Gill J M, McClellan S A
Department of Family and Community Medicine, Christian Care Health Services, Wilmington, DE, USA.
Del Med J. 1998 Jan;70(1):11-6.
In 1993, the Family Medicine Center (FMC) at the Medical Center of Delaware (MCD) implemented a performance improvement (PI) program to increase rates of adult preventive care. This program included adoption of evidence-based preventive care guidelines, education of physicians and nurses regarding these guidelines, development of a flow sheet for tracking preventive care on office charts, and adoption of a policy of nurse review to alert physicians of which preventive services are due. The purpose of this study was to determine whether this PI program had a positive impact on the delivery of preventive care to female patients of the FMC.
A retrospective chart review was conducted for 280 female patients of the FMC ages 40-75. We determined the percentage of women who had received appropriate screening for breast and cervical cancer as well as appropriate immunizations, according to the guidelines of the US Preventive Services Task Force. These percentages were compared for the three year time periods before and after the PI program was implemented (July, 1990-June, 1993 and July, 1993-June, 1996).
Prior to implementation of the PI program, PAP smears were completed in 65.3 percent of women, mammograms in 70.3 percent, breast exams in 44.2 percent, flu shots in 29.6 percent and tetanus shots in 15.5 percent. After the program, these percentages increased for all preventive services, especially PAP smears which increased by 12 percent and tetanus shots which tripled. After the program, the rate of flu shots was still low at 37 percent.
After implementation of a PI program at the FMC, performance of preventive care for female patients improved for both cancer screening and immunizations. This improvement suggests that an office-based strategy can improve performance of preventive care, especially if it incorporates the active involvement of nursing staff. However, there is still room for further improvement, notably with completion of flu shots. These improvements will likely require additional strategies, such as computerized tracking systems and preventive care reminders to patients.
1993年，特拉华医疗中心（MCD）的家庭医学中心（FMC）实施了一项绩效改进（PI）计划，以提高成人预防保健的比例。该计划包括采用循证预防保健指南，对医生和护士进行这些指南的培训，制定用于在病历上跟踪预防保健的流程表，以及采用护士审核政策，以提醒医生哪些预防服务到期。本研究的目的是确定该PI计划是否对FMC女性患者的预防保健服务产生了积极影响。
对FMC的280名年龄在40 - 75岁的女性患者进行了回顾性病历审查。根据美国预防服务工作组的指南，我们确定了接受乳腺癌和宫颈癌适当筛查以及适当免疫接种的女性比例。对PI计划实施前后的三年时间段（1990年7月 - 1993年6月和1993年7月 - 1996年6月）的这些比例进行了比较。
在PI计划实施之前，65.3%的女性完成了巴氏涂片检查，70.3%完成了乳房X光检查，44.2%完成了乳房检查，29.6%接种了流感疫苗，15.5%接种了破伤风疫苗。该计划实施后，所有预防服务的这些比例都有所增加，尤其是巴氏涂片检查增加了12%，破伤风疫苗接种增加了两倍。该计划实施后，流感疫苗接种率仍然较低，为37%。
FMC实施PI计划后，女性患者的癌症筛查和免疫接种的预防保健表现有所改善。这一改善表明基于办公室的策略可以提高预防保健的表现，特别是如果它纳入了护理人员的积极参与。然而，仍有进一步改进的空间，尤其是在完成流感疫苗接种方面。这些改进可能需要额外的策略，如计算机化跟踪系统和向患者提供预防保健提醒。
