Delaware Valley Outcomes Research, Newark, DE, USA.
Ann Fam Med. 2011 Jan-Feb;9(1):22-30. doi: 10.1370/afm.1172.
Electronic health records (EHRs) with clinical decision support hold promise for improving quality of care, but their impact on management of chronic conditions has been mixed. This study examined the impact of EHR-based clinical decision support on adherence to guidelines for reducing gastrointestinal complications in primary care patients on nonsteroidal anti-inflammatory drugs (NSAIDs).
This randomized controlled trial was conducted in a national network of primary care offices using an EHR and focused on patients taking traditional NSAIDs who had factors associated with a high risk for gastrointestinal complications (a history of peptic ulcer disease; concomitant use of anticoagulants, anti-platelet medications [including aspirin], or corticosteroids; or an age of 75 years or older). The offices were randomized to receive EHR-based guidelines and alerts for high-risk patients on NSAIDs, or usual care. The primary outcome was the proportion of patients who received guideline-concordant care during the 1-year study period (June 2007-June 2008), defined as having their traditional NSAID discontinued (including a switch to a lower-risk medication), having a gastroprotective medication coprescribed, or both.
Participants included 27 offices with 119 clinicians and 5,234 high-risk patients. Intervention patients were more likely than usual care patients to receive guideline-concordant care (25.4% vs 22.4%, adjusted odds ratio = 1.19; 95% confidence interval, 1.01-1.42). For individual high-risk groups, patients on low-dose aspirin were more likely to receive guideline-concordant care with the intervention vs usual care (25.0% vs 20.8%, adjusted odds ratio = 1.30; 95% confidence interval, 1.04-1.62), but there was no significant difference for patients in other high-risk groups.
This study showed only a small impact of EHR-based clinical decision support for high-risk patients on NSAIDs in primary care offices. These results add to the growing literature about the complexity of EHR-based clinical decision support for improving quality of care.
电子健康记录（EHR）与临床决策支持相结合，有望提高医疗质量，但它们对慢性病管理的影响参差不齐。本研究考察了基于 EHR 的临床决策支持对减少初级保健患者使用非甾体抗炎药（NSAIDs）时胃肠道并发症的指南遵循情况的影响。
这项随机对照试验在一个使用 EHR 的全国初级保健办公室网络中进行，重点关注使用传统 NSAIDs 的患者，这些患者存在与胃肠道并发症高风险相关的因素（消化性溃疡病史；同时使用抗凝剂、抗血小板药物[包括阿司匹林]或皮质类固醇；或年龄在 75 岁或以上）。这些办公室被随机分配接受 NSAIDs 高危患者的基于 EHR 的指南和警报，或接受常规护理。主要结局是在 1 年研究期间（2007 年 6 月至 2008 年 6 月）接受指南一致的护理的患者比例，定义为停止使用传统 NSAID（包括改用低风险药物）、同时使用胃保护药物或两者兼而有之。
参与者包括 27 个办公室的 119 名临床医生和 5234 名高危患者。与常规护理患者相比，干预患者更有可能接受指南一致的护理（25.4%对 22.4%，调整后的优势比=1.19；95%置信区间，1.01-1.42）。对于个别高危人群，服用低剂量阿司匹林的患者接受与常规护理相比，接受与常规护理相比，接受指南一致的护理的可能性更高（25.0%对 20.8%，调整后的优势比=1.30；95%置信区间，1.04-1.62），但其他高危人群没有显著差异。
本研究仅显示基于 EHR 的临床决策支持对初级保健办公室 NSAIDs 高危患者的影响较小。这些结果增加了关于基于 EHR 的临床决策支持改善医疗质量的复杂性的不断增长的文献。
