Joerz 2010-3-5 11:50
醫師往往會錯過預防心血管疾病的機會
作者：Nancy A. Melville
出處：WebMD醫學新聞
February 23, 2010 (維吉尼亞州阿靈頓) — 根據發表於「美國預防醫學院年會：2010預防醫學」的北卡羅萊納州病患病歷回顧報告，醫師往往未能使用有效的策略來預防心血管疾病，即便是治療那些風險因素相當高的病患時。
研究共同作者之一、位於北卡羅萊納州健康與人類服務部的資訊、品質與評估主任Annette DuBard醫師表示，雖然美國約有三分之一病患死於心血管疾病，該國在過去廿年已經顯著降低死亡率，部份是因為科技、治療與心血管事件照護方面的進步，但是，預防方法依舊是關鍵。
DuBard醫師表示，預防方面有一些不錯的成效，包括減少抽菸以及更佳的血壓控制，但是，顯然還有許多未善加利用的改善機會。
該研究的目標是確認在一線照護中更佳的心血管風險管理機會，研究者對北卡羅萊納州一線照護機構中，診斷有高血壓的3,742名Medicaid保險對象進行回溯病歷評估。
研究發現顯示，多數病患至少有3年各接受一次的一線照護、最近一年內有5次以上的就診。雖然多數接受糖尿病(95%)、膽固醇(81.2%)、與抽菸(72.9%)之篩檢，96%的病患有至少一種可調控的風險因素，包括肥胖。
血壓與膽固醇值分別有52.9%和37.2%的病患在希望的目標之上，但是，血壓控制不佳者只有43.9%處方含3類以上抗高血壓藥物，最近一年只有44.3%病患接受密集治療。
只有73%的病患篩檢抽菸情況；其中45%是目前有抽菸者，而只有47%收到書面的戒菸建議、7%被處方有戒菸藥物。
對於低密度脂蛋白(LDL)膽固醇升高的病患，37%在治療目標之上，其中只有半數處方有任何的降血脂藥物，資料中，只有三分之一案例的LDL膽固醇值檢查結果在目標之上。
使用身體質量指數或腰圍篩檢肥胖的比率只有23%，根據摘錄的身高體重資料，52%的人口是肥胖的。
在已經知道有心血管疾病或Framingham量表風險大於10%的1,000名病患中，只有38%治療達到他們的血壓目標，50%的LDL膽固醇治療低於目標，只有35%的病患病歷中有註記建議使用阿斯匹靈。
研究者確認醫師們是否未能對血壓值略高於正常值的時候有所反應，但是他們發現，令人驚訝的是，即便是超高比率時的反應率仍低。
DuBard醫師向Medscape Public Health Prevention表示，即便是收縮壓高出40單位或者舒張壓超出目標20單位，我們發現以藥物介入的依舊不到半數。
她提出一個理論，一線照護不足的背後有多種因素，包括醫師惰性以及不確定他們實際處置的是什麼問題。
DuBard醫師表示，就文獻以及我個人的臨床直覺，我認為，我們知道醫師在診間往往無法確定病患的真正血壓。
醫師們也不知道病患對於所開立之處方的遵醫囑性，我們瞭解，有三分之一的病患對於血壓處方的順從性不到80%，所以，醫師們在無法確定現有處方是否有被妥善服用時，會猶豫要不要增加劑量。
另一個問題是，病患除了高血壓之外的其他病症，包括精神疾病、物質濫用、慢性疼痛等，這些都會使照護複雜化。
她指出，另一個因素是，有些醫師會在血壓或膽固醇值跟目標差不多時就感到滿意。
DuBard醫師表示，但是，最大的問題可能就是時間－診視時間限制15分鐘！
我真的認為最大的問題是15分鐘診視限制，特別是對這類病患而言，通常需要評估與溝通相當多問題，這個情況雖是次要，但也須加以克服。
她指出，底線是，取得照護只是健康照護的一部份，這些Medicaid保險對象可以從他們的一線照護提供者順利獲得照護與定期訪視，在許多案例中，不足的部份其實是心血管疾病的適當預防照護。
DuBard醫師表示，病患在現有體制中接受的一般照護顯然還不夠好，因此，如果我們不改變提供照護的方式，我們也不可能達到降低心血管風險的目標。
她建議一些改善方法：不再只有針對單一疾病，而應考量多種病症的模式，使用包括護士與藥師的團隊方法，還要注意每次就診之間的照護。
DuBard醫師表示，即使是最簡單的方法－例如處方阿斯匹靈治療，結果也會有大不同。她表示，已經有心臟病或者有風險的病患使用阿斯匹靈治療，預期可以在5年內避免掉600-1800例心血管事件。
哥倫比亞、密蘇里健康照護大學家庭與社區醫學副主任、教授、Michael LeFevre醫師表示，雖然該研究點出心血管疾病預防照護中的缺失，但是，這些實際上並不全然令人感到驚訝。
他表示，我對於這些資料並不特別感到驚訝，諷刺的是，許多證明有效的預防服務顯然是未被充分使用，有些少有科學證明的方式卻被經常利用。
他向Medscape Public Health Prevention表示，這個病歷回顧研究雖然有其限制，但是，它的結果並非意料之外。
LeFevre醫師認為，以病歷回顧作為唯一的測量方法有些問題，可能也有一些摘要中未列出之其他方法學上的問題，但是，這些研究結果與我們所知的預防服務提供方式相當一致。
本研究由北卡羅來納州醫療輔導小組進行且未接受任何外部資金，DuBard醫師與LeFevre醫師皆宣告沒有相關財務關係。
美國預防醫學院(AAPM)年會：2010預防醫學：摘要212702，發表於2010年2月19日。
Clinicians Commonly Miss Opportunities to Prevent Cardiovascular Disease
By Nancy A. Melville
Medscape Medical News
February 23, 2010 (Crystal City, Virginia) — Clinicians commonly fail to use effective strategies to prevent cardiovascular disease, even when treating patients with the highest risk factors, according to a chart review of North Carolina patients presented here at Preventive Medicine 2010: the Annual Meeting of the American College of Preventive Medicine.
Although 1 of 3 people in the United States die from cardiovascular disease, the country has made significant improvement in the past 2 decades in decreasing mortality rates. Part of the credit goes to advances in technology, treatment, and systems of care for a cardiovascular event, but preventive measures have also played a role, said Annette DuBard, MD, MPH, director of informatics, quality, and evaluation at the North Carolina Department of Health and Human Services in Chapel Hill, and a coauthor of the study.
"There have been big successes on the prevention end, including decreases in smoking and better blood pressure control, but it's clear that there's a lot of untapped opportunity for improvement," Dr. DuBard said.
The study's goal was to identify opportunities for better management of cardiovascular risk in the primary care setting. The researchers conducted a retrospective chart review looking at 3742 Medicaid recipients with diagnosed hypertension managed in a primary care setting in North Carolina.
The findings showed that most of the patients had been with a single primary care provider for at least 3 years and had 5 or more office visits during the previous year. Although most had been screened for diabetes (95%), cholesterol (81.2%), and tobacco use (72.9%), 96% of the patients had at least 1 modifiable risk factor, including obesity.
Blood pressure and cholesterol levels were above desired goals in 52.9% and 37.2% of patients, respectively, yet only 43.9% of those with uncontrolled blood pressure were prescribed 3 or more antihypertensive drug classes, and only 44.3% had had therapy intensified in the previous year.
Only 73% of patients had been screened for tobacco use; among the 45% who were current smokers, only 47% had any documented advice to quit and just 7% had been prescribed a smoking cessation agent.
For patients with documented low-density-lipoprotein (LDL) cholesterol elevations, 37% were above treatment goal, and only half of those had been prescribed any lipid-lowering medication. Documentation of provider response to the lab results for LDL cholesterol levels that were above goal was only seen in a third of cases.
Obesity screening using body mass index or waist circumference showed a rate of 23%. On the basis of extracted height and weight information, 52% of the population was obese.
In the subgroup of 1000 patients with known cardiovascular disease or a greater than 10% risk on the Framingham scale, only 38% had been treated to their blood pressure goal and 50% had LDL cholesterol treatment to below goal. Only 35% of the patients had any notation of a recommendation for aspirin use in the chart.
The researchers checked to see if physicians were perhaps failing to respond when blood pressure levels were only slightly above normal, but they found surprisingly low responses even when rates were high.
"Even at high levels of blood pressure that were more than 40 points systolic or 20 points diastolic above their goal, we still saw medication intervention less than half of the time," Dr. DuBard told Medscape Public Health Prevention.
She theorized that several factors could be behind the shortfalls in preventive care, including clinician inertia and uncertainty about what they're truly dealing with.
"From the literature and my own clinical instincts, I think we know that clinicians are often feeling uncertain about what a patient's true blood pressure is in the office setting," Dr. DuBard said.
"There's also clinician uncertainty about adherence to the regimen that has already been prescribed. We know that about a third of patients have a less than 80% adherence to blood pressure prescriptions, so clinicians are hesitant to increase the dose if they're not sure whether the existing drug regimen is being taken."
Another issue is the multiple comorbidities that patients with high blood pressure tend to have, including mental illness, substance abuse, and chronic pain, which can complicate care.
Another factor could be complacency on the part of clinicians when blood pressure and cholesterol levels are not quite at their goal but almost there, she added.
But the biggest culprit of all is likely the simple issue of time — the limitations of 15-minute visits, Dr. DuBard said.
"I really think the biggest issue is the demand of the 15-minute visit, especially in this kind of patient population, where there are usually a lot of issues to be addressed. The issues that are of lesser urgency are going to fall through the cracks."
"The bottom line is that access to care is clearly only part of the healthcare solution," she added. "These Medicaid patients had excellent access to care and regular visits with their primary care providers. What they didn't have, in many cases, was adequate preventive care for cardiovascular disease."
"The usual care being received by patients in the current system is clearly not good enough and it's unlikely we'll be able to meet our goals of cardiovascular risk reduction if we don't change the way we deliver care," Dr. DuBard said.
She suggested some solutions for improvement: moving beyond approaches that only focus on a single disease and instead considering multiple morbidity models, and using team-based approaches that involve nurses, pharmacies, and between-visit care, she suggested.
Even the simplest of measures — such as prescribing aspirin therapy — can make a big difference, Dr. DuBard said. "The use of aspirin therapy alone (among patients with existing or a risk of heart disease) could be expected to avert between 600 and 1800 cardiovascular events within 5 years," she said.
Although the study's findings offer a discouraging picture of the state of care in cardiovascular disease prevention, they are not, unfortunately, all that surprising, said Michael LeFevre, MD, professor and associate chair of family and community medicine at the University of Missouri Health Care in Columbia.
"I find nothing particularly surprising about the data," he said. "There is irony in the fact that many preventive services that have been shown to be effective are significantly underutilized, and many others with less science to support them are used more frequently."
"The fact that the study is a chart review represents a limitation, but its results are not unexpected," he told Medscape Public Health Prevention.
"There are problems with chart review as a sole means for measurement, and there may be other methodologic issues that are not apparent in the abstract, but the findings are certainly consistent with what we know about the delivery of preventive services," Dr. LeFevre asserted.
The study was conducted by the North Carolina Division of Medical Assistance and did not receive any external funding. Dr. DuBard and Dr. LeFevre have disclosed no relevant financial relationships.
Preventive Medicine 2010: the Annual Meeting of the American College of Preventive Medicine (ACPM): Abstract?212702. Presented February?19, 2010.