A randomized clinical trial of clinician feedback to improve quality of care for inner-city children with asthma
A randomized clinical trial of clinician feedback to improve quality of care for inner-city children with asthma
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DOI：
10.1542/peds.2005-2160
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发表时间：
2006-06-01
期刊：
影响因子：
8
通讯作者：
Mitchell, Herman E.
中科院分区：
文献类型：
--
作者：
Kattan, Meyer;Crain, Ellen F.;Mitchell, Herman E.
上下文障碍阻碍将哮喘治疗的建议转化为实践，特别是在哮喘发病率最高的市中心。本研究的目的是测试及时的患者反馈的有效性，以信件的形式提供最近的患者特异性症状，药物和卫生服务的使用，结合基于指南的建议，改变治疗方法，以提高市中心初级保健提供者的哮喘护理质量和由此产生的哮喘发病率。这是一项随机、对照临床试验，在7个市中心城区的医院和社区诊所以及私人诊所接受医疗保健的5至11岁中度至重度哮喘儿童（n = 937）中进行。每名儿童的看护人每两个月接到一次电话，以收集有关儿童哮喘的临床信息。在整整一年的时间里，干预组儿童的提供者每两个月收到一封基于这些电话的计算机生成的信件，总结了儿童的哮喘症状、健康服务使用情况和药物使用情况，并提出了相应的建议，以加强或减少药物治疗。我们测量了计划就诊的数量和比例，这些就诊导致药物治疗、哮喘症状（2周回忆）和医疗保健使用（2个月回忆）的增加。在这一人群中，只有一小部分症状需要增加药物治疗的儿童实际上进行了定期访视，以重新评估他们的哮喘治疗。然而，在收到升级信件后的2个月内，干预组中17.1%的信件随后进行了计划访视，而具有可比临床症状的对照组儿童的计划访视率为12.3%。干预组中46.0%的这些访视后，哮喘药物治疗增加，而对照组为35.6%，当哮喘症状需要增加治疗时，干预儿童的药物变化发生得更早。在12个月的研究期间，在任何时候增加药物治疗的儿童中，干预组的症状天数减少了22.1%，缺课天数减少了37.9%。意向性治疗分析显示，在干预年内，症状天数没有差异，但与对照组相比，干预组的活动受限天数减少，急诊就诊次数显著减少。这24%的急诊就诊率下降导致干预措施在第一年就节省了成本。对市中心提供者的患者特定反馈增加了计划的哮喘就诊，增加了哮喘就诊，其中在临床指征时加强了药物治疗，并减少了急诊室就诊。
CONTEXT. Barriers impede translating recommendations for asthma treatment into practice, particularly in inner cities where asthma morbidity is highest.METHODS. The purpose of this study was to test the effectiveness of timely patient feedback in the form of a letter providing recent patient-specific symptoms, medication, and health service use combined with guideline-based recommendations for changes in therapy on improving the quality of asthma care by inner-city primary care providers and on resultant asthma morbidity. This was a randomized, controlled clinical trial in 5- to 11-year-old children (n = 937) with moderate to severe asthma receiving health care in hospital- and community-based clinics and private practices in 7 inner-city urban areas. The caretaker of each child received a bimonthly telephone call to collect clinical information about the child's asthma. For a full year, the providers of intervention group children received bimonthly computer-generated letters based on these calls summarizing the child's asthma symptoms, health service use, and medication use with a corresponding recommendation to step up or step down medications. We measured the number and proportion of scheduled visits resulting in stepping up of medications, asthma symptoms (2-week recall), and health care use (2-month recall).RESULTS. In this population, only a modest proportion of children whose symptoms warranted a medication increase actually had a scheduled visit to reevaluate their asthma treatment. However, in the 2-month interval after receipt of a step-up letter, 17.1% of the letters were followed by scheduled visits in the intervention group compared with scheduled visits 12.3% of the time by the control children with comparable clinical symptoms. Asthma medications were stepped up when indicated after 46.0% of these visits in the intervention group compared with 35.6% in the control group, and when asthma symptoms warranted a step up in therapy, medication changes occurred earlier among the intervention children. Among children whose medications were stepped up at any time during the 12-month study period, those in the intervention group experienced 22.1% fewer symptom days and 37.9% fewer school days missed. The intention-to-treat analysis showed no difference over the intervention year in the number of symptom days, yet there was a trend toward fewer days of limited activity and a significant decrease in emergency department visits by the intervention group compared with controls. This 24% drop in emergency department visits resulted in an intervention that was cost saving in its first year.CONCLUSIONS. Patient-specific feedback to inner-city providers increased scheduled asthma visits, increased asthma visits in which medications were stepped up when clinically indicated, and reduced emergency department visits.