推動明智抉擇於品質改善活動──來自台灣的經驗

The implementation of a Choosing Wisely®campaign on quality improvement --an experience from Taiwan

目標：減少低價值醫療是全球趨勢。本研究目的在從一個台灣醫學中心的角度來分享推動明智抉擇（Choose Wisely®, CW）於品質改進活動的經驗。方法：本研究選擇“在缺血性腦中風病人不常規使用預防性抗癲癇藥物”及“末期病人不要延後安寧緩和療護之介入時間”二項主題來推動明智抉擇，我們收集在中部某醫學中心推動明智抉擇前、中、後之數據。我們藉由臨床稽核檢核表之修正版本，運用於明智抉擇的推動過程。此外，我們也設立品質指標，定期召開會議進行回饋和檢討改善計劃。品質指標於“在缺血性腦中風病人不常規使用預防性抗癲癇藥物”部分包括：“缺血性腦中風病人住院中使用預防性抗癲癇藥物比率”及“缺血性腦中風病人出院開立預防性抗癲癇藥物比率”，而於“末期病人不要延後安寧緩和療護之介入時間”部分則包括：“癌症病人安寧緩和療護涵蓋率”及“癌症病人死亡前一週接受安寧緩和療護比率”。結果：從2020年1月至2022年12月，我們收集2,844名病人因缺血性腦中風入院。住院期間抗癲癇藥物使用比例從12.7%下降至9.4%（p = 0.001），出院後抗癲癇藥物使用比例從4.4%下降2.6%（p = 0.001）。在癌症病人中，有3,034名病人在研究期間死亡。上述病人接受安寧療護的比例從51.2%上升至68.0%（p < 0.01），而臨終1週前接受安寧療護的病人比例也從33.4%上升至41.0%（p < 0.01）。結論：藉由臨床稽核來推動明智抉擇活動能提高醫師對明智抉擇建議的遵循程度。

Objectives: Elimination of low-value healthcare is a global trend. We aimed to investigate the implementation of the Choosing Wisely®(CW) campaign on the improvements in quality from the perspective of a medical center of Taiwan. Methods: We chose“Don’t routinely use seizure prophylaxis in patients following ischemic stroke”and“Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment”as our topics for CW. We collected data before, during and after the launch of a CW campaign in the studied hospital. We modified the checklists used for the clinical audit to accommodate the process of adopting CW recommendations. In addition, quality indicators (QI) were set up and regular meetings were held for feedback and discussion of improvement plans. QIs for“Don’t routinely use seizure prophylaxis in patients following ischemic stroke”were“the proportion of prophylactic anticonvulsants in stroke hospitalized patients”and“the proportion of anticonvulsants after discharge in stroke hospitalized patients”. In addition, the QIs for“Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment”were“the coverage of hospice care in deceased patients due to cancer”and“the proportion of cancer patients receiving hospice care one week before they died”. Results: From Jan. 2020 till Dec. 2022, a total of 2,844 patients were admitted due to ischemic stroke. The proportion of prescriptions for anticonvulsants during hospitalization decreased from 12.7% to 9.4% (p = 0.001), while the proportion of anticonvulsant prescription after discharge decreased from 4.4% to 2.6% (p = 0.001). Among cancer patients, 3,034 patients died during the study period. The proportion of the abovementioned patients receiving hospice care increased from 51.2% to 68.0% (p < 0.01) while the proportion of patients receiving hospice care one week before dying also improved from 33.4% to 41.0% (p < 0.01). Conclusions: The CW campaign is useful for improving physicians’adherence to CW recommendation via clinical audit.