心血管疾病指南依从性：使用实践促进的 RCT。

Cardiovascular Disease Guideline Adherence: An RCT Using Practice Facilitation.

机构信息

Department of Policy and Public Health Management, College of Global Public Health, New York University, New York, New York.

University of California Berkeley, Department of Sociology, Berkeley, California.

出版信息

Am J Prev Med. 2020 May;58(5):683-690. doi: 10.1016/j.amepre.2019.12.013. Epub 2020 Feb 14.

DOI:10.1016/j.amepre.2019.12.013

PMID:32067871

Abstract

INTRODUCTION

Practice facilitation is a promising practice transformation strategy, but further examination of its effectiveness in improving adoption of guidelines for multiple cardiovascular disease risk factors is needed. The objective of the study is to determine whether practice facilitation is effective in increasing the proportion of patients meeting the Million Hearts ABCS outcomes: (A) aspirin when indicated, (B) blood pressure control, (C) cholesterol management, and (S) smoking screening and cessation intervention.

STUDY DESIGN

The study used a stepped-wedge cluster RCT design with 4 intervention waves. Data were extracted for 13 quarters between January 1, 2015 and March 31, 2018, which encompassed the control, intervention, and follow-up periods for all waves, and analyzed in 2019.

SETTING/PARTICIPANTS: A total of 257 small independent primary care practices in New York City were randomized into 1 of 4 waves.

INTERVENTION

The intervention consisted of practice facilitators conducting at least 13 practice visits over 1 year, focused on capacity building and implementing system and workflow changes to meet cardiovascular disease care guidelines.

MAIN OUTCOME MEASURES

The main outcomes were the Million Hearts' ABCS measures. Two additional measures were created: (1) proportion of tobacco users who received a cessation intervention (smokers counseled) and (2) a composite measure that assessed the proportion of patients meeting treatment targets for A, B, and C (ABC composite).

RESULTS

The S measure improved when comparing follow-up with the control period (incidence rate ratio=1.152, 95% CI=1.072, 1.238, p<0.001) and when comparing follow-up with intervention (incidence rate ratio=1.060, 95% CI=1.013, 1.109, p=0.007). Smokers counseled improved when comparing the intervention period with control (incidence rate ratio=1.121, 95% CI=1.037, 1.211, p=0.002).

CONCLUSIONS

Increasing the impact of practice facilitation programs that target multiple risk factors may require a longer, more intense intervention and greater attention to external policy and practice context.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02646488.

摘要

简介

实践促进是一种很有前途的实践转化策略，但需要进一步研究其在改善多种心血管疾病风险因素指南采用方面的有效性。本研究的目的是确定实践促进是否能有效增加符合“百万心脏 ABCS”结果的患者比例：(A)有指征时使用阿司匹林，(B)控制血压，(C)管理胆固醇，以及(S)筛查和干预吸烟。

研究设计

本研究采用了一个分阶段楔形集群 RCT 设计，共 4 个干预波。数据从 2015 年 1 月 1 日至 2018 年 3 月 31 日的 13 个季度中提取，涵盖了所有波的对照、干预和随访期，并于 2019 年进行分析。

地点/参与者：纽约市的 257 家小型独立初级保健诊所被随机分为 4 个波之一。

干预

干预措施包括由实践促进者进行至少 13 次实践访问，重点是能力建设和实施系统和工作流程的改变，以满足心血管疾病护理指南。

主要观察指标

主要结果是“百万心脏”的 ABCS 指标。另外创建了两个指标：(1)接受戒烟干预的吸烟者比例（吸烟者咨询）和(2)评估患者对 A、B 和 C 治疗目标达标比例的综合指标（ABC 综合）。

结果

与对照期相比，S 指标在随访期有所改善（发病率比=1.152，95%置信区间=1.072，1.238，p<0.001），与干预期相比也有所改善（发病率比=1.060，95%置信区间=1.013，1.109，p=0.007）。与对照期相比，吸烟者咨询在干预期有所改善（发病率比=1.121，95%置信区间=1.037，1.211，p=0.002）。