Coté Gregory A, Rice John P, Bulsiewicz William, Norvell John P, Christensen Keri, Bobb Anne, Postelnick Michael, Howden Colin W
Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
Am J Gastroenterol. 2008 May;103(5):1097-103. doi: 10.1111/j.1572-0241.2008.01907.x.
Gastrointestinal (GI) hemorrhage accounts for 200-400,000 admissions in the United States annually. Around 50% of patients with bleeding ulcer have used aspirin and/or nonsteroidal anti-inflammatory drugs (NSAIDs). Misoprostol and proton pump inhibitors (PPIs) may reduce NSAID-related upper GI tract complications in high-risk patients, but their targeted use may be suboptimal.
To determine the impact of physician education, a computer alert, or both on the targeted use of GI prophylaxis in high-risk patients discharged from hospital.
To target high-risk patients, we studied cardiology telemetry and coronary care unit (CCU) services. Every 4th wk, 8 different residents managed these patients. Over a 32-wk period, residents were assigned to one of the four 8-wk groups sequentially: Group I: control; Group II: physician education, consisting of a 10-min tutorial on risk factors for NSAID-related GI complications; Group III: computer alert; and Group IV: combination of tutorial and computer alert. We reviewed all patients admitted to these cardiology services during the study period. Exclusion criteria included discharge on no ulcerogenic medications, incomplete discharge data, and inpatient death. Patients readmitted during the study period were not re-counted. Medical records were reviewed for discharge medications, past medical history, demographics, admission and discharge diagnoses, hospital days, and the Charlson comorbidity index. Other indications for acid suppression were documented. A chi(2) test was used to determine independence among all four groups.
We enrolled 721 patients, of whom 120 (16.7%) were excluded. The remaining 601 were divided by physician intervention group and risk for NSAID-related GI complications. In total, 270 of 601 (45%) patients were discharged home on appropriate gastroprotection. The overall use of gastroprotection increased from 43 to 61% with the combination of an electronic alert and physician education (P < 0.001); among PPI-naïve patients, the rate increased from 26% to 55% (P < 0.0001). When stratified by known risk factors for GI complications of NSAIDs, the odds of receiving a gastroprotective prescription among PPI-naïve patients was 1.6 with education alone, 1.8 with electronic alert alone, and 2.9 with the combination (P < 0.0001).
The combination of a computer alert and brief physician education led to an increase in the use of gastroprotection among NSAID users at the time of discharge from hospital. This effect was most evident among high-risk, PPI-naïve patients. Combining physician education and a computer alert appears to have an additive effect.
在美国，胃肠道出血每年导致20万至40万人次住院。约50%的出血性溃疡患者使用过阿司匹林和/或非甾体抗炎药（NSAIDs）。米索前列醇和质子泵抑制剂（PPIs）可能会降低高危患者中与NSAIDs相关的上消化道并发症，但它们的靶向使用可能并不理想。
确定医生教育、计算机警报或两者对出院高危患者胃肠道预防措施靶向使用的影响。
为了确定高危患者，我们研究了心脏病遥测和冠心病监护病房（CCU）服务。每4周，8名不同的住院医师管理这些患者。在32周的时间里，住院医师被依次分配到四个8周组中的一组：第一组：对照组；第二组：医生教育，包括一个关于NSAIDs相关胃肠道并发症危险因素的10分钟教程；第三组：计算机警报；第四组：教程与计算机警报相结合。我们回顾了研究期间入住这些心脏病服务科室的所有患者。排除标准包括未使用致溃疡药物出院、出院数据不完整以及住院死亡。研究期间再次入院的患者不再重新计数。审查病历以获取出院用药、既往病史、人口统计学、入院和出院诊断、住院天数以及查尔森合并症指数。记录其他抑酸指征。使用卡方检验确定所有四组之间的独立性。
我们纳入了721例患者，其中120例（16.7%）被排除。其余601例按医生干预组和NSAIDs相关胃肠道并发症风险进行划分。总体而言，601例患者中有270例（45%）在出院时接受了适当的胃保护。电子警报和医生教育相结合使胃保护的总体使用率从43%提高到61%（P<0.001）；在未使用过PPI 的患者中，这一比例从26%提高到55%（P<0.0001）。当按已知的NSAIDs胃肠道并发症危险因素分层时，未使用过PPI的患者中，仅接受教育时接受胃保护处方的几率为1.6，仅使用电子警报时为1.8，两者结合时为2.9（P<0.0001）。
计算机警报与简短的医生教育相结合，使NSAIDs使用者出院时胃保护措施 的使用增加。这种效果在高危、未使用过PPI的患者中最为明显。医生教育与计算机警报相结合似乎具有累加效应。
