慢性病影响（初级保健项目中的慢性病早期检测与改善管理）：一项澳大利亚阶梯楔形整群随机试验。

Chronic disease IMPACT (chronic disease early detection and improved management in primary care project): An Australian stepped wedge cluster randomised trial.

作者信息

Jones Julia L, Simons Koen, Manski-Nankervis Jo-Anne, Lumsden Natalie G, Fernando Sanduni, de Courten Maximilian P, Cox Nicholas, Hamblin Peter Shane, Janus Edward D, Nelson Craig L

机构信息

Nephrology, Western Health, Melbourne, Australia.

Western Health Chronic Disease Alliance, Melbourne, Australia.

出版信息

Digit Health. 2023 Aug 14;9:20552076231194948. doi: 10.1177/20552076231194948. eCollection 2023 Jan-Dec.

DOI:10.1177/20552076231194948

PMID:37588155

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC10426307/

Abstract

BACKGROUND

Interrelated chronic vascular diseases (chronic kidney disease (CKD), type 2 diabetes (T2D) and cardiovascular disease (CVD)) are common with high morbidity and mortality. This study aimed to assess if an electronic-technology-based quality improvement intervention in primary care could improve detection and management of people with and at risk of these diseases.

METHODS

Stepped-wedge trial with practices randomised to commence intervention in one of five 16-week periods. Intervention included (1) electronic-technology tool extracting data from general practice electronic medical records and generating graphs and lists for audit; (2) education regarding chronic disease and the electronic-technology tool; (3) assistance with quality improvement audit plan development, benchmarking, monitoring and support. De-identified data analysis using R 3.5.1 conducted using Bayesian generalised linear mixed model with practice and time-specific random intercepts.

RESULTS

At baseline, eight included practices had 37,946 active patients (attending practice ≥3 times within 2 years) aged ≥18 years. Intervention was associated with increased OR (95% CI) for: kidney health checks (estimated glomerular filtration rate, urine albumin:creatinine ratio (uACR) and blood pressure) in those at risk 1.34 (1.26-1.42); coded diagnosis of CKD 1.18 (1.09-1.27); T2D diagnostic testing (fasting glucose or HbA1c) in those at risk 1.15 (1.08-1.23); uACR in patients with T2D 1.78 (1.56-2.05). Documented eye checks within recommended frequency in patients with T2D decreased 0.85 (0.77-0.96). There were no significant changes in other assessed variables.

CONCLUSIONS

This electronic-technology-based intervention in primary care has potential to help translate guidelines into practice but requires further refining to achieve widespread improvements across the interrelated chronic vascular diseases.

摘要

背景

慢性血管相关疾病（慢性肾脏病（CKD）、2型糖尿病（T2D）和心血管疾病（CVD））较为常见，发病率和死亡率都很高。本研究旨在评估基层医疗中基于电子技术的质量改进干预措施是否能改善这些疾病患者及高危人群的检测和管理。

方法

采用阶梯楔形试验，各医疗机构随机在五个16周时间段中的一个开始干预。干预措施包括：（1）电子技术工具，从基层医疗电子病历中提取数据并生成图表和清单以供审核；（2）关于慢性病和电子技术工具的教育；（3）协助制定质量改进审核计划、进行基准对比、监测和提供支持。使用R 3.5.1进行去识别数据分析，采用贝叶斯广义线性混合模型，设置医疗机构和特定时间的随机截距。

结果

基线时，纳入研究的8家医疗机构有37946名年龄≥18岁的活跃患者（2年内就诊≥3次）。干预与以下各项的比值比（OR）增加（95%置信区间）相关：高危人群的肾脏健康检查（估计肾小球滤过率、尿白蛋白：肌酐比值（uACR）和血压）为1.34（1.26 - 1.42）；CKD编码诊断为1.18（1.09 - 1.27）；高危人群的T2D诊断检测（空腹血糖或糖化血红蛋白）为1.15（1.08 - 1.23）；T2D患者的uACR为1.78（1.56 - 2.05）。T2D患者按推荐频率进行的眼底检查记录减少，为0.85（0.77 - 0.96）。其他评估变量无显著变化。