Lawler F H, Viviani N
Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, USA.
J Fam Pract. 1997 Apr;44(4):369-73.
Managed care organizations are focusing on how physicians manage their patients with diabetes mellitus as an indicator of physician compliance with clinical practice guidelines. Assessment of physician compliance with published guidelines may reveal areas of disagreement between physicians and guidelines or between physicians and patients and may show areas for potential improvement of care. Compliance with the diabetes care guidelines was assessed in our clinics to determine physician beliefs and performance and patients' accommodation of recommended practices.
We interviewed 295 patients with diabetes and surveyed 47 providers at an academic family practice center to assess practices and beliefs regarding the care of patients with diabetes. We also reviewed a 1-year compilation of billing and referral records for physician use of glycosylated hemoglobin (hemoglobin A1c) testing and referral of patients for eye examinations.
We found that physician beliefs and practices were divergent and that provider performance of these nationally recommended activities was low. More than 75% of providers said that they recommended hemoglobin A1c testing, but only about 50% of patients had a documented test in the billing system. When questioned, one third of the patients reported that their physicians recommended this test. Similarly, nearly all physicians stated that they recommended annual eye examinations, although only 43% of patients said that their primary care physician recommended this referral.
Physicians can and must improve intervention and patient education in the care of diabetic patients. Patient knowledge, motivation, and practice must be augmented by physician efforts. Lack of compliance with guidelines may indicate deficiencies in physician knowledge, implementation problems, lack of belief in guidelines, or problems in patient compliance. Attention should be directed to all these areas.
管理式医疗组织将关注医生如何管理糖尿病患者作为医生遵循临床实践指南的一个指标。评估医生对已发表指南的遵循情况可能会揭示医生与指南之间、医生与患者之间存在分歧的领域，并可能显示出护理方面潜在的改进领域。我们在诊所评估了对糖尿病护理指南的遵循情况，以确定医生的观念和表现以及患者对推荐做法的接受程度。
我们采访了295名糖尿病患者，并对一家学术性家庭医疗中心的47名医护人员进行了调查，以评估他们对糖尿病患者护理的做法和观念。我们还查阅了为期1年的计费和转诊记录汇编，以了解医生使用糖化血红蛋白（血红蛋白A1c）检测以及将患者转诊进行眼部检查的情况。
我们发现医生的观念和做法存在差异，而且这些全国推荐活动的医护人员表现较低。超过75%的医护人员表示他们推荐进行血红蛋白A1c检测，但计费系统中只有约50%的患者有该检测的记录。当被询问时，三分之一的患者报告称他们的医生推荐了这项检测。同样，几乎所有医生都表示他们推荐每年进行眼部检查，尽管只有43%的患者称他们的初级保健医生推荐了这种转诊。
医生能够且必须在糖尿病患者护理中改进干预措施和患者教育。医生的努力必须增强患者的知识、积极性和实践。对指南的不遵循可能表明医生知识不足、实施问题、对指南缺乏信心或患者依从性方面的问题。应关注所有这些领域。
