Ranta Annemarei, Dovey Susan, Weatherall Mark, O'Dea Des, Gommans John, Tilyard Murray
From the Department of Neurology (A.R.), MidCentral District Health Board, Palmerston North; the Department of Medicine (A.R., M.W., D.O.), University of Otago-Wellington; the Department of General Practice and Rural Health (S.D., M.T.), University of Otago, Dunedin School of Medicine; and the Department of Medicine (J.G.), Hawke's Bay District Health Board, Hastings, New Zealand.
Neurology. 2015 Apr 14;84(15):1545-51. doi: 10.1212/WNL.0000000000001472. Epub 2015 Mar 20.
To test if TIA/stroke electronic decision support in primary care improves management.
Multicenter, single-blind, parallel-group, cluster randomized, controlled trial comparing TIA/stroke electronic decision support guided management with usual care. Main outcomes were guideline adherence and 90-day stroke risk. Secondary outcomes were cerebrovascular/vascular/death/adverse events, cost, and user feedback. Main analysis was logistic regression with a normal random effect for clusters using a generalized linear mixed model.
Twenty-nine clinics were randomized to intervention, 27 to control, recruiting 172 and 119 eligible patients. More intervention patients received guideline-adherent care (131/172; 76.2%) than control patients (49/119; 41.2%) (adjusted odds ratio [OR] 4.57; 95% confidence interval [CI] 2.39-8.71; p < 0.001). Ninety-day stroke occurred in 2/172 (1.2%) intervention and 5/119 (4.2%) control patients (OR 0.27; 95% CI 0.05-1.41; p = 0.098). Ninety-day TIA or stroke occurrence was lower in the intervention group, 4/172 (2.3%) compared to 10/119 (8.5%) control (adjusted OR 0.26; 95% CI 0.70-0.97; p = 0.045). Fewer vascular events/deaths occurred in intervention, 6/172 (3.5%), than in control patients, 14/119 (11.9%) (adjusted OR 0.27; 95% CI 0.09-0.78; p = 0.016). Treatment cost ratio of 0.65 (95% CI 0.47-0.91; p = 0.013) favored the intervention without increased adverse events. Clinician feedback was positive.
Primary care use of the TIA/stroke electronic decision support tool improves guideline adherence, safely reduces treatment cost, achieves positive user feedback, and may reduce cerebrovascular and vascular event risk following TIA/stroke.
This study provides Class II evidence that a primary care electronic decision support tool improves guideline adherence and might reduce 90-day stroke risk.
检验初级保健中短暂性脑缺血发作/中风电子决策支持是否能改善管理。
多中心、单盲、平行组、整群随机对照试验，比较短暂性脑缺血发作/中风电子决策支持指导下的管理与常规护理。主要结局为指南依从性和90天中风风险。次要结局为脑血管/血管/死亡/不良事件、成本和用户反馈。主要分析采用广义线性混合模型，对整群进行具有正态随机效应的逻辑回归。
29个诊所被随机分配至干预组，27个诊所被分配至对照组，分别招募了172例和119例符合条件的患者。接受指南依从性护理的干预组患者（131/172；76.2%）多于对照组患者（49/119；41.2%）（调整比值比[OR]4.57；95%置信区间[CI]2.39 - 8.71；p < 0.001）。干预组2/172例（1.2%）患者和对照组5/119例（4.2%）患者发生90天中风（OR 0.27；95% CI 0.05 - 1.41；p = 0.098）。干预组90天短暂性脑缺血发作或中风发生率较低，为4/172例（2.3%），而对照组为10/119例（8.5%）（调整OR 0.26；95% CI 0.70 - 0.97；p = 0.045）。干预组发生血管事件/死亡的患者（6/172；3.5%）少于对照组患者（14/119；11.9%）（调整OR 0.27；95% CI 0.09 - 0.78；p = 0.016）。治疗成本比为0.65（95% CI 0.47 - 0.91；p = 0.013），有利于干预组，且未增加不良事件。临床医生反馈积极。
初级保健中使用短暂性脑缺血发作/中风电子决策支持工具可提高指南依从性，安全降低治疗成本，获得积极的用户反馈，并可能降低短暂性脑缺血发作/中风后的脑血管和血管事件风险。
本研究提供了II级证据，即初级保健电子决策支持工具可提高指南依从性，并可能降低90天中风风险。
