改善参与医疗辅助计划的少数族裔儿童哮喘控制：提供实践再设计支持以建立长期治疗模式
2010/11/04
摘要
背景：哮喘是儿童主要的慢性疾病，美国有620万儿童患有哮喘（8.5%）。尽管在哮喘研究和治疗上已经取得了很大进展，但许多儿童仍然未得到恰当的药物治疗来控制哮喘，而且过分依赖于哮喘缓解药物，以及缺少系统性随访护理。对于市中心贫民区儿童和少数族裔儿童，该状况更差。这些儿童具有很高的哮喘未控制率、较严重的哮喘及较差的哮喘转归。国家哮喘教育和预防项目指南推荐采用多重、慢性治疗方法。
目的：作者评价实践再设计和计算机化提供者反馈系统在改善实践者对国家哮喘教育和预防项目指南（NAEPP）依赖性及在哮喘转归中的有效性。患者为来自4个联邦医疗中心（FQHC）的295名贫困的少数民族儿童。
方法：本研究为非随机、两分组（干预组和对照组）、两相试验。对所有研究点提供再设计支持，以采用结构式随访表进行季度哮喘随访、让社区医务人员便于外展服务和随访、提供基于网络的疾病注册服务便于追踪和制定计划，同事提供一套教育包。向干预点提供其他基于网络的、计算机化的、患者特异性提供者反馈系统，该系统能产生基于指南的用药评价提示。
结果：Logistic回归结果显示，在I期注册期，本反馈系统接触后干预点提供者基于指南开具适当药物的可能性是对照点提供者的2倍以上（expB = 2.351, CI = 1.315-4.204）。在II期试验（注册后随访期）中，采用等级线性模型（HLMs）和潜在生长曲线进行分析，结果显示，4次随访中每次哮喘控制平均改善0.19 (SE = 0.05，约11%的标准误)，干预点改善更为明显。这些结果显示，在儿童长期治疗模型指导下的实践再设计支持能改善提供者对治疗指南的依从性和患者的哮喘控制。
结论：与单独基础实践再设计支持相比，给提供者增加患者特异性反馈，使其能更为快速地选择指南推荐方案，能更好地改善患者的哮喘控制。
（陈欣 审校）
J Asthma. 2010 Sep;47(7):718-727.
Improving pediatric asthma control among minority children participating in medicaid: providing practice redesign support to deliver a chronic care model.
Fifield J, McQuillan J, Martin-Peele M, Nazarov V, Apter AJ, Babor T, Burleson J, Cushman R, Hepworth J, Jackson E, Reisine S, Sheehan J, Twiggs J.
Department of Family Medicine, University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT 06030, USA. fifield@nso1.uchc.edu
Abstract
BACKGROUND: Asthma, a leading chronic disease of children, currently affects about 6.2 million (8.5%) children in the United States. Despite advances in asthma research and availability of increasingly effective therapy, many children do not receive appropriate medications to control the disease, have over-reliance on reliever medication, and lack systematic follow-up care. The situation is even worse for poor inner-city and minority children who have significantly worse asthma rates, severity, and outcomes. National Asthma Education and Prevention Program Guidelines recommend a multimodal, chronic care approach.
OBJECTIVE: The authors assessed the effectiveness of practice redesign and computerized provider feedback in improving both practitioner adherence to National Asthma Education and Prevention Program Guidelines (NAEPP), and patient outcomes in 295 poor minority children across four Federally Qualified Health Centers (FQHC).
METHODS: In a nonrandomized, two-group (intervention versus comparison), two-phase trial, all sites were provided redesign support to provide quarterly well-asthma visits using structured visit forms, community health workers for outreach and follow-up, a Web-based disease registry for tracking and scheduling, and a provider education package. Intervention sites were given an additional Web-based, computerized patient-specific provider feedback system that produced a guideline-driven medication assessment prompt.
RESULTS: Logistic regression results showed that providers at intervention sites were more than twice as likely on average to prescribe guideline-appropriate medications after exposure to our feedback system during the Phase I enrollment period than providers at comparison sites (exp(B) = 2.351, confidence interval [CI] = 1.315-4.204). In Phase II (the post-enrollment visit period), hierarchical linear models (HLMs) and latent growth curves were used to show that asthma control improved significantly by .19 (SE = .05) on average for each of the remaining four visits (about 11% of a standard deviation), and improved even more for patients at intervention sites. These results show that implementation of practice redesign support guided by a pediatric chronic care model can improve provider adherence to treatment guidelines as well as patients’ asthma control.
CONCLUSIONS: The addition of patient-specific feedback for providers results in quicker adoption of guideline recommendations and potentially greater improvements in asthma control compared to the basic practice redesign support alone.
J Asthma. 2010 Sep;47(7):718-27.
背景：哮喘是儿童主要的慢性疾病，美国有620万儿童患有哮喘（8.5%）。尽管在哮喘研究和治疗上已经取得了很大进展，但许多儿童仍然未得到恰当的药物治疗来控制哮喘，而且过分依赖于哮喘缓解药物，以及缺少系统性随访护理。对于市中心贫民区儿童和少数族裔儿童，该状况更差。这些儿童具有很高的哮喘未控制率、较严重的哮喘及较差的哮喘转归。国家哮喘教育和预防项目指南推荐采用多重、慢性治疗方法。
目的：作者评价实践再设计和计算机化提供者反馈系统在改善实践者对国家哮喘教育和预防项目指南（NAEPP）依赖性及在哮喘转归中的有效性。患者为来自4个联邦医疗中心（FQHC）的295名贫困的少数民族儿童。
方法：本研究为非随机、两分组（干预组和对照组）、两相试验。对所有研究点提供再设计支持，以采用结构式随访表进行季度哮喘随访、让社区医务人员便于外展服务和随访、提供基于网络的疾病注册服务便于追踪和制定计划，同事提供一套教育包。向干预点提供其他基于网络的、计算机化的、患者特异性提供者反馈系统，该系统能产生基于指南的用药评价提示。
结果：Logistic回归结果显示，在I期注册期，本反馈系统接触后干预点提供者基于指南开具适当药物的可能性是对照点提供者的2倍以上（expB = 2.351, CI = 1.315-4.204）。在II期试验（注册后随访期）中，采用等级线性模型（HLMs）和潜在生长曲线进行分析，结果显示，4次随访中每次哮喘控制平均改善0.19 (SE = 0.05，约11%的标准误)，干预点改善更为明显。这些结果显示，在儿童长期治疗模型指导下的实践再设计支持能改善提供者对治疗指南的依从性和患者的哮喘控制。
结论：与单独基础实践再设计支持相比，给提供者增加患者特异性反馈，使其能更为快速地选择指南推荐方案，能更好地改善患者的哮喘控制。
（陈欣 审校）
J Asthma. 2010 Sep;47(7):718-727.
Improving pediatric asthma control among minority children participating in medicaid: providing practice redesign support to deliver a chronic care model.
Fifield J, McQuillan J, Martin-Peele M, Nazarov V, Apter AJ, Babor T, Burleson J, Cushman R, Hepworth J, Jackson E, Reisine S, Sheehan J, Twiggs J.
Department of Family Medicine, University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT 06030, USA. fifield@nso1.uchc.edu
Abstract
BACKGROUND: Asthma, a leading chronic disease of children, currently affects about 6.2 million (8.5%) children in the United States. Despite advances in asthma research and availability of increasingly effective therapy, many children do not receive appropriate medications to control the disease, have over-reliance on reliever medication, and lack systematic follow-up care. The situation is even worse for poor inner-city and minority children who have significantly worse asthma rates, severity, and outcomes. National Asthma Education and Prevention Program Guidelines recommend a multimodal, chronic care approach.
OBJECTIVE: The authors assessed the effectiveness of practice redesign and computerized provider feedback in improving both practitioner adherence to National Asthma Education and Prevention Program Guidelines (NAEPP), and patient outcomes in 295 poor minority children across four Federally Qualified Health Centers (FQHC).
METHODS: In a nonrandomized, two-group (intervention versus comparison), two-phase trial, all sites were provided redesign support to provide quarterly well-asthma visits using structured visit forms, community health workers for outreach and follow-up, a Web-based disease registry for tracking and scheduling, and a provider education package. Intervention sites were given an additional Web-based, computerized patient-specific provider feedback system that produced a guideline-driven medication assessment prompt.
RESULTS: Logistic regression results showed that providers at intervention sites were more than twice as likely on average to prescribe guideline-appropriate medications after exposure to our feedback system during the Phase I enrollment period than providers at comparison sites (exp(B) = 2.351, confidence interval [CI] = 1.315-4.204). In Phase II (the post-enrollment visit period), hierarchical linear models (HLMs) and latent growth curves were used to show that asthma control improved significantly by .19 (SE = .05) on average for each of the remaining four visits (about 11% of a standard deviation), and improved even more for patients at intervention sites. These results show that implementation of practice redesign support guided by a pediatric chronic care model can improve provider adherence to treatment guidelines as well as patients’ asthma control.
CONCLUSIONS: The addition of patient-specific feedback for providers results in quicker adoption of guideline recommendations and potentially greater improvements in asthma control compared to the basic practice redesign support alone.
J Asthma. 2010 Sep;47(7):718-27.
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