Effect of Clinical Decision Support at Community Health Centers on the Risk of Cardiovascular Disease: A Cluster Randomized Clinical Trial.
Effect of Clinical Decision Support at Community Health Centers on the Risk of Cardiovascular Disease: A Cluster Randomized Clinical Trial.
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DOI：
10.1001/jamanetworkopen.2021.46519
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发表时间：
2022-02-01
影响因子：
13.8
通讯作者：
O'Connor PJ
中科院分区：
文献类型：
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作者：
Gold R;Larson AE;Sperl-Hillen JM;Boston D;Sheppler CR;Heintzman J;McMullen C;Middendorf M;Appana D;Thirumalai V;Romer A;Bava J;Davis JV;Yosuf N;Hauschildt J;Scott K;Moore S;O'Connor PJ
临床决策支持系统（CDSS）被证明可以降低综合护理环境中的心血管风险，是否也可以降低社区卫生中心的心血管风险？在这项包含18578名合格患者的随机分组临床试验中，尽管CDSS采用率较低，但在基线风险水平最高的患者中，CDSS的使用与心血管疾病可逆风险的显著改善相关。在社区卫生中心使用CDSS有可能改善社会经济脆弱的高风险患者心血管疾病的可逆风险;在这种情况下需要增加CDSS采用的策略。这项随机分组临床试验评估了在综合护理环境中开发的临床决策支持系统是否改善了在社区卫生中心接受治疗的心血管疾病风险患者的结局。在社会经济脆弱的患者中，心血管疾病（CVD）风险的管理是次优的;更好的风险因素控制可以改善CVD结局。评估社区卫生中心（CHC）针对心血管疾病风险的临床决策支持系统（CDSS）的影响。这项随机临床试验包括70个CHC诊所，从2018年9月20日至2020年3月15日随机分配到干预组（42个诊所; 8个组织）或未接受干预的对照组（28个诊所; 7个组织）。根据组织规模，由CHC组织进行随机化。年龄在40 - 75岁之间的患者（1）患有糖尿病或动脉粥样硬化性CVD，并且至少有1个不受控制的CVD主要风险因素，或（2）总可逆性CVD风险至少为10%，是CDSS干预的目标人群。即时CDSS显示实时CVD风险因素控制数据和个性化、优先循证护理建议。总心血管疾病风险和可逆心血管疾病风险的一年变化（即，如果6个关键风险因素达到循证控制水平，则认为可以实现10年心血管疾病风险的降低）。在18578名合格患者中，（9490例[51.1%]女性;平均[SD]年龄，58.7 [8.8]岁），在对照诊所就诊的患者（n = 7419）的平均（SD）基线CVD风险较高（16.6% [12.8%]）高于干预诊所（n = 11159）（15.6% [12.3%]; P <0.001）;对照诊所患者的基线可逆性CVD风险同样较高。在91988个合格的干预诊所就诊中，19.8%使用了CDSS。在对照或干预诊所的患者中，没有观察到人群水平的CVD风险降低;对照组患者的平均可逆风险（-0.1%[95%CI，-0.3%至0.02%]）比干预诊所（0.4% [95%CI，0.3%至0.5%]; P <0.001）显著改善。然而，当使用CDSS时，干预组基线风险高的患者的两项风险指标均比对照组降低更多;值得注意的是，平均可逆风险绝对值下降了4.4%，（95% CI，−5.2%至−3.7%），相比之下，（95% CI，-3.4%至1.9%）（P = .001）。CDSS的使用率较低，未能改善总体人群的CVD风险，但当其持续用于CHC治疗的高基线风险患者时，似乎对CVD风险有获益。尽管存在一些局限性，但这些结果提供了初步证据，表明该技术有可能改善具有高CVD风险的社会经济脆弱患者的临床护理。ClinicalTrials.gov标识符：NCT 03001713
Does a clinical decision support system (CDSS) proven to reduce cardiovascular risk in integrated care settings also reduce cardiovascular risk in community health centers? In this cluster randomized clinical trial of 18 578 eligible patients, although CDSS adoption rates were low, CDSS use was associated with significantly improved reversible risk of cardiovascular disease among patients with the highest levels of baseline risk. The use of a CDSS in community health centers has the potential to improve reversible risk of cardiovascular disease among socioeconomically vulnerable high-risk patients; strategies to increase CDSS adoption in this setting are needed. This cluster randomized clinical trial assesses whether a clinical decision support system developed in an integrated care setting improves outcomes of patients at risk for cardiovascular disease who are treated in community health centers. Management of cardiovascular disease (CVD) risk in socioeconomically vulnerable patients is suboptimal; better risk factor control could improve CVD outcomes. To evaluate the impact of a clinical decision support system (CDSS) targeting CVD risk in community health centers (CHCs). This cluster randomized clinical trial included 70 CHC clinics randomized to an intervention group (42 clinics; 8 organizations) or a control group that received no intervention (28 clinics; 7 organizations) from September 20, 2018, to March 15, 2020. Randomization was by CHC organization accounting for organization size. Patients aged 40 to 75 years with (1) diabetes or atherosclerotic CVD and at least 1 uncontrolled major risk factor for CVD or (2) total reversible CVD risk of at least 10% were the population targeted by the CDSS intervention. A point-of-care CDSS displaying real-time CVD risk factor control data and personalized, prioritized evidence-based care recommendations. One-year change in total CVD risk and reversible CVD risk (ie, the reduction in 10-year CVD risk that was considered achievable if 6 key risk factors reached evidence-based levels of control). Among the 18 578 eligible patients (9490 [51.1%] women; mean [SD] age, 58.7 [8.8] years), patients seen in control clinics (n = 7419) had higher mean (SD) baseline CVD risk (16.6% [12.8%]) than patients seen in intervention clinics (n = 11 159) (15.6% [12.3%]; P < .001); baseline reversible CVD risk was similarly higher among patients seen in control clinics. The CDSS was used at 19.8% of 91 988 eligible intervention clinic encounters. No population-level reduction in CVD risk was seen in patients in control or intervention clinics; mean reversible risk improved significantly more among patients in control (−0.1% [95% CI, −0.3% to −0.02%]) than intervention clinics (0.4% [95% CI, 0.3% to 0.5%]; P < .001). However, when the CDSS was used, both risk measures decreased more among patients with high baseline risk in intervention than control clinics; notably, mean reversible risk decreased by an absolute 4.4% (95% CI, −5.2% to −3.7%) among patients in intervention clinics compared with 2.7% (95% CI, −3.4% to −1.9%) among patients in control clinics (P = .001). The CDSS had low use rates and failed to improve CVD risk in the overall population but appeared to have a benefit on CVD risk when it was consistently used for patients with high baseline risk treated in CHCs. Despite some limitations, these results provide preliminary evidence that this technology has the potential to improve clinical care in socioeconomically vulnerable patients with high CVD risk. ClinicalTrials.gov Identifier: NCT03001713
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DOI：
10.1161/hcq.0000000000000057
发表时间：
2019-11
期刊：
Circulation. Cardiovascular quality and outcomes
影响因子：
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作者：
Casey DE Jr;Thomas RJ;Bhalla V;Commodore-Mensah Y;Heidenreich PA;Kolte D;Muntner P;Smith SC Jr;Spertus JA;Windle JR;Wozniak GD;Ziaeian B
通讯作者：
Ziaeian B
影响因子：
8.2
作者：
Altmann, EM;Gray, WD
通讯作者：
Gray, WD
影响因子：
5.7
作者：
Jean-Jacques, Muriel;Persell, Stephen D.;Baker, David W.
通讯作者：
Baker, David W.
DOI：
10.1093/jamia/ocv030
发表时间：
2015-07-01
影响因子：
6.4
作者：
Ancker, Jessica S.;Kern, Lisa M.;Kaushal, Rainu
通讯作者：
Kaushal, Rainu
影响因子：
16.2
作者：
通讯作者：
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