品質改善介入方式對氣喘小孩有效


  June 23, 2009 — 根據發表於6月小兒及青少年醫學檔案期刊的一篇系統性回顧結果,品質改善(QI)介入方式可改善氣喘小孩接受門診小兒氣喘照護的過程與結果。
  
  加州史丹佛大學的Dena M. Bravata醫師等人寫道,儘管有具實證基礎的小兒氣喘處置指引,在美國,最佳小兒氣喘照護實務與氣喘病患實際接受的照護之間仍有一大鴻溝。例如,雖然國家品質確保委員會發現,最近幾年接受適當氣喘藥物處方的病患增加(從2000年的63%增加為2003年的71% ),仍有許多氣喘小孩與其照護者沒有使用預防性藥物,或者不知道如何預防或治療氣喘發作。
  
  本回顧的目標為評估QI策略可改善氣喘小孩之照護過程與結果的證據,回顧者搜尋1966年1月至2006年4月間的Cochrane有效實務與照護小組組織資料庫、1966年1月至2006年5月間的Cochrane消費者與溝通小組資料庫,以及相關文章的參考文獻。
  
  納入回顧的標準包括,QI策略之隨機控制試驗、前後控制試驗或者間斷時間系列的英文研究,包括一種以上之小兒氣喘門診病患的QI策略。初級終點為呼吸量計與其他臨床結果、缺課天數、其他功能性結果、住院天數、其他健康服務的使用情況。
  
  符合納入規範的79篇研究中,69篇探討病患教育、自我監控、自我管理;13篇探討組織改變;7篇納入提供者教育。自我管理介入與每年增加10天無症狀天數有關(P = .02),且與每月減少缺課天數0.1天有關(P = .03)。
  
  提供者教育以及合併組織改變的介入方式,比較會觀察到藥物使用的改善。提供多種教育課程、比較長期,且合併使用各種教育類型的QI介入方式,與沒有這些特徵的方式相比,通常與改善病患結果有關。
  
  研究作者寫道,各種QI介入改善了氣喘小孩的照護過程與結果。使用類似的結果測量以及完整的介入方式描述,可以促進QI用於小兒氣喘照護的研究。
  
  本回顧的限制包括,使用QI策略之強度的異質性、研究設計品質、提供的特定資料。納入的研究中少數幾篇有提及經濟面的結果。
  
  研究作者結論表示,儘管有這些限制,文獻認為QI策略可以作為氣喘孩童之氣喘照護最佳實務與實際照護之間的橋樑。使用類似的結果測量以及完整的介入方式描述,可以促進QI用於小兒氣喘照護的研究。後續研究的關鍵目標為,分辨哪些策略可以有效降低急診與緊急照護、降低氣喘病患的整體花費、提升他們的生活品質。
  
  健康照護研究與品質局支持本研究。退伍軍人事務部部份支持其中兩名回顧作者。其他回顧作者宣告沒有相關財務關係。
  

Quality Improvement Interventions May Be Effective for Children With Asthma

By Laurie Barclay, MD
Medscape Medical News

June 23, 2009 — Quality improvement (QI) interventions improve the outcomes and processes of outpatient pediatric asthma care for children with asthma, according to the results of a systematic review reported in the June issue of the Archives of Pediatric & Adolescent Medicine.

"Despite the availability of evidence-based guidelines for the management of pediatric asthma, a significant gap remains between accepted best practices for pediatric asthma care and actual care delivered to asthmatic patients in the United States," write Dena M. Bravata, MD, MS, from Stanford University in Stanford, California, and colleagues. "For example, although the National Committee for Quality Assurance has found that more patients with asthma have been prescribed appropriate asthma mediations in recent years (71% in 2003 vs 63% in 2000), many children with asthma and their caregivers do not use preventive medications or know how to prevent or treat asthma attacks."

The goal of this review was to assess the evidence that QI strategies can improve delivery and outcomes of care for children with asthma. The reviewers searched Cochrane Effective Practice and Organisation of Care Group database from January 1966 to April 2006, MEDLINE from January 1966 to April 2006, and Cochrane Consumers and Communication Group database from January 1966 to May 2006, as well as reference lists of identified articles.

Inclusion criteria for the review were randomized controlled trials, controlled before-after trials, or interrupted time series trials of English-language QI evaluations that included 1 or more QI strategies for the treatment of pediatric outpatients with asthma. Primary endpoints were spirometric and other clinical outcomes, days absent from school and other functional outcomes, and hospital admissions and other use of health services.

Of 79 identified studies meeting inclusion criteria, 69 tested at least some component of patient education, self-monitoring, or self-management; 13 tested some component of organizational change; and 7 included provider education. Self-management interventions were associated with an increase of approximately 10 symptom-free days per year (P = .02) and with a decrease in school absenteeism by approximately 0.1 day per month (P = .03).

Improvements in medication use were more likely to be observed with interventions of provider education and those that incorporated organizational changes. QI interventions offering multiple educational sessions, longer duration, and combined use of various instructional modalities were more often associated with improved patient outcomes vs interventions that did not have these features.

"A variety of QI interventions improve the outcomes and processes of care for children with asthma," the study authors write. "Use of similar outcome measures and thorough descriptions of interventions would advance the study of QI for pediatric asthma care."

Limitations of this review include heterogeneity with respect to the rigor of the QI strategies used, study design quality, and specific data provided. Economic outcomes were reported by relatively few of the included studies.

"Despite these limitations, the literature suggests that QI strategies can begin to bridge the gap between best practices for asthma care and actual care delivered to children with asthma," the study authors conclude. "Use of similar outcome measures and thorough descriptions of interventions would advance the study of QI for asthma care. The key targets for future study are identifying those strategies that can effectively reduce emergency department and urgent care visits, reduce overall costs for patients with asthma, and increase their quality of life."

The Agency for Healthcare Research and Quality supported this study. Two of the review authors were supported in part by the Department of Veterans Affairs. The other review authors have disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med. 2009;163:572-581.

    
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