Tajmir Shahein, Raja Ali S, Ip Ivan K, Andruchow James, Silveira Patricia, Smith Stacy, Khorasani Ramin
Harvard Medical School, Boston, Massachusetts.
Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.
West J Emerg Med. 2017 Apr;18(3):487-495. doi: 10.5811/westjem.2017.1.33053. Epub 2017 Mar 7.
While only 15-20% of patients with foot and ankle injuries presenting to urgent care centers have clinically significant fractures, most undergo radiography. We examined the impact of electronic point-of-care clinical decision support (CDS) on adherence to the Ottawa Ankle Rules (OAR), as well as use and yield of foot and ankle radiographs in patients with acute ankle injury.
We obtained institutional review board approval for this randomized controlled study performed April 18, 2012-December 15, 2013. All ordering providers credentialed at an urgent care affiliated with a quaternary care academic hospital were randomized to either receive or not receive CDS, based on the OAR and integrated into the physician order-entry system, with feedback at the time of imaging order. If the patient met OAR low-risk criteria, providers were advised against imaging and could either cancel the order or ignore the alert. We identified patients with foot and ankle complaints via ICD-9 billing codes and electronic health records and radiology reports reviewed for those who were eligible. Chi-square was used to compare adherence to the OAR (primary outcome), radiography utilization rate and radiography yield of foot and ankle imaging (secondary outcomes) between the intervention and control groups.
Of 14,642 patients seen at urgent care during the study period, 613 (4.2%, representing 632 visits) presented with acute ankle injury and were eligible for application of the OAR; 374 (59.2%) of these were seen by control-group providers. In the intervention group, CDS adherence was higher for both ankle (239/258=92.6% vs. 231/374=61.8%, p=0.02) and foot radiography (209/258=81.0% vs. 238/374=63.6%; p<0.01). However, ankle radiography use was higher in the intervention group (166/258=64.3% vs. 183/374=48.9%; p<0.01), while foot radiography use (141/258=54.6% vs. 202/374=54.0%; p=0.95) was not. Radiography yield was also higher in the intervention group (26/307=8.5% vs. 18/385=4.7%; p=0.04).
Clinical decision support, previously demonstrated to improve guideline adherence for high-cost imaging, can also improve guideline adherence for radiography - as demonstrated by increased OAR adherence and increased imaging yield.
虽然在紧急护理中心就诊的足踝损伤患者中，只有15% - 20%存在具有临床意义的骨折，但大多数患者都接受了X光检查。我们研究了电子即时临床决策支持（CDS）对渥太华踝关节规则（OAR）依从性的影响，以及急性踝关节损伤患者足踝关节X光片的使用情况和阳性率。
我们获得了机构审查委员会对这项随机对照研究的批准，该研究于2012年4月18日至2013年12月15日进行。所有在一家四级医疗学术医院附属的紧急护理中心获得资格认证的开单医生，根据OAR被随机分为接受或不接受CDS组，CDS被整合到医生医嘱录入系统中，并在开具影像检查医嘱时提供反馈。如果患者符合OAR低风险标准，医生会被建议不要进行影像检查，他们可以取消医嘱或忽略警报。我们通过ICD - 9计费代码、电子健康记录以及对符合条件者的放射学报告来识别有足踝问题的患者。使用卡方检验比较干预组和对照组在OAR依从性（主要结果）、足部和踝关节影像检查的X光片使用率及阳性率（次要结果）方面的差异。
在研究期间，在紧急护理中心就诊的14642名患者中，有613名（4.2%，代表632次就诊）出现急性踝关节损伤且符合应用OAR的条件；其中374名（59.2%）由对照组医生诊治。在干预组中，踝关节X光检查（239/258 = 92.6% 对比 231/374 = 61.8%，p = 0.02）和足部X光检查（209/258 = 81.0% 对比 238/374 = 63.6%；p < 0.01）的CDS依从性更高。然而，干预组的踝关节X光检查使用率更高（166/258 = 64.3% 对比 183/374 = 48.9%；p < 0.01），而足部X光检查使用率（141/258 = 54.6% 对比 202/374 = 54.0%；p = 0.95）无差异。干预组的X光检查阳性率也更高（26/307 = 8.5% 对比 18/385 = 4.7%；p = 0.04）。
临床决策支持此前已被证明可提高高成本影像检查的指南依从性，也能提高X光检查的指南依从性——这表现为OAR依从性增加和影像检查阳性率提高。
