1 Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Silverstein 1, Philadelphia, PA 19104.
2 Center for Evidence-Based Imaging, Brigham and Women's Hospital, Boston, MA.
AJR Am J Roentgenol. 2019 Feb;212(2):386-394. doi: 10.2214/AJR.18.19780. Epub 2018 Nov 26.
The purpose of this study is to determine whether the type of feedback on evidence-based guideline adherence influences adult primary care provider (PCP) lumbar spine (LS) MRI orders for low back pain (LBP).
Four types of guideline adherence feedback were tested on eight tertiary health care system outpatient PCP practices: no feedback during baseline (March 1, 2012-October 4, 2012), randomization by practice to either clinical decision support (CDS)-generated report cards comparing providers to peers only or real-time CDS alerts at order entry during intervention 1 (February 6, 2013-December 31, 2013), and both feedback types for all practices during intervention 2 (January 14, 2014-June 20, 2014, and September 4, 2014-January 21, 2015). International Classification of Disease codes identified LBP visits (excluding Medicare fee-for-service). The primary outcome of the likelihood of LS MRI order being made on the day of or 1-30 days after the outpatient LBP visit was adjusted by feedback type (none, report cards only, real-time alerts only, or both); patient age, sex, race, and insurance status; and provider sex and experience.
Half of PCPs (54/108) remained for all three periods, conducting 9394 of 107,938 (8.7%) outpatient LBP visits. The proportion of LBP visits increased over the course of the study (p = 0.0001). In multilevel hierarchic regression, report cards resulted in a lower likelihood of LS MRI orders made the day of and 1-30 days after the visit versus baseline: 38% (p = 0.009) and 37% (p = 0.006) for report cards alone, and 27% (p = 0.020) and 27% (p = 0.016) with alerts, respectively. Real-time alerts alone did not affect MRI orders made the day of (p = 0.585) or 1-30 days after (p = 0.650) the visit. No patient or provider variables were associated with LS MRI orders being generated on the day of or 1-30 days after the LBP visit.
CDS-generated evidence-based report cards can substantially reduce outpatient PCP LS MRI orders on the day of and 1-30 days after the LBP visit. Real-time CDS alerts do not.
本研究旨在确定对循证指南依从性的反馈类型是否会影响成人初级保健提供者（PCP）对腰椎（LS）磁共振成像（MRI）的低背痛（LBP）的医嘱。
在 8 个三级医疗系统门诊 PCP 实践中测试了 4 种类型的指南依从性反馈：在基线期（2012 年 3 月 1 日至 2012 年 10 月 4 日）期间无反馈，根据实践随机分配给临床决策支持（CDS）生成的报告卡，仅将提供者与同行进行比较，或在干预 1 期间在医嘱输入时实时 CDS 警报（2013 年 2 月 6 日至 2013 年 12 月 31 日），以及在干预 2 期间（2014 年 1 月 14 日至 2014 年 6 月 20 日和 2014 年 9 月 4 日至 2015 年 1 月 21 日）对所有实践同时使用这两种反馈类型。国际疾病分类代码确定了 LBP 就诊（不包括医疗保险按服务收费）。LS MRI 医嘱在门诊 LBP 就诊当天或就诊后 1-30 天内开出的可能性是通过反馈类型（无反馈、仅报告卡、仅实时警报或两者兼有）、患者年龄、性别、种族和保险状况、提供者性别和经验进行调整的。
54/108 名 PCP （54/108）完成了所有三个阶段的研究，进行了 9394/107938 次（8.7%）门诊 LBP 就诊。就诊次数在研究过程中有所增加（p=0.0001）。在多层次层次回归中，与基线相比，报告卡导致当天和就诊后 1-30 天 LS MRI 医嘱的可能性降低：单独使用报告卡为 38%（p=0.009）和 37%（p=0.006），使用警报时分别为 27%（p=0.020）和 27%（p=0.016）。实时警报本身并不会影响当天就诊（p=0.585）或就诊后 1-30 天就诊（p=0.650）的 MRI 医嘱。没有患者或提供者变量与 LBP 就诊当天或就诊后 1-30 天 LS MRI 医嘱的生成有关。
CDS 生成的基于证据的报告卡可以大大减少门诊 PCP 在 LBP 就诊当天和就诊后 1-30 天 LS MRI 医嘱的数量。实时 CDS 警报则没有。
