Developing an electronic health record measure of low-value esophagogastroduodenoscopy for GERD at a large academic health system.
Developing an electronic health record measure of low-value esophagogastroduodenoscopy for GERD at a large academic health system.
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DOI：
10.1136/bmjoq-2023-002363
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发表时间：
2023-12-22
期刊：
影响因子：
1.4
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针对无并发症的胃食管反流病 (GERD) 的低价值食管胃十二指肠镜检查 (EGD) 可能会伤害患者并增加患者和付款人的费用。我们开发了电子健康记录 (EHR)“eMeasure”来检测低值 EGD。由 518 名诊断为 GERD 的成年患者组成的回顾性队列，这些患者在 2019 年 1 月 1 日至 2019 年 12 月 31 日期间接受了初次 EGD。门诊初级保健和胃肠病诊所位于大型城市学术健康中心。加州大学洛杉矶分校的成人初级保健患者于 2019 年因 GERD 接受了初始 EGD。EGD 适当性标准基于美国胃肠病学会 2012 年指南。如果初始 EGD 缺乏基于指南的适应症记录，包括警报症状（例如缺铁性贫血），则被认为是低价值的；为期 8 周的质子泵抑制剂试验失败或巴雷特食管风险升高。我们对 204 名患者的随机样本进行了手动图表审查，作为 eMeasure 有效性的黄金标准。我们使用 Medicare 医生和设施费率估算了 EGD 成本。在 518 例初始 EGD 中（平均年龄 53 岁；54% 为女性），eMeasure 确定 81 例 (16%) 为低值。 eMeasure 的敏感性为 42%（95% CI 22 至 61），特异性为 93%（95% CI 89 至 96）。对诊所进行分层，16 家诊所中有 2 家 (12.5%) 产生了 62 家 (74.6%) 低值 EGD。 81 例低价值 EGD 的总成本约为 75 573 美元，其中包括 14 985 美元的患者自付费用。我们开发了一种高度具体的 eMeasure，显示低值 EGD 在我们的医疗保健系统中频繁发生，并且集中在少数诊所。这些结果可以为我们机构未来的 QI 工作提供信息，例如为医嘱医生提供最佳实践警报。此外，这种开源 eMeasure 具有更广泛的潜在影响，因为它可以集成到任何 EHR 中并改善护理点的医疗决策。
Low-value esophagogastroduodenoscopies (EGDs) for uncomplicated gastro-oesophageal reflux disease (GERD) can harm patients and raise patient and payer costs. We developed an electronic health record (EHR) ‘eMeasure’ to detect low-value EGDs. Retrospective cohort of 518 adult patients diagnosed with GERD who underwent initial EGD between 1 January 2019 and 31 December 2019. Outpatient primary care and gastroenterology clinics at a large, urban, academic health centre. Adult primary care patients at the University of California Los Angeles who underwent initial EGD for GERD in 2019. EGD appropriateness criteria were based on the American College of Gastroenterology 2012 guidelines. An initial EGD was considered low-value if it lacked a documented guideline-based indication, including alarm symptoms (eg, iron-deficiency anaemia); failure of an 8-week proton pump inhibitor trial or elevated Barrett’s oesophagus risk. We performed manual chart review on a random sample of 204 patients as a gold standard of the eMeasure’s validity. We estimated EGD costs using Medicare physician and facility fee rates. Among 518 initial EGDs performed (mean age 53 years; 54% female), the eMeasure identified 81 (16%) as low-value. The eMeasure’s sensitivity was 42% (95% CI 22 to 61) and specificity was 93% (95% CI 89 to 96). Stratifying across clinics, 62 (74.6%) low-value EGDs originated from 2 (12.5%) out of 16 clinics. Total cost for 81 low-value EGDs was approximately US$75 573, including US$14 985 in patients’ out-of-pocket costs. We developed a highly specific eMeasure that showed that low-value EGDs occurred frequently in our healthcare system and were concentrated in a minority of clinics. These results can inform future QI efforts at our institution, such as best practice alerts for the ordering physician. Moreover, this open-source eMeasure has a much broader potential impact, as it can be integrated into any EHR and improve medical decision-making at the point of care.