
NCT02375932。
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