Cook David A, Enders Felicity, Caraballo Pedro J, Nishimura Rick A, Lloyd Farrell J
Knowledge Delivery Center, Mayo Clinic, Rochester, MN, United States of America; Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, United States of America; Mayo Clinic Online Learning, Mayo Clinic College of Medicine, Rochester, MN, United States of America.
Knowledge Delivery Center, Mayo Clinic, Rochester, MN, United States of America; Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN, United States of America.
PLoS One. 2015 Apr 7;10(4):e0122153. doi: 10.1371/journal.pone.0122153. eCollection 2015.
Clinical decision support systems that notify providers of abnormal test results have produced mixed results. We sought to develop, implement, and evaluate the impact of a computer-based clinical alert system intended to improve atrial fibrillation stroke prophylaxis, and identify reasons providers do not implement a guideline-concordant response.
We conducted a cohort study with historical controls among patients at a tertiary care hospital. We developed a decision rule to identify newly-diagnosed atrial fibrillation, automatically notify providers, and direct them to online evidence-based management guidelines. We tracked all notifications from December 2009 to February 2010 (notification period) and applied the same decision rule to all patients from December 2008 to February 2009 (control period). Primary outcomes were accuracy of notification (confirmed through chart review) and prescription of warfarin within 30 days.
During the notification period 604 notifications were triggered, of which 268 (44%) were confirmed as newly-diagnosed atrial fibrillation. The notifications not confirmed as newly-diagnosed involved patients with no recent electrocardiogram at our institution. Thirty-four of 125 high-risk patients (27%) received warfarin in the notification period, compared with 34 of 94 (36%) in the control period (odds ratio, 0.66 [95% CI, 0.37-1.17]; p = 0.16). Common reasons to not prescribe warfarin (identified from chart review of 151 patients) included upcoming surgical procedure, choice to use aspirin, and discrepancy between clinical notes and the medication record.
An automated system to identify newly-diagnosed atrial fibrillation, notify providers, and encourage access to management guidelines did not change provider behaviors.
向医疗服务提供者通报异常检查结果的临床决策支持系统产生了好坏参半的结果。我们试图开发、实施并评估一个基于计算机的临床警报系统的影响，该系统旨在改善心房颤动的卒中预防，并确定医疗服务提供者未采取符合指南的应对措施的原因。
我们在一家三级护理医院对患者进行了一项有历史对照的队列研究。我们制定了一个决策规则，以识别新诊断的心房颤动，自动通知医疗服务提供者，并引导他们查阅在线循证管理指南。我们追踪了2009年12月至2010年2月（通知期）的所有通知，并将相同的决策规则应用于2008年12月至2009年2月的所有患者（对照期）。主要结局是通知的准确性（通过病历审查确认）和30天内华法林的处方情况。
在通知期内触发了604次通知，其中268次（44%）被确认为新诊断的心房颤动。未被确认为新诊断的通知涉及在我们机构近期未进行心电图检查的患者。125名高危患者中有34名（27%）在通知期接受了华法林治疗，而对照期94名患者中有34名（36%）接受了华法林治疗（优势比，0.66[95%CI，0.37-1.17]；p=0.16）。不处方华法林的常见原因（从151名患者的病历审查中确定）包括即将进行的外科手术、选择使用阿司匹林以及临床记录与用药记录之间的差异。
一个用于识别新诊断的心房颤动、通知医疗服务提供者并鼓励查阅管理指南的自动化系统并未改变医疗服务提供者的行为。
