Safer Prescribing - A Trial of Education, Informatics, and Financial Incentives
Safer Prescribing - A Trial of Education, Informatics, and Financial Incentives
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DOI：
10.1056/nejmsa1508955
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发表时间：
2016-03-17
影响因子：
158.5
通讯作者：
Guthrie, Bruce
中科院分区：
文献类型：
--
作者：
Dreischulte, Tobias;Donnan, Peter;Guthrie, Bruce
背景：高危处方和可预防的药物相关并发症在初级保健中很常见。我们评估了初级保健临床医生的高风险处方率和相关的临床结果是否会通过复杂的干预来降低。方法：在苏格兰泰赛德进行的这一集群随机楔形试验中，我们将参与的初级保健实践随机分配到不同的开始日期，进行为期48周的干预，包括专业教育、便于审查的信息学以及对实践审查患者图表以评估适当性的财务激励。主要结局是患者水平暴露于非甾体抗炎药（NSAIDs）或选定抗血小板药物（例如，慢性肾病患者的非甾体抗炎药处方或非甾体抗炎药和口服抗凝剂的联合处方，无胃保护作用）的九种高危处方中的任何一种。预先指定的次要结局包括相关住院的发生率。根据意向治疗原则进行分析，使用混合效应模型来解释数据中的聚类。结果共34例患者接受随机分组，其中33例完成研究。研究人员分析了33,334名患者在干预前一个或多个时点的风险数据，以及33,060名患者在干预期一个或多个时点的风险数据。有针对性的高风险处方显著降低，从干预前的3.7%（29,537例高危患者中的1102例）降至干预结束时的2.2%（30,187例患者中的674例）(调整优势比为0.63；95%可信区间[CI]， 0.57 ~ 0.68
BACKGROUNDHigh-risk prescribing and preventable drug-related complications are common in primary care. We evaluated whether the rates of high-risk prescribing by primary care clinicians and the related clinical outcomes would be reduced by a complex intervention.METHODSIn this cluster-randomized, stepped-wedge trial conducted in Tayside, Scotland, we randomly assigned participating primary care practices to various start dates for a 48-week intervention comprising professional education, informatics to facilitate review, and financial incentives for practices to review patients' charts to assess appropriateness. The primary outcome was patient-level exposure to any of nine measures of high-risk prescribing of nonsteroidal antiinflammatory drugs (NSAIDs) or selected antiplatelet agents (e.g., NSAID prescription in a patient with chronic kidney disease or coprescription of an NSAID and an oral anticoagulant without gastroprotection). Prespecified secondary outcomes included the incidence of related hospital admissions. Analyses were performed according to the intention-to-treat principle, with the use of mixed-effect models to account for clustering in the data.RESULTSA total of 34 practices underwent randomization, 33 of which completed the study. Data were analyzed for 33,334 patients at risk at one or more points in the preintervention period and for 33,060 at risk at one or more points in the intervention period. Targeted high-risk prescribing was significantly reduced, from a rate of 3.7% (1102 of 29,537 patients at risk) immediately before the intervention to 2.2% (674 of 30,187) at the end of the intervention (adjusted odds ratio, 0.63; 95% confidence interval [CI], 0.57 to 0.68; P