决策支持在慢性非癌痛阿片类药物处方中的临床效果：一项前瞻性队列研究。
Clinical Effectiveness of Decision Support for Prescribing Opioids for Chronic Noncancer Pain: A Prospective Cohort Study.
机构信息
Center for Outcomes and Health Services Research, Ochsner Health System, New Orleans, LA, USA; Ochsner Clinical School, University of Queensland, New Orleans, LA, USA.
Center for Outcomes and Health Services Research, Ochsner Health System, New Orleans, LA, USA.
出版信息
Value Health. 2020 Feb;23(2):157-163. doi: 10.1016/j.jval.2019.09.2748. Epub 2019 Nov 22.
OBJECTIVES
This prospective cohort study examines the clinical effectiveness of electronic medical record clinical decision support (EMR CDS) for opioid prescribing.
METHODS
Data analysis included primary care patients with chronic opioid therapy for noncancer pain seen within an integrated health delivery system in Louisiana between January 2017 and October 2018. EMR CDS incorporated an opioid health maintenance tool to display the status of risk mitigation, and the medication order embedded the morphine equivalent daily dose (MEDD) calculator and a hyperlink to the Louisiana pharmacy drug monitoring program. Outcome measures included change in the average MEDD and rates of opioid risk mitigation, hospitalization, and emergency department use.
RESULTS
Among 14 221 patients, 9% had prescriptions with an average MEDD ≥90 mg. There were no significant changes in MEDD after EMR CDS implementation. Increasing age, Charlson Comorbidity Index score, female sex, black non-Hispanic race, non-opioid pain medication co-prescriptions, and specialty referrals were associated with a lower odds of MEDD ≥90 (high-dose threshold). Medicare or self-pay, substance abuse history, and pain agreements were associated with increased odds of prescribing above this high-dose threshold. After incorporation of EMR CDS, patients had higher rates of urine drug screens (17% vs 7%) and naloxone prescriptions (3% vs 1%, all P < .001). In addition, specialty referrals to physical or occupational therapy, orthopedics, neurology, and psychiatry or psychology increased in the postintervention period. Although emergency department use decreased (rate ratio 0.92; 95% confidence interval 0.89-0.95), hospitalization rates did not change.
CONCLUSIONS
EMR CDS improved adherence to opioid risk mitigation strategies. Further research examining which practice redesign interventions effectively reduce high-dose opioid prescribing is needed.
目的
本前瞻性队列研究考察了电子病历临床决策支持（EMR CDS）在阿片类药物处方方面的临床效果。
方法
数据分析纳入了 2017 年 1 月至 2018 年 10 月期间在路易斯安那州一个综合医疗服务系统内接受慢性阿片类药物治疗非癌性疼痛的初级保健患者。EMR CDS 纳入了一种阿片类药物健康维护工具，以显示风险缓解状态，而药物医嘱则嵌入了吗啡等效日剂量（MEDD）计算器和路易斯安那州药房药物监测计划的超链接。主要观察指标包括平均 MEDD 的变化以及阿片类药物风险缓解、住院和急诊使用的发生率。
结果
在 14221 名患者中，9%的患者处方的 MEDD 平均值≥90mg。在 EMR CDS 实施后，MEDD 没有显著变化。年龄、Charlson 合并症指数评分、女性、非裔美国人、非阿片类药物疼痛药物联合处方以及专科转诊与 MEDD≥90（高剂量阈值）的可能性降低相关。医疗保险或自付、药物滥用史和疼痛协议与超过该高剂量阈值的处方相关。在纳入 EMR CDS 后，患者尿液药物检测（17%比 7%）和纳洛酮处方（3%比 1%，均 P<0.001）的比例更高。此外，在干预后期间，向物理治疗或职业治疗、骨科、神经科以及精神科或心理科的专科转诊增加。虽然急诊使用减少（比率比 0.92；95%置信区间 0.89-0.95），但住院率没有变化。
结论
EMR CDS 提高了阿片类药物风险缓解策略的依从性。需要进一步研究哪些实践设计干预措施可以有效地减少高剂量阿片类药物的处方。
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