The association between quality of care and the intensity of diabetes disease management programs
The association between quality of care and the intensity of diabetes disease management programs
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DOI：
10.7326/0003-4819-145-2-200607180-00008
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发表时间：
2006-07-18
影响因子：
39.2
通讯作者：
Selby, Joe V.
中科院分区：
文献类型：
--
作者：
Mangione, Carol M.;Gerzoff, Robert B.;Selby, Joe V.
背景：虽然疾病管理计划得到了广泛实施，但对其有效性知之甚少。目的：确定医生小组的疾病管理是否与糖尿病护理过程、中间结果的控制或中间结果高于目标水平时的用药量相关。设计：横断面研究。背景：从将研究转化为糖尿病行动（87%）资助的 7 个健康计划中的 63 个医生小组中随机抽取患者，并从 4 个与个人医生签订合同的健康计划中随机抽取患者。 (13%)。患者：8661 名成人糖尿病患者完成了一项调查（2000-2001 年）并拥有病历数据。测量：医生小组和健康计划主管在调查中描述了其组织对医生提醒、绩效反馈和结构化护理管理的使用情况；他们的反应被用来确定疾病管理强度的衡量标准。目前的研究测量了 8 个护理过程，包括最近的血红蛋白 A 水平、收缩压、血清低密度脂蛋白胆固醇水平和几种药物使用指标。结果：增加使用 3 种疾病管理策略中的任何一种与视网膜筛查、肾病筛查、足部检查和血红蛋白 Aye 水平测量的调整率较高显着相关。血清脂质水平测试和流感疫苗接种与更多地使用结构化护理管理和绩效反馈相关。更多地使用表现反馈与足部检查率的增加相关（差异，5 个百分点 [95% Cl，1 至 8 个百分点]），更多地使用医生提醒与肾病筛查率的增加相关（差异，15 个百分点 [Cl，6 至 23 个百分点]）。没有策略与中间结果水平或药物管理水平相关。局限性：医生组不是从基于人群的列表中随机抽样的，疾病管理策略不是在组之间随机分配的。结论：疾病管理策略与更好的糖尿病护理过程相关，但与改善的中间结果或药物管理水平无关。更多地关注中间结果水平或药物管理水平的直接测量、反馈和报告可能会提高这些计划的有效性。
Background: Although disease management programs are widely implemented, little is known about their effectiveness.Objective: To determine whether disease management by physician groups is associated with diabetes care processes, control of intermediate outcomes, or the amount of medication used when intermediate outcomes are above target levels.Design: Cross-sectional study.Setting: Patients were randomly sampled from 63 physician groups nested in 7 health plans sponsored by Translating Research into Action for Diabetes (87%) and from 4 health plans with individual physician contracts (13%).Patients: 8661 adults with diabetes who completed a survey (2000-2001) and had medical record data.Measurements: Physician group and health plan directors described their organizations' use of physician reminders, performance feedback, and structured care management on a survey; their responses were used to determine measures of intensity of disease management. The current study measured 8 processes of care, including most recent hemoglobin A, level, systolic blood pressure, serum low-density lipoprotein cholesterol level, and several measures of medication use.Results: Increased use of any of 3 disease management strategies was significantly associated with higher adjusted rates of retinal screening, nephropathy screening, foot examinations, and measurement of hemoglobin Aye levels. Serum lipid level testing and influenza vaccine administration were associated with greater use of structured care management and performance feedback. Greater use of performance feedback correlated with an increased rate of foot examinations (difference, 5 percentage points [95% Cl, 1 to 8 percentage points]), and greater use of physician reminders was associated with an increased rate of nephropathy screening (difference, 15 percentage points [Cl, 6 to 23 percentage points]). No strategies were associated with intermediate outcome levels or level of medication management.Limitations: Physician groups were not randomly sampled from population-based listings, and disease management strategies were not randomly allocated across groups.Conclusions: Disease management strategies were associated with better processes of diabetes care but not with improved intermediate outcomes or level of medication management. A greater focus on direct measurement, feedback, and reporting of intermediate outcome levels or of level of medication management may enhance the effectiveness of these programs.