Implementation of Asthma Guidelines in Primary Care; Comparison of 4 approaches

在初级保健中实施哮喘指南；

• 批准号: 7924791
• 负责人: JAMES W. MOLD
• 金额: $ 86.04万
• 依托单位: UNIVERSITY OF OKLAHOMA HLTH SCIENCES CTR
• 依托单位国家: 美国
• 财政年份: 2009
• 资助国家: 美国
• 起止时间: 2009-09-01 至 2012-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7924791
• 关键词: Accident and Emergency department; Adoption; Adrenal Cortex Hormones; Age; Asthma; Breathing; Caring; Characteristics; Chronic Disease; Collaborations; Education; Effectiveness; Electronic Health Record; Feedback; Guidelines; Hospitalization; Intervention; Learning; Methods; Motivation; National Heart, Lung, and Blood Institute; Outcome; Outpatients; Ownership; Patients; Performance; Physicians; Prevention program; Primary Health Care; Process; Randomized Controlled Clinical Trials; Randomized Controlled Trials; Recommendation; Resources; System; Testing; United States; Visit; arm; compare effectiveness; evidence based guidelines; improved; public health relevance

DESCRIPTION (provided by applicant): Evidence-based guidelines for asthma management have been available to practicing physicians since 1991.1 Randomized controlled clinical trials have demonstrated that implementation of asthma guideline recommendations can significantly improve patient- level outcomes in asthmatics of all ages. However, in primary care practices, adoption and implementation of guideline recommendations continues to be inconsistent and uneven. Implementation of guidelines is challenging. Simple strategies like clinician education and toolkits alone are usually insufficient. Significant widespread and long- lasting improvements will require generalizable interventions that increase motivation and capacity for change and focus on changing processes of care. These interventions must be feasible and acceptable to primary care practices. Interventions like practice facilitation (PF), which add to rather than deplete practice resources, and local learning collaboratives (LLC), which produce competition and collaboration between practices have shown promise but require further study. We propose to conduct a 2 x 2 factorial (four-arm), mixed-method, cluster randomized controlled trial (RCT) of PF and LLC, provided individually and in combination, compared to provision of the asthma guidelines and a toolkit plus performance feedback (GTF) alone, to test the effectiveness and acceptability of these interventions for implementation of the most recent National Heart Lung and Blood Institute-endorsed asthma guideline in primary care practices. The specific aims are: Aim 1 (System-Level Effects): Evaluate the impacts of the proposed interventions -- GTF, PF, LLC, and the combination of PF and LLC -- on three key components of practice change, priority for the specific changes, change process capability (capacity to change), and care process content (the specific changes in process required for guideline implementation); Aim 2 (Guideline-Level Effects): Compare the effectiveness of four implementation interventions -- A) GTF, B) GTF plus PF, C) GTF plus LLC, and D) GTF, PF, and LLC -- on the practices' implementation of the six key messages of the NHLBI asthma guidelines; and Aim 3 (Moderators): Test the relationships between key practice characteristics -- use of electronic health records (Y/N), presence of mid-level clinicians (Y/N), practice ownership (clinicians own Y/N), and number of clinicians in the practice (#) -- guideline implementation. PUBLIC HEALTH RELEVANCE: Statement of Relevance If evidence-based guidelines for asthma management were implemented in primary care practices throughout the United States, we could reduce outpatient and emergency room visits by 56% and 91% respectively. This project will provide valuable information that will allow us to evaluate the effectiveness of four practice change strategies to improve asthma guideline implementation in primary care practices. If effective, the same strategies could be used to facilitate implementation of other chronic disease guidelines.

描述（由申请人提供）：自1991年以来，执业医师可获得哮喘管理的循证指南。1随机对照临床试验表明，实施哮喘指南建议可显著改善所有年龄段哮喘患者的患者水平结局。然而，在初级保健实践中，准则建议的通过和执行仍然不一致和不平衡。准则的执行具有挑战性。像临床医生教育和工具包这样的简单策略通常是不够的。显著、广泛和持久的改善将需要可推广的干预措施，以提高变革的动力和能力，并侧重于不断变化的护理过程。这些干预措施必须是可行的，并为初级保健实践所接受。干预措施，如实践促进（PF），增加而不是耗尽实践资源，和本地学习合作（LLC），产生的做法之间的竞争和合作已经显示出希望，但需要进一步研究。我们建议进行一个2x2阶乘（四组），混合方法，PF和LLC的随机对照试验（RCT），单独和联合提供，与哮喘指南和工具包加性能反馈（GTF）单独提供相比，测试这些干预措施的有效性和可接受性，以实施最新的国家心肺和血液研究所-在初级保健实践中认可哮喘指南。具体目标是：要求1（系统级效应）：评估拟议干预措施- GTF、PF、LLC以及PF和LLC的组合-对实践变革的三个关键组成部分、具体变革的优先级、变革过程能力的影响（改变能力）和护理过程内容（准则实施所需的具体流程变更）;目标2（指南级效应）：比较四种实施干预措施的有效性-- A）GTF，B）GTF加PF，C）GTF加LLC，D）GTF，PF，和有限责任公司-关于实践中NHLBI哮喘指南的六个关键信息的实施;以及目标3（主持人）：测试关键实践特征之间的关系-使用电子健康记录（Y/N），中级临床医生的存在（Y/N），实践所有权（临床医生拥有Y/N），以及实践中的临床医生数量（#）-指南实施。公共卫生相关性：相关性声明如果在美国的初级保健实践中实施基于证据的哮喘管理指南，我们可以分别减少56%和91%的门诊和急诊就诊。该项目将提供有价值的信息，使我们能够评估四种实践改变策略的有效性，以改善哮喘指南在初级保健实践中的实施。如果有效，同样的策略可以用来促进其他慢性病指南的实施。