Reuben D B, Maly R C, Hirsch S H, Frank J C, Oakes A M, Siu A L, Hays R D
Multicampus Program in Geriatric Medicine and Gerontology, UCLA School of Medicine, Los Angeles, California 90095-1687, USA.
Am J Med. 1996 Apr;100(4):444-51. doi: 10.1016/s0002-9343(97)89521-6.
The goals of this study were to develop and determine the feasibility of interventions designed to increase both primary care physician implementation of and patient adherence to recommendations from ambulatory-based consultative comprehensive geriatric assessment (CGA), and to identify sociodemographic and intervention-related predictors of physician and patient adherence.
One hundred thirty-nine community-dwelling older persons who failed a screen for functional impairment, depressive symptoms, falls, or urinary incontinence received outpatient CGA consultation. These patients and the 115 physicians who provided primary care for them received one of three adherence interventions, each of which had a physician education component and a patient education and empowerment component. Recommendations were classified as physician-initiated or self-care and as "major" or "minor"; one was deemed "most important". Adherence rates were determined on the basis of face-to-face interviews with patients.
Based on 528 recommendations for 139 subjects, physician implementation of "most important" recommendations was 83% and of major recommendations was 78.5%. Patient adherence with physician-initiated "most important" and "major" recommendations were 81.8% and 78.8% respectively. In multivariate models, only the status of the recommendation of "most important" (odds ratio 2.4, 95% CI [confidence interval] 1.3 to 4.5) and health maintenance organization (HMO) status of the patient (odds ratio 2.1, 95% CI 1.3 to 3.6) remained significant in predicting physician implementation. The logistic model predicting patient adherence to physician-initiated recommendations included male patient gender (odds ratio 3.1, 95% CI 1.3 to 7.0), the status of the recommendation of "most important" (odds ratio 1.9, 95% CI 1.0 to 3.8), total number of recommendations (odds ratio 0.7, 95% CI 0.5 to 0.9), and total number of problems identified by CGA (odds ratio 1.8, 95% CI 1.2 to 2.7).
These findings indicate that relatively modest interventions strategies are feasible and lead to high levels of physician implementation of and patient adherence to physician-initiated CGA recommendations. These interventions appear to be particularly effective in HMO patients and for recommendations that were deemed to be "most important".
本研究的目标是开发并确定旨在提高基层医疗医生对基于门诊的咨询性综合老年评估（CGA）建议的实施率以及患者对这些建议的依从性的干预措施的可行性，并确定医生和患者依从性的社会人口统计学及与干预相关的预测因素。
139名社区居住的老年人在功能障碍、抑郁症状、跌倒或尿失禁筛查中未通过，接受了门诊CGA咨询。这些患者以及为他们提供初级保健的115名医生接受了三种依从性干预措施之一，每种干预措施都有一个医生教育部分以及一个患者教育与赋权部分。建议被分类为医生发起的或自我护理的，以及“主要”或“次要”的；其中一项被视为“最重要的”。依从率是根据对患者的面对面访谈确定的。
基于对139名受试者的528条建议，医生对“最重要的”建议的实施率为83%，对主要建议的实施率为78.5%。患者对医生发起的“最重要的”和“主要”建议的依从率分别为81.8%和78.8%。在多变量模型中，仅“最重要的”建议状态（比值比2.4，95%置信区间[CI]1.3至4.5）和患者的健康维护组织（HMO）状态（比值比2.1，95%CI 1.3至3.6）在预测医生实施方面仍具有显著性。预测患者对医生发起的建议的依从性的逻辑模型包括男性患者性别（比值比3.1，95%CI 1.3至7.0）、“最重要的”建议状态（比值比1.9，95%CI 1.0至3.8）、建议总数（比值比0.7，95%CI 0.5至0.9）以及CGA确定的问题总数（比值比1.8，95%CI 1.2至2.7）。
这些发现表明相对适度的干预策略是可行的，并且能使基层医疗医生对医生发起的CGA建议的实施率以及患者的依从率达到较高水平。这些干预措施在HMO患者以及被视为“最重要的”建议方面似乎特别有效。
