Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon.
OCHIN Inc, Portland, Oregon.
JAMA Netw Open. 2022 Feb 1;5(2):e2146519. doi: 10.1001/jamanetworkopen.2021.46519.
Management of cardiovascular disease (CVD) risk in socioeconomically vulnerable patients is suboptimal; better risk factor control could improve CVD outcomes.
To evaluate the impact of a clinical decision support system (CDSS) targeting CVD risk in community health centers (CHCs).
DESIGN, SETTING, AND PARTICIPANTS: This cluster randomized clinical trial included 70 CHC clinics randomized to an intervention group (42 clinics; 8 organizations) or a control group that received no intervention (28 clinics; 7 organizations) from September 20, 2018, to March 15, 2020. Randomization was by CHC organization accounting for organization size. Patients aged 40 to 75 years with (1) diabetes or atherosclerotic CVD and at least 1 uncontrolled major risk factor for CVD or (2) total reversible CVD risk of at least 10% were the population targeted by the CDSS intervention.
A point-of-care CDSS displaying real-time CVD risk factor control data and personalized, prioritized evidence-based care recommendations.
One-year change in total CVD risk and reversible CVD risk (ie, the reduction in 10-year CVD risk that was considered achievable if 6 key risk factors reached evidence-based levels of control).
Among the 18 578 eligible patients (9490 [51.1%] women; mean [SD] age, 58.7 [8.8] years), patients seen in control clinics (n = 7419) had higher mean (SD) baseline CVD risk (16.6% [12.8%]) than patients seen in intervention clinics (n = 11 159) (15.6% [12.3%]; P < .001); baseline reversible CVD risk was similarly higher among patients seen in control clinics. The CDSS was used at 19.8% of 91 988 eligible intervention clinic encounters. No population-level reduction in CVD risk was seen in patients in control or intervention clinics; mean reversible risk improved significantly more among patients in control (-0.1% [95% CI, -0.3% to -0.02%]) than intervention clinics (0.4% [95% CI, 0.3% to 0.5%]; P < .001). However, when the CDSS was used, both risk measures decreased more among patients with high baseline risk in intervention than control clinics; notably, mean reversible risk decreased by an absolute 4.4% (95% CI, -5.2% to -3.7%) among patients in intervention clinics compared with 2.7% (95% CI, -3.4% to -1.9%) among patients in control clinics (P = .001).
The CDSS had low use rates and failed to improve CVD risk in the overall population but appeared to have a benefit on CVD risk when it was consistently used for patients with high baseline risk treated in CHCs. Despite some limitations, these results provide preliminary evidence that this technology has the potential to improve clinical care in socioeconomically vulnerable patients with high CVD risk.
ClinicalTrials.gov Identifier: NCT03001713.
重要性：在社会经济弱势群体中，心血管疾病（CVD）风险的管理并不理想；更好地控制风险因素可以改善 CVD 结局。
目的：评估针对社区卫生中心（CHC）CVD 风险的临床决策支持系统（CDSS）的影响。
设计、地点和参与者：这项集群随机临床试验纳入了 70 家 CHC 诊所，随机分为干预组（42 家诊所；8 个组织）或对照组（28 家诊所；7 个组织），从 2018 年 9 月 20 日至 2020 年 3 月 15 日。按照 CHC 组织（按组织规模）进行分层随机化。目标人群为年龄在 40 岁至 75 岁之间的患者，患有以下疾病之一：（1）糖尿病或动脉粥样硬化性 CVD，且至少有一种 CVD 主要风险因素未得到控制；或（2）总可逆 CVD 风险至少为 10%。
干预措施：一种实时显示 CVD 风险因素控制数据以及个性化、优先考虑的循证护理建议的床边 CDSS。
主要结局和测量指标：CVD 总风险和可逆 CVD 风险的一年变化（即，如果 6 个关键风险因素达到循证控制水平，那么 10 年 CVD 风险降低的幅度）。
结果：在 18578 名符合条件的患者中（9490[51.1%]名女性；平均[标准差]年龄，58.7[8.8]岁），与干预诊所（n=11159）的患者相比，接受对照组诊所（n=7419）治疗的患者的基线 CVD 风险（16.6%[12.8%]）更高（P<0.001）；基线可逆 CVD 风险在对照组患者中也明显更高。在 91988 例符合条件的干预诊所就诊中，CDSS 的使用率为 19.8%。对照组或干预组患者的 CVD 风险均未出现人群水平的降低；对照组（0.4%[95%CI，0.3%至 0.5%]）的可逆风险显著改善优于干预组（0.1%[95%CI，0.3%至 0.02%]；P<0.001）。然而，当使用 CDSS 时，高基线风险患者的风险指标在干预组中比对照组中下降更多；值得注意的是，与对照组相比，干预组患者的可逆风险绝对值下降了 4.4%（95%CI，-5.2%至-3.7%）（P=0.001）。
结论和相关性：CDSS 的使用率较低，未能改善总体人群的 CVD 风险，但对于高基线风险的患者，当在 CHC 中持续使用时，似乎对 CVD 风险有一定的益处。尽管存在一些局限性，但这些结果初步表明，该技术有可能改善社会经济弱势群体中高 CVD 风险患者的临床护理。
试验注册：ClinicalTrials.gov 标识符：NCT03001713。
