Prioritized Clinical Decision Support to Reduce Cardiovascular Risk

描述(由申请人提供)：该项目的目标是开发和实施复杂的基于护理点EHR的临床决策支持，以(A)确定并(B)优先考虑所有可用的循证治疗方案，以降低特定患者的心血管风险(CVR)。在开发了基于电子病历的决策支持干预措施后，我们将在一项小组随机试验中测试其对CVR的影响，该试验包括18家初级保健诊所、60名初级保健医生和18,000名患有中度或高度CVR的成年人。如果成功，这种方法将(A)改善慢性疾病的结局，并减少约35%的美国成年人口的CVR，(B)最大限度地提高对尖端门诊EHR系统的大规模投资的临床回报，以及(C)为如何利用EHR技术支持在初级保健环境中提供“个性化医疗”提供一个模式。 公共卫生相关性：该项目的目标是开发和实施复杂的基于护理点EHR的临床决策支持，以(A)确定并(B)优先考虑所有可用的循证治疗方案，以降低特定患者的心血管风险(CVR)。在具有中到高CVR和次优控制和潜在可逆CVR因素的患者每次就诊时，以不同的格式向初级保健医生(PCP)和患者提供治疗选项的优先列表。根据每种治疗方案潜在的CVR降低幅度，对可用的循证治疗方案进行优先排序。这种干预策略被称为优先临床决策支持(PCS)，是专门为在初级保健环境中广泛使用而设计的，有可能大幅加强目前在35%的美国成年人中控制CVR的努力，这些成年人的10年Framingham CVR为10%或更高。为了评估PCS干预措施降低成人CVR的能力，我们将随机选择18家初级保健诊所，其中包括60名初级保健医生(PCP)和大约18,000名符合条件的成年人，他们的基线Framingham 10年重大心血管事件(心脏病发作或中风)风险为10%或更高，分为两种实验条件之一：第一组包括9家诊所(30名初级保健医生和9,000名患者)，这些诊所将获得优先临床决策支持(PCS)，以在符合条件的成年人每次临床遇到时减少CVR。第二组包括9个诊所(30个初级保健医生和9000名患者)，这些诊所没有接受研究干预，构成了常规护理对照组。这项研究将正式检验这一假设，即在控制基线CVR后，在干预开始后12个月和24个月，组1的干预后10年Framingham CVR将好于组2。此外，还将评估干预对CVR特定成分(血压、血脂、血糖、阿司匹林的使用和吸烟)的影响，并量化干预的成本效益。这个创新项目建立在我们研究团队10年前的工作基础上，并通过引入优先顺序、通过在办公室访问时为患者和PCP提供决策支持以及通过将决策支持扩展到广泛而关键的临床领域来扩展先前成功的EHR临床决策支持干预措施。这个项目的结果，无论是积极的还是消极的，都将扩大我们对如何从目前正在复杂的门诊EHR系统中进行的大规模公共和私营部门投资中获得最大临床回报的理解。如果成功，这个决策支持工具可以广泛用于标准化和个性化由病例经理、药剂师和其他提供者在广泛的护理提供配置中提供的护理。

DESCRIPTION (provided by applicant): The objective of this project is to develop and implement sophisticated point-of-care EHR-based clinical decision support that (a) identifies and (b) prioritizes all available evidence-based treatment options to reduce a given patient's cardiovascular risk (CVR). After developing the EHR-based decision support intervention, we will test its impact on CVR, the components of CVR, in a group randomized trial that includes 18 primary care clinics, 60 primary care physicians, and 18,000 adults with moderate or high CVR. This approach, if successful, will (a) improve chronic disease outcomes and reduce CVR for about 35% of the U.S. adult population, (b) maximize the clinical return on the massive investments that are increasingly being made in sophisticated outpatient EHR systems, and (c) provide a model for how to use EHR technology support to deliver "personalized medicine" in primary care settings. PUBLIC HEALTH RELEVANCE: The objective of this project is to develop and implement sophisticated point-of-care EHR-based clinical decision support that (a) identifies and (b) prioritizes all available evidence-based treatment options to reduce a given patient's cardiovascular risk (CVR). The prioritized list of treatment options is provided in different formats to both the primary care physician (PCP) and patient at the time of each office visit made by a patient with moderate to high CVR and sub-optimally controlled and potentially reversible CVR factors. Available evidence-based treatment options are prioritized based on the magnitude of potential CVR reduction of each treatment option. This intervention strategy, referred to as Prioritized Clinical Decision Support (PCS), is specifically designed for widespread use in primary care settings and has the potential to substantially augment current efforts to control CVR in the 35% of American adults with 10-year Framingham CVR of 10% or higher. To assess the ability of the PCS intervention to reduce CVR in adults, we will randomize 18 primary care clinics with 60 primary care physicians (PCPs) and approximately 18,000 eligible adults with baseline Framingham 10-year risk of a major CV event (either heart attack or stroke) of 10% or more into one of two experimental conditions: Group 1 includes 9 clinics (with 30 PCPs and 9,000 patients) that will receive prioritized clinical decision support (PCS) to reduce CVR at the time of each clinical encounter made by an eligible adult. Group 2 includes 9 clinics (with 30 PCPs and 9,000 patients) that receive no study intervention and constitute a usual care control group. The study will formally test the hypothesis that after control for baseline CVR, post- intervention 10-year Framingham CVR will be better in Group 1 than Group 2 at 12 and 24 months after start of the intervention. In addition, impact of the intervention on specific components of CVR (BP, lipids, glucose, aspirin use, and smoking) will be assessed, and the cost-effectiveness of the intervention will be quantified. This innovative project builds upon 10 years of prior work by our research team, and extends prior successful EHR clinical decision support interventions by introducing prioritization, by providing decision support to both patients and PCPs at the time of the office visit, and by extending the decision support across the broad and critically important clinical terrain of CVR reduction. The results of this project, whether positive or negative, will extend our understanding of how to maximize the clinical return on massive public and private sector investments now being made in sophisticated outpatient EHR systems. If successful, this decision support tool could be broadly used to both standardize and personalize care delivered by case managers, pharmacists, and other providers in a wide range of care delivery configurations.