临床心力衰竭决策支持的持续效果：应用实施科学的自然实验。

Sustained Effect of Clinical Decision Support for Heart Failure: A Natural Experiment Using Implementation Science.

机构信息

Department of Family Medicine, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States.

UCHealth, Aurora, Colorado, United States.

出版信息

Appl Clin Inform. 2023 Oct;14(5):822-832. doi: 10.1055/s-0043-1775566. Epub 2023 Oct 18.

DOI:10.1055/s-0043-1775566

PMID:37852249

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC10584394/

Abstract

OBJECTIVES

In a randomized controlled trial, we found that applying implementation science (IS) methods and best practices in clinical decision support (CDS) design to create a locally customized, "enhanced" CDS significantly improved evidence-based prescribing of β blockers (BB) for heart failure compared with an unmodified commercially available CDS. At trial conclusion, the enhanced CDS was expanded to all sites. The purpose of this study was to evaluate the real-world sustained effect of the enhanced CDS compared with the commercial CDS.

METHODS

In this natural experiment of 28 primary care clinics, we compared clinics exposed to the commercial CDS (preperiod) to clinics exposed to the enhanced CDS (both periods). The primary effectiveness outcome was the proportion of alerts resulting in a BB prescription. Secondary outcomes included patient reach and clinician adoption (dismissals).

RESULTS

There were 367 alerts for 183 unique patients and 171 unique clinicians (pre: March 2019-August 2019; post: October 2019-March 2020). The enhanced CDS increased prescribing by 26.1% compared with the commercial (95% confidence interval [CI]: 17.0-35.1%), which is consistent with the 24% increase in the previous study. The odds of adopting the enhanced CDS was 81% compared with 29% with the commercial (odds ratio: 4.17, 95% CI: 1.96-8.85). The enhanced CDS adoption and effectiveness rates were 62 and 14% in the preperiod and 92 and 10% in the postperiod.

CONCLUSION

Applying IS methods with CDS best practices was associated with improved and sustained clinician adoption and effectiveness compared with a commercially available CDS tool.

摘要

目的

在一项随机对照试验中，我们发现应用实施科学（IS）方法和最佳临床决策支持（CDS）设计实践来创建本地定制的“增强型”CDS，与使用未修改的商业可用 CDS 相比，可显著提高心力衰竭患者β受体阻滞剂（BB）的基于证据的处方率。试验结束时，增强型 CDS 已扩展到所有站点。本研究的目的是评估与商业 CDS 相比，增强型 CDS 的实际持续效果。

方法

在这项针对 28 家初级保健诊所的自然实验中，我们比较了暴露于商业 CDS（预期间）的诊所和暴露于增强型 CDS（两个期间）的诊所。主要有效性结果是导致 BB 处方的警报比例。次要结果包括患者覆盖率和临床医生采用率（拒绝）。

结果

在 183 名独特患者和 171 名独特临床医生中，有 367 次警报（预期间：2019 年 3 月至 2019 年 8 月；后期间：2019 年 10 月至 2020 年 3 月）。与商业 CDS 相比，增强型 CDS 使处方增加了 26.1%（95%置信区间[CI]：17.0-35.1%），这与之前研究中 24%的增幅一致。与商业 CDS 相比，采用增强型 CDS 的可能性增加了 81%，而采用商业 CDS 的可能性则降低了 29%（优势比：4.17，95%CI：1.96-8.85）。在预期间，增强型 CDS 的采用率和效果率分别为 62%和 14%，在后期间分别为 92%和 10%。