Horowitz C R, Goldberg H I, Martin D P, Wagner E H, Fihn S D, Christensen D B, Cheadle A D
Department of Health Policy, Mount Sinai Medical Center, New York, NY 10029, USA.
Jt Comm J Qual Improv. 1996 Nov;22(11):734-50. doi: 10.1016/s1070-3241(16)30279-6.
A multisite, randomized controlled trial was conducted from August 1994 through January 1996 to compare the impact of two strategies-academic detailing (AD) and continuous quality improvement (CQI) teams-on the implementation of national guidelines for the primary care of hypertension and depression.
Twelve small groups of providers at four clinics-two at Group Health Cooperative of Puget Sound (Seattle) and two at academic medical centers-were randomized in blocks along with their primary care patients to receive AD alone, AD plus CQI, or usual care. A detailing session conducted by a physician and two follow-up sessions conducted by a pharmacist lasted an average of 8-9 minutes. Each CQI team, which met, on average, 14 times in nine months, devised at least one intervention (for example, weight loss counseling for hypertensives by nurse practitioners).
The detailing endeavors differed greatly across organizations. Although all teams generally worked well together, organizational factors such as staff layoffs and reorganizations competed for the teams' attention. Team leaders differed in their ability to inspire members to "run with" ideas and to motivate personnel outside the team to implement interventions.
Surveys and semi-structured interviews suggest that both the AD and CQI interventions involved complex social interactions that resulted in varied implementation across the different organizations. Final analyses will need to focus on identifying factors associated with the relative success or failure of both clinical change techniques.
1994年8月至1996年1月进行了一项多地点随机对照试验，以比较两种策略——学术推广（AD）和持续质量改进（CQI）团队——对高血压和抑郁症初级护理国家指南实施的影响。
四个诊所的12个小医疗服务提供者小组——普吉特海湾集团健康合作社（西雅图）的两个小组和两个学术医疗中心的小组——与其初级护理患者一起按区随机分组，分别接受单纯学术推广、学术推广加持续质量改进或常规护理。由一名医生进行的推广会议和由一名药剂师进行的两次跟进会议平均持续8 - 9分钟。每个持续质量改进团队在九个月内平均会面14次，至少设计了一项干预措施（例如，执业护士为高血压患者提供减肥咨询）。
各组织的推广工作差异很大。尽管所有团队总体上合作良好，但诸如员工裁员和重组等组织因素分散了团队的注意力。团队领导者在激励成员“践行”想法以及促使团队外人员实施干预措施方面的能力各不相同。
调查和半结构化访谈表明，学术推广和持续质量改进干预措施都涉及复杂的社会互动，导致不同组织的实施情况各异。最终分析需要聚焦于确定与这两种临床变革技术的相对成败相关的因素。
