Effects of two guideline implementation strategies on patient outcomes in primary care - A cluster randomized controlled trial
Effects of two guideline implementation strategies on patient outcomes in primary care - A cluster randomized controlled trial
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DOI：
10.1097/brs.0b013e3181657e0d
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发表时间：
2008-03-01
期刊：
影响因子：
3
通讯作者：
Chenot, Jean F.
中科院分区：
文献类型：
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作者：
Becker, Annette;Leonhardt, Corinna;Chenot, Jean F.
研究设计。整群随机对照试验。为了改善下腰痛(LBP)患者的护理质量，德国在全科医生中实施了多方面的全科医生教育，并与执业护士的激励咨询相结合。与不干预相比，我们研究了对功能能力(主要结果)、疼痛天数、体力活动、生活质量或病假天数(次要结果)的影响。国际研究导致了德国LBP全科医生指南的制定。然而，最有效的实施战略仍存在疑问。虽然对护理过程的影响经常被观察到，但很少看到患者预后的变化。我们在118个普通诊所招募了1378名LBP患者，他们被随机分成3个研究部分中的一个：多方面指南实施(GI)，GI加上对实习护士进行激励咨询(MC)的培训，以及指南的邮寄传播(对照组，C)。在基线、6个月和12个月后收集数据(问卷调查和患者访谈)。多水平混合效应模型用于调整数据的聚集性和潜在的混杂因素。6个月后，干预组的功能能力较高，经整群调整后，MC组与对照组的平均差异为3.650(95%CI=0.320~6.979，P=0.032)，GI组与对照组的差异为2.652(95%CI=-0.704~6.007，P=0.120)。在每年的疼痛天数方面，干预效果更为明显，与对照组相比，6个月后(12个月后12天和9天后)平均减少16天(GI)至17天(MC)。结论。积极实施德国LBP指南在6个月内的结果略好于其邮寄传播的结果。当实习护士接受激励咨询培训时，效果会更明显。
Study Design. Cluster randomized controlled trial.Objective. To improve quality of care for patients with low back pain (LBP) a multifaceted general practitioner education alone and in combination with motivational counseling by practice nurses has been implemented in German general practices. We studied effects on functional capacity (main outcome), days in pain, physical activity, quality of life, or days of sick leave (secondary outcomes) compared with no intervention.Summary of Background Data. International research has lead to the development of the German LBP guideline for general practitioners. However, there is still doubt about the most effective implementation strategy. Although effects on process of care have been observed frequently, changes in patient outcomes are rarely seen.Methods. We recruited 1378 patients with LBP in 118 general practices, which were randomized to 1 of 3 study arms: a multifaceted guideline implementation (GI), GI plus training of practice nurses in motivational counseling (MC), and the postal dissemination of the guideline (controls, C). Data were collected (questionnaires and patient interviews) at baseline and after 6 and 12 months. Multilevel mixed effects modeling was used to adjust for clustering of data and potential confounders.Results. After 6 months, functional capacity was higher in the intervention groups with a cluster adjusted mean difference of 3.650 between the MC group and controls (95% CI = 0.320-6.979, P = 0.032) and 2.652 between the GI group and controls (95% CI = -0.704 to 6.007, P = 0.120). Intervention effects were more pronounced regarding days in pain per year with an average reduction of 16 (GI) to 17 days (MC) after 6 months (12 and 9 days after 12 months) compared with controls. Conclusion. Active implementation of the German LBP guideline results in slightly better outcomes during 6 months follow-up than its postal dissemination. Results are more distinct when practice nurses are trained in motivational counseling.