预测分析靶向方案对阿片类药物使用者的影响：一项阶梯式楔形集群随机对照试验。

Effect of a Predictive Analytics-Targeted Program in Patients on Opioids: a Stepped-Wedge Cluster Randomized Controlled Trial.

机构信息

Department of Health Law, Policy and Management, Boston University of Public Health, Boston, MA, USA.

Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA.

出版信息

J Gen Intern Med. 2023 Feb;38(2):375-381. doi: 10.1007/s11606-022-07617-y. Epub 2022 May 2.

DOI:10.1007/s11606-022-07617-y

PMID:35501628

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC9060407/

Abstract

BACKGROUND

Risk of overdose, suicide, and other adverse outcomes are elevated among sub-populations prescribed opioid analgesics. To address this, the Veterans Health Administration (VHA) developed the Stratification Tool for Opioid Risk Mitigation (STORM)-a provider-facing dashboard that utilizes predictive analytics to stratify patients prescribed opioids based on risk for overdose/suicide.

OBJECTIVE

To evaluate the impact of the case review mandate on serious adverse events (SAEs) and all-cause mortality among high-risk Veterans.

DESIGN

A 23-month stepped-wedge cluster randomized controlled trial in all 140 VHA medical centers between 2018 and 2020.

PARTICIPANTS

A total of 44,042 patients actively prescribed opioid analgesics with high STORM risk scores (i.e., percentiles 1% to 5%) for an overdose or suicide-related event.

INTERVENTION

A mandate requiring providers to perform case reviews on opioid analgesic-prescribed patients at high risk of overdose/suicide.

MAIN MEASURES

Nine serious adverse events (SAEs), case review completion, number of risk mitigation strategies, and all-cause mortality.

KEY RESULTS

Mandated review inclusion was associated with a significant decrease in all-cause mortality within 4 months of inclusion (OR: 0.78; 95% CI: 0.65-0.94). There was no detectable effect on SAEs. Stepped-wedge analyses found that mandated review patients were five times more likely to receive a case review than non-mandated patients with similar risk (OR: 5.1; 95% CI: 3.64-7.23) and received more risk mitigation strategies than non-mandated patients (0.498; CI: 0.39-0.61).

CONCLUSIONS

Among VHA patients prescribed opioid analgesics, identifying high risk patients and mandating they receive an interdisciplinary case review was associated with a decrease in all-cause mortality. Results suggest that providers can leverage predictive analytic-targeted population health approaches and interdisciplinary collaboration to improve patient outcomes.

TRIAL REGISTRATION

ISRCTN16012111.

摘要

背景

在接受阿片类镇痛药处方的亚人群中，药物过量、自杀和其他不良后果的风险增加。为了解决这个问题，退伍军人健康管理局 (VHA) 开发了一种针对阿片类药物风险缓解的分层工具 (STORM) - 一个面向提供者的仪表板，利用预测分析根据药物过量/自杀风险对开处阿片类药物的患者进行分层。

目的

评估案例审查任务对高危退伍军人的严重不良事件 (SAE) 和全因死亡率的影响。

设计

2018 年至 2020 年期间，在所有 140 个退伍军人健康管理局医疗中心进行了为期 23 个月的分步楔形集群随机对照试验。

参与者

共有 44042 名积极服用阿片类镇痛药的患者，这些患者的风险评分较高（即 1% 至 5% 之间的百分位），有药物过量或自杀相关事件的风险。

干预

要求提供者对有药物过量/自杀风险的阿片类药物处方患者进行案例审查的任务。

主要措施

九个严重不良事件 (SAE)、案例审查完成情况、风险缓解策略数量和全因死亡率。

主要结果

纳入审查任务与纳入后 4 个月内全因死亡率的显著下降相关（OR：0.78；95%CI：0.65-0.94）。对 SAE 没有可检测到的影响。分步楔形分析发现，与风险相似的非强制审查患者相比，强制审查患者进行案例审查的可能性高出五倍（OR：5.1；95%CI：3.64-7.23），并且接受的风险缓解策略多于非强制审查患者（0.498；CI：0.39-0.61）。