Cardiovascular care guideline implementation in community health centers in Oregon: a mixed-methods analysis of real-world barriers and challenges.
Cardiovascular care guideline implementation in community health centers in Oregon: a mixed-methods analysis of real-world barriers and challenges.
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DOI：
10.1186/s12913-017-2194-3
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发表时间：
2017-04-05
影响因子：
2.8
通讯作者：
DeVoe J
中科院分区：
文献类型：
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作者：
Gold R;Bunce A;Cowburn S;Davis JV;Hollombe C;Nelson CA;Puro J;Muench J;Hill C;Jaworski V;Mercer M;Howard C;Perrin N;DeVoe J
在医疗机构之间传播有效的，基于指南的心脏保护护理质量改善策略可以产生巨大的好处，特别是在资源不足的情况下。了解促进或阻碍此类指南实施的各种因素可以提高脆弱患者的心血管护理质量和结果。我们试图确定影响社区卫生中心（CHCs）心脏保护护理指南的多层次因素，在一个成功的试验中，交叉设置实施有效的干预措施。定量分析使用多变量logistic回归来检查2011年6月至2014年5月期间10个CHC的患者面对面接触情况。在这些遭遇中，一个即时护理警报标记了患有糖尿病的成年人，他们在临床上有心脏保护药物的指征，但目前没有开处方。主要的结果指标是在两天内开出相关处方的比率。定性分析集中在CHC供应商和工作人员，并在不断的比较方法的指导下，用于提高对影响这种处方的因素的理解。推荐的处方发生在13-16%的患者遇到谁是这样的处方指示。当患者为男性、HbA 1c ≥7、既往曾开过类似药物、以糖尿病为主诉、看过中级医生或看过初级保健提供者时，这种处方的几率更高。当患者有保险，在过去一年中有≥1次门诊就诊，患有肾脏疾病或处方某些其他药物时，该几率较低。其他因素与每种药物类别的处方相关。定性结果支持和挑战的定量研究结果，说明重要的紧张局势涉及基于指南的处方。诊所工作人员强调，在面对相互竞争的优先事项和护理需求以及快速变化的指南的影响时，提供者-患者关系在指导处方决策方面的重要性。与指南一致性处方相关的各种因素说明了在CHCs中提供循证护理的复杂性。我们提出了解决基于指南的处方障碍的可能策略。本试验进行了回顾性登记。当前对照试验NCT 02299791。2014年11月10日登记的追溯。本文的在线版本（doi：10.1186/s12913-017-2194-3）包含补充材料，可供授权用户使用。
Spreading effective, guideline-based cardioprotective care quality improvement strategies between healthcare settings could yield great benefits, particularly in under-resourced contexts. Understanding the diverse factors facilitating or impeding such guideline implementation could improve cardiovascular care quality and outcomes for vulnerable patients. We sought to identify multi-level factors affecting uptake of cardioprotective care guidelines in community health centers (CHCs), within a successful trial of cross-setting implementation of an effective intervention. Quantitative analyses used multivariable logistic regression to examine in-person patient encounters at 10 CHCs from June 2011-May 2014. At these encounters, a point-of-care alert flagged adults with diabetes who were clinically indicated for, but not currently prescribed, cardioprotective medications. The main outcome measure was the rate of relevant prescriptions issued within two days of encounters. Qualitative analyses focused on CHC providers and staff, and, guided by the constant comparative method, were used to enhance understanding of the factors that influenced this prescribing. Recommended prescribing occurred at 13–16% of encounters with patients who were indicated for such prescribing. The odds of this prescribing were higher when the patient was male, had HbA1c ≥7, was previously prescribed a similar medication, gave diabetes as the chief complaint, saw a mid-level practitioner, or saw their primary care provider. The odds were lower when the patient was insured, had ≥1 clinic visits in the past year, had kidney disease, or was prescribed certain other medications. Additional factors were associated with prescribing of each medication class. Qualitative results both supported and challenged the quantitative findings, illustrating important tensions involved in guideline-based prescribing. Clinic staff stressed the importance of the provider-patient relationship in guiding prescribing decisions in the face of competing priorities and care needs, and the impact of rapidly changing guidelines. Diverse factors associated with guideline-concordant prescribing illuminate the complexity of delivering evidence-based care in CHCs. We present possible strategies for addressing barriers to guideline-based prescribing. This trial was registered retrospectively. Currently Controlled Trials NCT02299791. Retrospectively registered 10 November 2014. The online version of this article (doi:10.1186/s12913-017-2194-3) contains supplementary material, which is available to authorized users.