有或没有共同决策的临床决策支持以改善癌症预防护理：一项集群随机试验。
Clinical Decision Support with or without Shared Decision Making to Improve Preventive Cancer Care: A Cluster-Randomized Trial.
机构信息
HealthPartners Institute, South, Minneapolis, MN, USA.
Essentia Institute of Rural Health, Duluth, MN, USA.
出版信息
Med Decis Making. 2022 Aug;42(6):808-821. doi: 10.1177/0272989X221082083. Epub 2022 Feb 25.
BACKGROUND
Innovative interventions are needed to address gaps in preventive cancer care, especially in rural areas. This study evaluated the impact of clinical decision support (CDS) with and without shared decision making (SDM) on cancer-screening completion.
METHODS
In this 3-arm, parallel-group, cluster-randomized trial conducted at a predominantly rural medical group, 34 primary care clinics were randomized to clinical decision support (CDS), CDS plus shared decision making (CDS+SDM), or usual care (UC). The CDS applied web-based clinical algorithms identifying patients overdue for United States Preventive Services Task Force-recommended preventive cancer care and presented evidence-based recommendations to patients and providers on printouts and on the electronic health record interface. Patients in the CDS+SDM clinic also received shared decision-making tools (SDMTs). The primary outcome was a composite indicator of the proportion of patients overdue for breast, cervical, or colorectal cancer screening at index who were up to date on these 1 y later.
RESULTS
From August 1, 2018, to March 15, 2019, 69,405 patients aged 21 to 74 y had visits at study clinics and 25,198 were overdue for 1 or more cancer screening tests at an index visit. At 12-mo follow-up, 9,543 of these (37.9%) were up to date on the composite endpoint. The adjusted, model-derived percentage of patients up to date was 36.5% (95% confidence interval [CI]: 34.0-39.1) in the UC group, 38.1% (95% CI: 35.5-40.9) in the CDS group, and 34.4% (95% CI: 31.8-37.2) in the CDS+SDM group. For all comparisons, the screening rates were higher than UC in the CDS group and lower than UC in the CDS+SDM group, although these differences did not reach statistical significance.
CONCLUSION
The CDS did not significantly increase cancer-screening rates. Exploratory analyses suggest a deeper understanding of how SDM and CDS interact to affect cancer prevention decisions is needed. Trial registration: ClinicalTrials.gov ID: NCT02986230, December 6, 2016.
背景
需要创新干预措施来解决预防癌症护理方面的差距，尤其是在农村地区。本研究评估了临床决策支持（CDS）联合和不联合共享决策（SDM）对癌症筛查完成情况的影响。
方法
在这项主要在农村医疗集团进行的 3 臂、平行组、群组随机试验中，34 家初级保健诊所被随机分为临床决策支持（CDS）、CDS 加共享决策（CDS+SDM）或常规护理（UC）组。CDS 应用基于网络的临床算法，识别出美国预防服务工作组推荐的预防癌症护理中超过预约时间的患者，并通过打印件和电子健康记录界面向患者和提供者提供基于证据的建议。CDS+SDM 诊所的患者还接受了共享决策工具（SDMTs）。主要结局是在索引时超过 1 年未进行乳腺癌、宫颈癌或结直肠癌筛查的患者中，1 年后这些患者中有比例达到最新筛查要求的综合指标。
结果
从 2018 年 8 月 1 日至 2019 年 3 月 15 日，69405 名 21 至 74 岁的患者在研究诊所就诊，25198 名患者在索引就诊时超过 1 项癌症筛查测试的预约时间。在 12 个月的随访中，这些患者中有 9543 名（37.9%）达到了综合终点的最新要求。调整后的模型推导的患者最新比例在 UC 组为 36.5%（95%置信区间[CI]：34.0-39.1），在 CDS 组为 38.1%（95% CI：35.5-40.9），在 CDS+SDM 组为 34.4%（95% CI：31.8-37.2）。对于所有比较，CDS 组的筛查率均高于 UC 组，而 CDS+SDM 组的筛查率均低于 UC 组，但这些差异均无统计学意义。
结论
CDS 并未显著提高癌症筛查率。探索性分析表明，需要更深入地了解 SDM 和 CDS 如何相互作用影响癌症预防决策。
试验注册
ClinicalTrials.gov 标识符：NCT02986230，2016 年 12 月 6 日。
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