1998和2003年间纵向观察研究英国全科医生提高医疗服务质量
2007/03/09
采用纵向队列研究评价1998和2003年间开展优质服务对3种主要慢性疾病，冠心病，哮喘和二型糖尿病的影响。调查了英国6个地区42个全科医师的医业，包括糖尿病，哮喘和冠心病，病例记录有1998年的2300例和2003年的1495例。主要观察指标为依据已经定义的循征医学评审标准来判断优质服务的效果。
结果显示1998和2003年间优质服务显著的提高了评审标准的最大可能分数，冠心病的患者从60.5% 上升至 78.1%（改变为17.6, 95% 的可信区间为13.9至21.4; P < 0.001），哮喘患者从60.1% 上升至 70.3%（改变为10.2, 95% 的可信区间为4.6至15.8; P= 0.001），糖尿病患者从70.4% 上升至 77.7%（改变为7.3, 95% 的可信区间为3.5至11.1; P= 0.001）。提示改善健康相关的几个指数发生重大变化，包括血清胆固醇浓度控制得到改善（<=5 mmol/l）的患者在冠心病中变化为从17.6%到61.4%,在糖尿病的患者中为从21.5%到52%, 血压<=150/90的冠心病患者由47.3%上升至72.2%，血压<=145/85的糖尿病患者由21.8%上升至35.8%。在糖尿病患者中血糖控制有小的改善，但没有显著性差异(HbA1c < 7.4%由37.9% 上升至39.7%)。其他一些数据也有明显的改善，包括冠心病患者的运动耐量，节食和控制体重的医嘱的执行情况；哮喘患者的戒烟意见的执行，峰流速和症状；糖尿病患者的肌酐，体重和糖化血红蛋白。在这5年里，对冠心病患者护理的进步更多发生于大的和富裕地区的医疗机构。
结论是1998和2003年间全民医疗服务体系系统的开展提高服务质量计划的实施显著的改善了以上3种疾病患者的生存状况，以冠心病患者的改善最为显著。在英国，2004年以后由于经济因素的刺激，全科医生可能会在接下来的几年提高医疗服务质量评分。
结果显示1998和2003年间优质服务显著的提高了评审标准的最大可能分数，冠心病的患者从60.5% 上升至 78.1%（改变为17.6, 95% 的可信区间为13.9至21.4; P < 0.001），哮喘患者从60.1% 上升至 70.3%（改变为10.2, 95% 的可信区间为4.6至15.8; P= 0.001），糖尿病患者从70.4% 上升至 77.7%（改变为7.3, 95% 的可信区间为3.5至11.1; P= 0.001）。提示改善健康相关的几个指数发生重大变化，包括血清胆固醇浓度控制得到改善（<=5 mmol/l）的患者在冠心病中变化为从17.6%到61.4%,在糖尿病的患者中为从21.5%到52%, 血压<=150/90的冠心病患者由47.3%上升至72.2%，血压<=145/85的糖尿病患者由21.8%上升至35.8%。在糖尿病患者中血糖控制有小的改善，但没有显著性差异(HbA1c < 7.4%由37.9% 上升至39.7%)。其他一些数据也有明显的改善，包括冠心病患者的运动耐量，节食和控制体重的医嘱的执行情况；哮喘患者的戒烟意见的执行，峰流速和症状；糖尿病患者的肌酐，体重和糖化血红蛋白。在这5年里，对冠心病患者护理的进步更多发生于大的和富裕地区的医疗机构。
结论是1998和2003年间全民医疗服务体系系统的开展提高服务质量计划的实施显著的改善了以上3种疾病患者的生存状况，以冠心病患者的改善最为显著。在英国，2004年以后由于经济因素的刺激，全科医生可能会在接下来的几年提高医疗服务质量评分。
（韩福军 广州呼吸疾病研究所 510120 摘译）
（ BMJ 2005,331:1097-1098）
Campbell SM, Roland MO, Middleton E, Reeves D.
Improvements in quality of clinical care in English general practice 1998-2003:
longitudinal observational study.
BMJ. 2005 Nov 12;331(7525):1097-8.
OBJECTIVE: To measure changes in quality of care for three major chronicdiseases (coronary heart disease, asthma, and type 2 diabetes) between 1998 and 2003.
DESIGN: Longitudinal cohort study.
SETTING: 42 general practices in six geographical areas of England (Avon, Bury/Rochdale, Enfield, Oldham, Somerset, South Essex).
PARTICIPANTS: Medical record data for 2300 patients with diabetes,asthma, or coronary heart disease in 1998, and 1495 patients in 2003.
MAIN OUTCOME MEASURE: Quality of care assessed against predefined evidence basedreview criteria.
RESULTS: Between 1998 and 2003, quality of care improved markedly in terms of maximum possible scores on the review criteria, from 60.5% to 78.1% for coronary heart disease (change = 17.6, 95% confidence interval 13.9 to 21.4; P < 0.001), 60.1% to 70.3% for asthma (10.2, 4.6 to 15.8; P = 0.001), and 70.4% to 77.7% for diabetes (7.3, 3.5 to 11.1; P = 0.001). Important changes occurred to several indicators potentially related to improved health outcomes. These included improved control of serum cholesterol (to < or = 5 mmol/l) from 17.6% to 61.4% in coronary heart disease and from 21.5% to 52% in diabetes and control of blood pressure to < or = 150/90 in coronary heart disease from 47.3% to 72.2% and to < or = 145/85 in diabetes from 21.8% to 35.8%. A small, non-significant improvement in glycaemic control occurred among diabetic patients (37.9% to 39.7% with HbA1c < 7.4%). Significant improvements also occurred in the recording of exercise capacity and diet and weight advice for patients with coronary heart disease; of smoking advice, peak flow, and symptoms for patients with asthma; and of creatinine, weight, and HbA(1c) for patients with diabetes. Over the five years, more improvement in coronary heart disease care occurred in large practices and practices in affluent areas.
CONCLUSIONS: Substantial improvements were seen in quality of care for the three conditions studied between 1998 and 2003, a time of systematic quality improvement initiatives in the NHS. The changes were most marked for coronary heart disease. English general practices could be expected to achieve high clinical quality scores in the initial year of a new contact, which provides financial incentives
for high quality care from 2004.
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变态反应性疾病的初级预防
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哮喘控制和健康状态的相关性：GOAL研究
