Does Clinical Decision Support Reduce Unwarranted Variation in Yield of CT Pulmonary Angiogram?
Does Clinical Decision Support Reduce Unwarranted Variation in Yield of CT Pulmonary Angiogram?
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DOI：
10.1016/j.amjmed.2013.04.018
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发表时间：
2013-11-01
影响因子：
5.9
通讯作者：
Khorasani, Ramin
中科院分区：
文献类型：
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作者：
Prevedello, Luciano M.;Raja, Ali S.;Khorasani, Ramin
目的：研究目的是确定先前记录的临床决策支持对急诊科肺栓塞计算机断层扫描的影响（即减少使用和增加产量）是否由于减少了不必要的变异。在这种情况下，我们评估了临床决策支持对肺栓塞计算机断层扫描（PE-CT）产率的内科和内科变异性的影响。方法：该研究在一个学术成人医疗中心急诊科进行，每年有6万人次就诊。我们招募了所有进行了18个月PE-CT临床前和临床后决策支持实施的患者。评估了医师内部和医师之间的产率差异（急性肺栓塞PE-CT阳性百分比）。采用考虑患者特征的逻辑回归来测量产量变异性。结果：临床决策支持前共进行了1542次PE-CT扫描，临床决策支持后共进行了1349次PE-CT扫描。在临床决策支持后，PE-CT的使用从每1000例患者26.5次降至24.3次（P < 0.02）；产量由9.2%提高到12.6% （P < 0.01）。在临床决策支持前，医师间的粗差异率为2.6% ~ 20.5%，在临床决策支持后为0% ~ 38.1%。在控制患者特征后，临床后决策支持期显示出显著的医生间差异（P < .04）。在25名医生中，有3名医生的内部变异性是显著的（P < .04），所有这些医生的临床后决策支持都增加了。结论：尽管医生之间存在显著的异质性，但实施临床决策支持后，PE-CT的总体产出率增加。临床决策支持后医师间产量的增加差异不能单独用患者特征来解释，可能是由于不同医师对临床决策支持的接受程度不同。临床决策支持本身不太可能消除不必要的可变性，可能需要额外的战略和干预措施来帮助优化临床决策支持的接受度，以最大限度地提高国家卫生信息技术投资的回报。(C) 2013爱思唯尔公司版权所有。
OBJECTIVE: The study objective was to determine whether previously documented effects of clinical decision support on computed tomography for pulmonary embolism in the emergency department (ie, decreased use and increased yield) are due to a decrease in unwarranted variation. We evaluated clinical decision support effect on intra-and inter-physician variability in the yield of pulmonary embolism computed tomography (PE-CT) in this setting.METHODS: The study was performed in an academic adult medical center emergency department with 60,000 annual visits. We enrolled all patients who had PE-CT performed 18 months pre- and post-clinical decision support implementation. Intra-and inter-physician variability in yield (% PE-CT positive for acute pulmonary embolism) were assessed. Yield variability was measured using logistic regression accounting for patient characteristics.RESULTS: A total of 1542 PE-CT scans were performed before clinical decision support, and 1349 PE-CT scans were performed after clinical decision support. Use of PE-CT decreased from 26.5 to 24.3 computed tomography scans/1000 patient visits after clinical decision support (P < .02); yield increased from 9.2% to 12.6% (P < .01). Crude inter-physician variability in yield ranged from 2.6% to 20.5% before clinical decision support and from 0% to 38.1% after clinical decision support. After controlling for patient characteristics, the post-clinical decision support period showed significant inter-physician variability (P < .04). Intra-physician variability was significant in 3 of the 25 physicians (P < .04), all with increased yield post-clinical decision support.CONCLUSIONS: Overall PE-CT yield increased after clinical decision support implementation despite significant heterogeneity among physicians. Increased inter-physician variability in yield after clinical decision support was not explained by patient characteristics alone and may be due to variable physician acceptance of clinical decision support. Clinical decision support alone is unlikely to eliminate unwarranted variability, and additional strategies and interventions may be needed to help optimize acceptance of clinical decision support to maximize returns on national investments in health information technology. (C) 2013 Elsevier Inc. All rights reserved.