Feldstein Adrianne C, Smith David H, Perrin Nancy, Yang Xiuhai, Simon Steven R, Krall Michael, Sittig Dean F, Ditmer Diane, Platt Richard, Soumerai Stephen B
Center for Health Research, Kaiser Permanente, 3800 N. Interstate Avenue, Portland, OR 97227, USA.
Arch Intern Med. 2006 May 8;166(9):1009-15. doi: 10.1001/archinte.166.9.1009.
Computerized decision support reduces medication errors in inpatients, but limited evidence supports its effectiveness in reducing the coprescribing of interacting medications, especially in the outpatient setting. The usefulness of academic detailing to enhance the effectiveness of medication interaction alerts also is uncertain.
This study used an interrupted time series design. In a health maintenance organization with an electronic medical record, we evaluated the effectiveness of electronic medical record alerts and group academic detailing to reduce the coprescribing of warfarin and interacting medications. Participants were 239 primary care providers at 15 primary care clinics and 9910 patients taking warfarin. All 15 clinics received electronic medical record alerts for the coprescription of warfarin and 5 interacting medications: acetaminophen, nonsteroidal anti-inflammatory medications, fluconazole, metronidazole, and sulfamethoxazole. Seven clinics were randomly assigned to receive group academic detailing. The primary outcome, the interacting prescription rate (ie, the number of coprescriptions of warfarin-interacting medications per 10 000 warfarin users per month), was analyzed with segmented regression models, controlling for preintervention trends.
At baseline, nearly a third of patients had an interacting prescription. Coinciding with the alerts, there was an immediate and continued reduction in the warfarin-interacting medication prescription rate (from 3294.0 to 2804.2), resulting in a 14.9% relative reduction (95% confidence interval, -19.5 to -10.2) at 12 months. Group academic detailing did not enhance alert effectiveness.
This study, using a strong and quasi-experimental design in ambulatory care, found that medication interaction alerts modestly reduced the frequency of coprescribing of interacting medications. Additional efforts will be required to further reduce rates of inappropriate prescribing of warfarin with interacting drugs.
计算机化决策支持可减少住院患者的用药错误，但仅有有限的证据支持其在减少相互作用药物联合处方方面的有效性，尤其是在门诊环境中。学术指导对于提高药物相互作用警报有效性的作用也尚不确定。
本研究采用间断时间序列设计。在一个拥有电子病历的健康维护组织中，我们评估了电子病历警报和小组学术指导在减少华法林与相互作用药物联合处方方面的有效性。参与者为15家初级保健诊所的239名初级保健提供者以及9910名服用华法林的患者。所有15家诊所均收到了华法林与5种相互作用药物联合处方的电子病历警报，这5种药物为对乙酰氨基酚、非甾体抗炎药、氟康唑、甲硝唑和磺胺甲恶唑。7家诊所被随机分配接受小组学术指导。主要结局指标为相互作用处方率（即每月每10000名华法林使用者中，华法林与相互作用药物联合处方的数量），采用分段回归模型进行分析，并对干预前的趋势进行控制。
在基线时，近三分之一的患者有相互作用处方。与警报同时出现的是，华法林与相互作用药物的处方率立即且持续下降（从3294.0降至2804.2），在12个月时相对下降了14.9%（95%置信区间为-19.5至-10.2）。小组学术指导并未提高警报的有效性。
本研究在门诊护理中采用了强有力的准实验设计，发现药物相互作用警报适度降低了相互作用药物联合处方的频率。需要进一步努力以进一步降低华法林与相互作用药物不适当处方的发生率。
