Impart of a program to improve adherence to diabetes guidelines by primary care physicians
Impart of a program to improve adherence to diabetes guidelines by primary care physicians
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DOI：
10.2337/diacare.25.11.1946
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发表时间：
2002-11-01
期刊：
影响因子：
16.2
通讯作者：
Marrero, DG
中科院分区：
文献类型：
--
作者：
Kirkman, MS;Williams, SR;Marrero, DG
目的-先前的研究表明，初级保健医生(PCP)对糖尿病指南的遵守是次优的。我们试图确定印第安纳州一个农村县独立执业的PCP所提供的糖尿病护理状况，以及针对PCP、患者和医疗系统的多方面干预是否会改善对糖尿病指南的遵守情况。研究设计和方法-在该县七个PCP的图表上进行基线审计，以评估对糖尿病指南的遵守情况。在制定了当地共识指南和基线表现反馈后，以及在实施各种干预措施(练习辅助工具、医生详细说明、患者教育会议和实施计算机化的个人膳食计划)后，重复进行审计。结果-在任何干预之前，遵守指南的比率很低(足检15%，糖化血红蛋白(1c)测量20%，眼科检查23%，尿蛋白筛查33%，血脂谱44%，家庭血糖监测73%，血压测量78%)。在制定了当地共识指南和基线表现反馈一年后，血压测量(71vs.83%；P=0.002)、足部检查(19vs.42%；P<；0.001)、糖化血红蛋白(1c)测量(26vs.37%；P=0.012)和PCP眼科检查(38vs.46%；P=0.043)出现了显著改善；转诊至眼科专家方面出现了改善的趋势(25vs.33%；P=0.059)。经过第二年的多重干预，只有血压测量(70%比92%；P<；0.001)和足部检查(22%比47%；P<；0.001)仍然有显著改善；所有其他领域的比率都恢复到与基线没有区别的水平。结论-在忙碌的初级保健实践中，缺乏组织支持和计算机化的跟踪系统，使用传统的医生目标方法很难实现糖尿病护理的持续改善。
OBJECTIVES - Previous studies have shown that primary care physician (PCP) adherence to diabetes guidelines is suboptimal. We sought to determine the state of diabetes care given by independently practicing PCPs in a rural county in Indiana and whether a multifaceted intervention targeting PCPs, patients, and the health care system would improve adherence to diabetes guidelines.RESEARCH DESIGN AND METHODS - Baseline audits to assess adherence to diabetes guidelines were done on charts of the seven PCPs in the county. Audits were repeated after development of local consensus guidelines and feedback of baseline performance and after implementation of various interventions (practice aids, physician detailing, patient education sessions, and implementation of computerized individual meal planning).RESULTS - Before any intervention, rates of adherence to guidelines were low (15% for foot exams, 20% for HbA(1c) measurement, 23% for eye exam referrals, 33% for urine protein screening, 44% for lipid profiles, 73% for home glucose monitoring, and 78% for blood pressure measurements). One year after development of local consensus guidelines and feedback of baseline performance, significant improvements were seen in blood pressure measurements (71 vs. 83%; P = 0.002), foot exams (19 vs. 42%; P < 0.001), HbA(1c) measurements (26 vs. 37%; P = 0.012), and PCP eye exams (38 vs. 46%; P = 0.043); a trend toward improvement was seen in referral to eye specialists (25 vs. 33%; P = 0.059). After a second year of multiple interventions, only blood pressure measurements (70 vs. 92%; P < 0.001) and foot exams (22 vs. 47%; P < 0.001) remained significantly improved; all other areas returned to rates indistinguishable from baseline.CONCLUSIONS - In busy primary care practices lacking organizational support and computerized tracking systems, sustained improvements in diabetes care are difficult to attain using traditional physician-targeted approaches.