电子病历中的默认医嘱与警示对住院患者丙型肝炎病毒筛查的影响：一项阶梯式随机临床试验。
Effect of a Default Order vs an Alert in the Electronic Health Record on Hepatitis C Virus Screening Among Hospitalized Patients: A Stepped-Wedge Randomized Clinical Trial.
机构信息
Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
Center for Health Care Innovation, University of Pennsylvania, Philadelphia.
出版信息
JAMA Netw Open. 2022 Mar 1;5(3):e222427. doi: 10.1001/jamanetworkopen.2022.2427.
IMPORTANCE
Hepatitis C virus (HCV) screening has been recommended for patients born between 1945 and 1965, but rates remain low.
OBJECTIVE
To evaluate whether a default order within the admission order set increases HCV screening compared with a preexisting alert within the electronic health record.
DESIGN, SETTING, AND PARTICIPANTS: This stepped-wedge randomized clinical trial was conducted from June 23, 2020, to April 10, 2021, at 2 hospitals within an academic medical center. Hospitalized patients born between 1945 and 1965 with no history of screening were included in the analysis.
INTERVENTIONS
During wedge 1 (a preintervention period), both hospital sites had an electronic alert prompting clinicians to consider HCV screening. During wedge 2, the first intervention wedge, the hospital site randomized to intervention (hospital B) had a default order for HCV screening implemented within the admission order set. During wedge 3, the second intervention wedge, the hospital site randomized to control (hospital A) had the default order set implemented.
MAIN OUTCOMES AND MEASURES
Percentage of eligible patients who received HCV screening during the hospital stay.
RESULTS
The study included 7634 patients (4405 in the control group and 3229 in the intervention group). The mean (SD) age was 65.4 (5.8) years; 4246 patients (55.6%) were men; 2142 (28.1%) were Black and 4625 (60.6%) were White; and 2885 (37.8%) had commercial insurance and 3950 (51.7%) had Medicare. The baseline rate of HCV screening in wedge 1 was 585 of 1560 patients (37.5% [95% CI, 35.1%-40.0%]) in hospital A and 309 of 1003 patients (30.8% [95% CI, 27.9%-33.7%]) in hospital B. The main adjusted model showed an increase of 31.8 (95% CI, 29.7-33.8) percentage points in test completion in the intervention group compared with the control group (P <. 001).
CONCLUSIONS AND RELEVANCE
This stepped-wedge randomized clinical trial found that embedding HCV screening as a default order in the electronic health record substantially increased ordering and completion of testing in the hospital compared with a conventional interruptive alert.
TRIAL REGISTRATION
Clinicaltrials.gov: NCT04525690.
重要性
丙型肝炎病毒（HCV）筛查已被推荐用于 1945 年至 1965 年出生的患者，但筛查率仍然很低。
目的
评估在入院医嘱集中设置默认医嘱是否比电子病历中的现有提醒更能增加 HCV 筛查。
设计、地点和参与者：这是一项在学术医疗中心的 2 家医院进行的阶梯式随机临床试验，从 2020 年 6 月 23 日至 2021 年 4 月 10 日进行。分析纳入了在 1945 年至 1965 年出生且无筛查史的住院患者。
干预措施
在第 1 阶段（干预前阶段），两家医院都有一个电子提醒，提示临床医生考虑进行 HCV 筛查。在第 2 阶段（第 1 个干预阶段），医院 B 被随机分配到干预组（干预医院），在入院医嘱集中实施了 HCV 筛查的默认医嘱。在第 3 阶段（第 2 个干预阶段），医院 A 被随机分配到对照组（控制医院），实施了默认医嘱集。
主要结局和措施
在住院期间接受 HCV 筛查的合格患者比例。
结果
研究纳入了 7634 名患者（对照组 4405 名，干预组 3229 名）。患者的平均（标准差）年龄为 65.4（5.8）岁；4246 名患者（55.6%）为男性；2142 名（28.1%）为黑人，4625 名（60.6%）为白人；2885 名（37.8%）有商业保险，3950 名（51.7%）有医疗保险。第 1 阶段的 HCV 筛查基线率为：医院 A 中 1560 名患者中有 585 名（37.5%[95%CI，35.1%-40.0%]），医院 B 中 1003 名患者中有 309 名（30.8%[95%CI，27.9%-33.7%]）。主要调整模型显示，与对照组相比，干预组完成测试的比例增加了 31.8（95%CI，29.7-33.8）个百分点（P<.001）。
结论和相关性
这项阶梯式随机临床试验发现，在电子病历中嵌入 HCV 筛查作为默认医嘱，与传统的中断式提醒相比，大大增加了医院的医嘱和检测完成率。
试验注册
Clinicaltrials.gov：NCT04525690。
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