Electronic risk alerts to improve primary care management of chest pain: a randomized, controlled trial.
Electronic risk alerts to improve primary care management of chest pain: a randomized, controlled trial.
复制标题
电子风险警报可改善胸痛的初级保健管理：一项随机对照试验。
DOI：
10.1007/s11606-011-1911-6
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发表时间：
2012
影响因子：
5.7
通讯作者：
Lee,ThomasH
中科院分区：
文献类型：
--
作者：
Sequist,ThomasD;Morong,ShaneM;Marston,Amy;Keohane,CarolA;Cook,EFrancis;Orav,EJohn;Lee,ThomasH
背景胸痛的初级保健评估是一个重大的诊断挑战。目的确定向医生发出的电子警报是否可以提高胸痛评估的质量和安全性。设计和参与者在 2008 年 11 月至 2010 年 1 月期间对 292 名初级保健临床医生进行了随机对照试验，这些医生负责治疗 7,083 名没有心血管疾病史的成年胸痛患者。干预临床医生在就诊期间收到电子健康记录中的警报因胸痛就诊。一个警报建议对高危患者（弗雷明汉风险评分（FRS） ≥10%）进行心电图检查和服用阿司匹林，第二个警报建议不要对低风险患者进行心脏负荷测试（FRS < 10%）。 主要指标主要结果包括对高危患者进行心电图检查和服用阿司匹林治疗；避免对低风险患者进行心脏负荷测试。 主要结果 大多数 (81%) 胸痛患者被归类为低风险。高风险患者比低风险患者更有可能在急诊科接受评估（11% vs 5%，p<0.01）和住院治疗（7% vs 3%，p<0.01）。 26 名患者（0.4%）发生急性心肌梗死，与低风险患者相比，高风险患者更常见（1.1% 与 0.2%，p< 0.01）。在高危患者中，干预组和对照组之间进行心电图检查（51% vs 48%，p= 0.33）或服用阿司匹林（20% vs 18%，p= 0.43）的比率没有差异。在低风险患者中，干预组和对照组之间的心脏负荷测试率没有差异（10% vs 9%，p= 0.40）。结论对于高风险和低风险患者来说，胸痛的初级保健管理都不是最佳的。电子警报不会增加对这些患者的风险适当护理。
BACKGROUNDThe primary care evaluation of chest pain represents a significant diagnostic challenge.OBJECTIVETo determine if electronic alerts to physicians can improve the quality and safety of chest pain evaluations.DESIGN AND PARTICIPANTSRandomized, controlled trial conducted between November 2008 and January 2010 among 292 primary care clinicians caring for 7,083 adult patients with chest pain and no history of cardiovascular disease.INTERVENTIONClinicians received alerts within the electronic health record during office visits for chest pain. One alert recommended performance of an electrocardiogram and administration of aspirin for high risk patients (Framingham Risk Score (FRS) ≥ 10%), and a second alert recommended against performance of cardiac stress testing for low risk patients (FRS < 10%).MAIN MEASURESThe primary outcomes included performance of an electrocardiogram and administration of aspirin therapy for high risk patients; and avoidance of cardiac stress testing for low risk patients.KEY RESULTSThe majority (81%) of patients with chest pain were classified as low risk. High risk patients were more likely than low risk patients to be evaluated in the emergency department (11% versus 5%,p< 0.01) and to be hospitalized (7% versus 3%,p< 0.01). Acute myocardial infarction occurred among 26 (0.4%) patients, more commonly among high risk compared to low risk patients (1.1% versus 0.2%,p< 0.01). Among high risk patients, there was no difference between the intervention and control groups in rates of performing electrocardiograms (51% versus 48%,p= 0.33) or administering aspirin (20% versus 18%,p= 0.43). Among low risk patients, there was no difference between intervention and control groups in rates of cardiac stress testing (10% versus 9%,p= 0.40).CONCLUSIONSPrimary care management of chest pain is suboptimal for both high and low risk patients. Electronic alerts do not increase risk-appropriate care for these patients.