The Changing Face of Chronic Illness Management in Primary Care: A Qualitative Study of Underlying Influences and Unintended Outcomes
The Changing Face of Chronic Illness Management in Primary Care: A Qualitative Study of Underlying Influences and Unintended Outcomes
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DOI：
10.1370/afm.1380
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发表时间：
2012-09-01
影响因子：
4.4
通讯作者：
Brody, Howard
中科院分区：
文献类型：
--
作者：
Hunt, Linda M.;Kreiner, Meta;Brody, Howard
目的 最近，常见慢性疾病的诊断和药物管理急剧增加。利用初级保健诊所收集的定性数据，我们评估了这些趋势在临床护理中的表现。 方法 这项定性研究重点关注密歇根州 44 家初级保健诊所的 2 型糖尿病和高血压管理，基于对 58 名临床医生和 70 名患者的访谈，以及对 107 次临床咨询的观察。我们评估了临床医生的治疗策略和对影响治疗决策的因素的讨论，以及患者对治疗这些疾病的理解和经验。 结果 临床医生专注于帮助患者达到国家指南推荐的测试结果，大多数报告称每种情况结合使用 2 种或更多药物来达到目标。药物选择和管理是我们观察到的咨询的核心焦点。多重用药在患者中很常见，超过一半的患者服用 5 种或更多药物。患者访谈表明，对药物的严重依赖给患者的健康带来了挑战，包括财务成本和不良健康影响的经历。结论促进大量使用药物的因素包括较低的诊断和治疗阈值、临床医生审核和奖励系统以及处方级联，即开出更多药物来控制已开处方药物的影响。我们提出了一个概念模型，即逆效益定律，以深入了解药品营销工作对观察到的趋势的影响。我们提出有关限制制药行业对临床实践的影响的建议，以改善慢性病患者的福祉。
PURPOSE Recently, there has been dramatic increase in the diagnosis and pharmaceutical management of common chronic illnesses. Using qualitative data collected in primary care clinics, we assessed how these trends play out in clinical care.METHODS This qualitative study focused on management of type 2 diabetes and hypertension in 44 primary care clinics in Michigan and was based on interviews with 58 clinicians and 70 of their patients, and observations of 107 clinical consultations. We assessed clinicians' treatment strategies and discussions of factors influencing treatment decisions, and patients' understandings and experiences in managing these illnesses.RESULTS Clinicians focused on helping patients achieve test results recommended by national guidelines, and most reported combining 2 or more medications per condition to reach targets. Medication selection and management was the central focus of the consultations we observed. Polypharmacy was common among patients, with more than one-half taking 5 or more medications. Patient interviews indicated that heavy reliance on pharmaceuticals presents challenges to patient well-being, including financial costs and experiences of adverse health effects.CONCLUSIONS Factors promoting heavy use of pharmaceuticals include lower diagnostic and treatment thresholds, clinician-auditing and reward systems, and the prescribing cascade, whereby more medications are prescribed to control the effects of already-prescribed medications. We present a conceptual model, the inverse benefit law, to provide insight into the impact of pharmaceutical marketing efforts on the observed trends. We make recommendations about limiting the influence of the pharmaceutical industry on clinical practice, toward improving the well-being of patients with chronic illness.