Trinkley Katy E, Simon Steven T, Rosenberg Michael A
Adult and Child Center for Outcomes Research and Delivery Science Center, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.
Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.
J Med Internet Res. 2025 Apr 14;27:e68256. doi: 10.2196/68256.
Prevention of drug-induced QT prolongation (diLQTS) has been the focus of many system-wide clinical decision support (CDS) tools, which can be directly embedded within the framework of the electronic health record system and triggered to alert in high-risk patients when a known QT-prolonging medication is ordered. Justification for these CDS systems typically lies in the ability to accurately predict which patients are at high risk; however, it is not always evident that identification of risk alone is sufficient for appropriate CDS implementation.
In this investigation, we examined the impact of a system-wide, alert-based, inpatient CDS tool designed to prevent diLQTS across 10 known QT-prolonging medications.
We compared the risk of diLQTS, duration of hospitalization, and in- and out-of-hospital mortality before and after implementation of the CDS system in 178,097 hospitalizations among 102,847 patients. We also compared outcomes between those in whom an alert fired and those in whom it did not, and within the various responses to the alert by providers. Analyses were adjusted for age, sex, race and ethnicity, inpatient location, electrolyte values, and comorbidities, with the latter processed using an unsupervised clustering analysis applied to the top 500 most common medications and diagnosis codes, respectively.
We found that the simple, rule-based logic of the CDS (any prior electrocardiograph with heart rate-corrected QT interval (QTc)≥500 ms) successfully identified patients at high risk of diLQTS with an odds ratio of 2.28 (95% CI 2.10-2.47, P<.001) among those in whom it fired. However, we did not identify any impact on the risk of diLQTS based on provider responses or on the risk of inpatient, 3-month, 6-month, or 1-year mortality. When compared with rates prior to implementation, the risk of diLQTS was not significantly different after the CDS tools were deployed across the system, although mortality was significantly higher after the tools were implemented.
We found that despite successful identification of high-risk patients for diLQTS, deployment of an alert-based CDS did not impact the risk of diLQTS. These findings suggest that quantification of high risk may be insufficient rationale for implementation of a CDS system and that hospital systems should consider evaluation of the system in its entirety prior to adoption to improve clinical outcomes.
预防药物引起的QT间期延长（diLQTS）一直是许多全系统临床决策支持（CDS）工具的重点，这些工具可直接嵌入电子健康记录系统框架内，并在开具已知可延长QT间期的药物时触发警报，提醒高危患者。这些CDS系统的合理性通常在于能够准确预测哪些患者处于高危状态；然而，仅识别风险是否足以适当地实施CDS并不总是显而易见的。
在本研究中，我们考察了一种全系统、基于警报的住院患者CDS工具对预防10种已知可延长QT间期药物引起的diLQTS的影响。
我们比较了102847例患者的178097次住院中，CDS系统实施前后diLQTS风险、住院时间以及院内和院外死亡率。我们还比较了警报触发组和未触发组之间的结果，以及提供者对警报的不同反应之间的结果。分析对年龄、性别、种族和民族、住院地点、电解质值和合并症进行了调整，后者分别使用应用于前500种最常用药物和诊断代码的无监督聚类分析进行处理。
我们发现，CDS的简单、基于规则的逻辑（任何先前心电图的心率校正QT间期（QTc）≥500毫秒）成功识别了diLQTS高危患者，在警报触发的患者中，优势比为2.28（95%CI 2.10-2.47，P<0.001）。然而，我们没有发现基于提供者反应的diLQTS风险或住院、3个月、6个月或1年死亡率风险有任何影响。与实施前的发生率相比，在全系统部署CDS工具后，diLQTS风险没有显著差异，尽管工具实施后死亡率显著更高。
我们发现，尽管成功识别了diLQTS高危患者，但基于警报的CDS的部署并未影响diLQTS风险。这些发现表明，对高危进行量化可能不足以成为实施CDS系统的理由，医院系统在采用之前应考虑对整个系统进行评估，以改善临床结果。
