McAlister N H, Covvey H D, Tong C, Lee A, Wigle E D
Br Med J (Clin Res Ed). 1986 Sep 13;293(6548):670-4. doi: 10.1136/bmj.293.6548.670.
The hypothesis that general practitioners would obtain better outcomes for patients with hypertension using a computer than doctors not using a computer was tested. Sixty family physicians were randomised to two treatment strategies. "Test" physicians completed a data collection form after each visit from a patient with hypertension and mailed the forms to the test centre for processing. Computer feedback on management was mailed to the doctors. This encouraged doctors to apply the "stepped care" protocol, supplied charts of diastolic blood pressure v time, and ranked patients' diastolic blood pressures by percentile. Letters were mailed to patients to remind them of appointments. "Control" doctors filled out the same data collection forms as test physicians, but neither doctors nor patients received computer feedback. Physicians who used the computer saw more patients per practice than control doctors (test 50 patients, control 40). For all patients the length of follow up was significantly longer in test practices (test 199 days, control 167), and a smaller percentage dropped out of active treatment in test practices (test 37.5%, control 42.1%). For patients with "moderate" hypertension of a baseline diastolic pressure of greater than 104 mm Hg the mean score of the last recorded pressure was below the goal of 90 mm Hg in test practices (88.5 mm Hg), but it failed to reach this goal in control practices (93.3 mm Hg). A greater average reduction of diastolic pressure was achieved in test practices (test 21.7 mm Hg, control 16.7 mm Hg). Though patients with "moderate" hypertension were better controlled in test practices than in control practices, the patients in test practices visited their doctors less often (test 13.3 visits per patient-year, control 17.4 visits). Among patients with newly detected hypertension test practices achieved a greater reduction in diastolic pressure than control practices (test 15.1 mm Hg v control 11.3 mm Hg) and more sustained control of hypertension (test 323 days per patient-year with a diastolic pressure of 90 mm Hg or less v control 259 days).
研究对全科医生使用计算机为高血压患者治疗是否比不使用计算机的医生能取得更好疗效这一假设进行了验证。60名家庭医生被随机分为两种治疗策略组。“试验组”医生在每次诊治高血压患者后填写一份数据收集表，并将表格邮寄至试验中心进行处理。关于治疗管理的计算机反馈信息会邮寄给医生。这促使医生应用“阶梯式治疗”方案，提供舒张压随时间变化的图表，并按百分位数对患者的舒张压进行排名。还会给患者邮寄信件提醒他们预约就诊。“对照组”医生填写与试验组医生相同的数据收集表，但医生和患者均未收到计算机反馈信息。使用计算机的医生在每个诊所看诊的患者比对照组医生更多（试验组50名患者，对照组40名）。对所有患者而言，试验组的随访时间显著更长（试验组199天，对照组167天），试验组中退出积极治疗的患者比例更小（试验组37.5%，对照组42.1%）。对于基线舒张压大于104 mmHg的“中度”高血压患者，试验组最后记录的血压平均得分低于90 mmHg的目标值（88.5 mmHg），但对照组未达到该目标（93.3 mmHg）。试验组舒张压的平均降幅更大（试验组21.7 mmHg，对照组16.7 mmHg）。虽然“中度”高血压患者在试验组中的控制情况比对照组更好，但试验组患者看诊医生的频率更低（试验组每位患者每年13.3次就诊，对照组17.4次）。在新诊断的高血压患者中，试验组的舒张压降幅比对照组更大（试验组15.1 mmHg对对照组11.3 mmHg），且对高血压的控制更持久（试验组每位患者每年有323天舒张压在90 mmHg或更低，对照组为259天）。
