电子风险警报改善胸痛的初级保健管理：一项随机对照试验。
Electronic risk alerts to improve primary care management of chest pain: a randomized, controlled trial.
机构信息
Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120, USA.
出版信息
J Gen Intern Med. 2012 Apr;27(4):438-44. doi: 10.1007/s11606-011-1911-6. Epub 2011 Oct 13.
BACKGROUND
The primary care evaluation of chest pain represents a significant diagnostic challenge.
OBJECTIVE
To determine if electronic alerts to physicians can improve the quality and safety of chest pain evaluations.
DESIGN AND PARTICIPANTS
Randomized, controlled trial conducted between November 2008 and January 2010 among 292 primary care clinicians caring for 7,083 adult patients with chest pain and no history of cardiovascular disease.
INTERVENTION
Clinicians received alerts within the electronic health record during office visits for chest pain. One alert recommended performance of an electrocardiogram and administration of aspirin for high risk patients (Framingham Risk Score (FRS) ≥ 10%), and a second alert recommended against performance of cardiac stress testing for low risk patients (FRS < 10%).
MAIN MEASURES
The primary outcomes included performance of an electrocardiogram and administration of aspirin therapy for high risk patients; and avoidance of cardiac stress testing for low risk patients.
KEY RESULTS
The majority (81%) of patients with chest pain were classified as low risk. High risk patients were more likely than low risk patients to be evaluated in the emergency department (11% versus 5%, p < 0.01) and to be hospitalized (7% versus 3%, p < 0.01). Acute myocardial infarction occurred among 26 (0.4%) patients, more commonly among high risk compared to low risk patients (1.1% versus 0.2%, p < 0.01). Among high risk patients, there was no difference between the intervention and control groups in rates of performing electrocardiograms (51% versus 48%, p = 0.33) or administering aspirin (20% versus 18%, p = 0.43). Among low risk patients, there was no difference between intervention and control groups in rates of cardiac stress testing (10% versus 9%, p = 0.40).
CONCLUSIONS
Primary care management of chest pain is suboptimal for both high and low risk patients. Electronic alerts do not increase risk-appropriate care for these patients.
背景
初级保健对胸痛的评估是一项重大的诊断挑战。
目的
确定电子警示是否能提高胸痛评估的质量和安全性。
设计和参与者
2008 年 11 月至 2010 年 1 月期间，对 292 名初级保健临床医生进行了一项随机对照试验，这些临床医生照顾了 7083 名患有胸痛且无心血管疾病史的成年患者。
干预措施
临床医生在胸痛就诊时在电子病历中收到警示。一个警示建议对高危患者（弗雷明汉风险评分（FRS）≥10%）进行心电图检查和阿司匹林治疗，另一个警示建议对低危患者（FRS<10%）避免进行心脏应激测试。
主要结果
主要结果包括对高危患者进行心电图检查和阿司匹林治疗；以及对低危患者避免进行心脏应激测试。
关键结果
大多数（81%）胸痛患者被归类为低危。高危患者比低危患者更有可能在急诊科接受评估（11%对 5%，p<0.01）和住院（7%对 3%，p<0.01）。26 名（0.4%）患者发生急性心肌梗死，高危患者比低危患者更常见（1.1%对 0.2%，p<0.01）。在高危患者中，干预组和对照组在进行心电图检查的比例（51%对 48%，p=0.33）或给予阿司匹林的比例（20%对 18%，p=0.43）之间没有差异。在低危患者中，干预组和对照组之间进行心脏应激测试的比例（10%对 9%，p=0.40）没有差异。
结论
高危和低危患者的初级保健胸痛管理都不理想。电子警示并不能增加这些患者的风险适当治疗。
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