Individualized Guidelines: The Potential for Increasing Quality and Reducing Costs
Individualized Guidelines: The Potential for Increasing Quality and Reducing Costs
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DOI：
10.7326/0003-4819-154-9-201105030-00008
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发表时间：
2011-05-03
影响因子：
39.2
通讯作者：
Morris, Macdonald
中科院分区：
文献类型：
--
作者：
Eddy, David M.;Adler, Joshua;Morris, Macdonald
背景：目前的指南侧重于特定的风险因素，并规定了将患者归入少数治疗组的标准。目标：在血压管理的背景下，比较当前指南和个性化指南(使用每个人的现成特征来计算预期的治疗风险降低，并按预期收益递减的顺序确定接受治疗的人)。设计：针对特定人的分析，纵向资料。地点：ARIC(社区动脉粥样硬化风险)研究。参与者：年龄在45岁至之间、既往无心血管疾病且目前未接受降压治疗的人群。干预：根据国家高血压预防、检测、评估和治疗联合委员会第七次报告(JNC7指南)的标准进行治疗；结果：与按随机护理治疗的患者相比，个体化指南可预防相同数量的心肌梗死和卒中，比JNC 7指南节省67%的费用，或可在相同成本下以与JNC 7指南相同的成本防止误诊和中风。个体化指南的优越性对关于成本、治疗效果、人群中心血管疾病风险水平或对工作流程影响的广泛假设不敏感。优势程度对用于对患者进行排名的方法的准确性及其跨度(可以计算所有感兴趣的结果的人群的比例)敏感。限制：在ARIC研究人群中，特定的结果适用于血压管理对心肌梗死和中风的影响。个体受益的计算方法需要风险因素、长期结果和治疗效果之间关系的定量证据。结论：使用个体化指南有助于提高护理质量，降低护理成本。
Background: Current guidelines focus on a particular risk factor and specify criteria for categorizing persons into a small number of treatment groups.Objective: To compare current guidelines with individualized guidelines (that use readily available characteristics from each person to calculate the risk reduction expected from treatment and to identify persons for treatment in ranked order of decreasing expected benefit), in the context of blood pressure management.Design: Analysis of person-specific, longitudinal data.Setting: The ARIC (Atherosclerosis Risk in Communities) Study.Participants: Persons aged 45 to 64 years without preexisting cardiovascular disease who currently do not receive antihypertensive treatment.Intervention: Treatment according to the criteria of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7 guidelines); individualized guidelines, or treatment in decreasing order of expected benefit; and random care, or treatment of persons selected at random.Measurements: Number of myocardial infarctions (MIs) and strokes and medical costs.Results: Compared with treating people according to random care, individualized guidelines could prevent the same number of MIs and strokes as JNC 7 guidelines at savings that are 67% greater than using JNC 7 guidelines, or it could prevent 43% more MIs and strokes for the same cost as treatment according to JNC 7 guidelines. The superiority of individualized guidelines was not sensitive to a wide range of assumptions about costs, treatment effectiveness, level of risk for cardiovascular disease in the population, or effects on workflow. The degree of superiority was sensitive to the accuracy of the method used to rank patients and to its span (the proportion of the population for whom all of the outcomes of interest can be calculated).Limitations: Specific results apply to the effects of blood pressure management on MI and stroke in the ARIC Study population. The methods for calculating individual benefits require quantitative evidence about the relationships among risk factors, long-term outcomes, and treatment effects.Conclusion: Use of individualized guidelines can help to increase the quality and reduce the cost of care.