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美国耶鲁大学医学院Edward R Melnick团队研究了以用户为中心的临床决策支持在急诊科启用丁丙诺啡治疗阿片类药物使用障碍患者的影响。2022年6月27日出版的《英国医学杂志》发表了这项成果。

为了确定以用户为中心的临床决策支持工具与常规护理对阿片类药物使用障碍患者常规急诊护理中丁丙诺啡启用率的影响，研究组使用Epic或Cerner电子健康记录平台，在代表美国东北、东南和西部地区的五个州的五个医疗保健系统中建立了18个从社区医院到三级护理中心的急诊科集群，进行了一项实用性集群随机对照试验（EMBED）。共有599名急诊主治医师护理5047名患有阿片类药物使用障碍的成年患者。

一个以用户为中心、面向医生的临床决策支持系统无缝集成到电子健康记录中的用户工作流程中，通过帮助临床医生诊断阿片类药物使用障碍、评估戒断的严重程度、激励患者接受治疗，支持在急诊科启用丁丙诺啡，并通过自动化临床和就诊后文档、医嘱输入、处方和转诊来完成电子健康记录任务。主要观察指标为阿片类药物使用障碍患者在急诊室开始使用丁丙诺啡（丁丙诺啡的服用或处方）的比率。次要实施结局通过RE-AIM（达到、有效性、采用、实施和维护）框架衡量。

2019年11月至2021年5月，研究组对1413693例急诊患者（干预组775873例，常规护理组637820例）进行了资格评估，共有5047例阿片类药物使用障碍者，其中干预组2787例，常规护理组2260例，两组在599名主治医师（干预组340名，常规护理组259名）的护理下进行分析。干预组中有347名（12.5%）患者开始使用丁丙诺啡，常规护理组有271名（12.0%），组间差异不显著。干预组中有151名医生（44.4%）至少使用过一次丁丙诺啡，显著高于常规护理组的88名医生（34.0%）。

研究结果表明，以用户为中心的临床决策支持并没有增加急诊科患者使用丁丙诺啡的比率。虽然电子健康记录工作流程的简化和自动化可能会增加复杂、陌生的循证实践的采用，但仍需要更多干预措施来研究成瘾治疗的其他障碍，并提高阿片类药物使用障碍患者在急诊室使用丁丙诺啡的比率。

附：英文原文

Title: User centered clinical decision support to implement initiation of buprenorphine for opioid use disorder in the emergency department: EMBED pragmatic cluster randomized controlled trial

Author: Edward R Melnick, Bidisha Nath, James D Dziura, Martin F Casey, Molly M Jeffery, Hyung Paek, William E Soares, Jason A Hoppe, Haseena Rajeevan, Fangyong Li, Rachel M Skains, Lauren A Walter, Mehul D Patel, Srihari V Chari, Timothy F Platts-Mills, Erik P Hess, Gail D’Onofrio

Issue&Volume: 2022/06/27

Abstract:

Objective To determine the effect of a user centered clinical decision support tool versus usual care on rates of initiation of buprenorphine in the routine emergency care of individuals with opioid use disorder.

Design Pragmatic cluster randomized controlled trial (EMBED).

Setting 18 emergency department clusters across five healthcare systems in five states representing the north east, south east, and western regions of the US, ranging from community hospitals to tertiary care centers, using either the Epic or Cerner electronic health record platform.

Participants 599 attending emergency physicians caring for 5047 adult patients presenting with opioid use disorder.

Intervention A user centered, physician facing clinical decision support system seamlessly integrated into user workflows in the electronic health record to support initiating buprenorphine in the emergency department by helping clinicians to diagnose opioid use disorder, assess the severity of withdrawal, motivate patients to accept treatment, and complete electronic health record tasks by automating clinical and after visit documentation, order entry, prescribing, and referral.

Main outcome measures Rate of initiation of buprenorphine (administration or prescription of buprenorphine) in the emergency department among patients with opioid use disorder. Secondary implementation outcomes were measured with the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework.

Results 1413693 visits to the emergency department (775873 in the intervention arm and 637820 in the usual care arm) from November 2019 to May 2021 were assessed for eligibility, resulting in 5047 patients with opioid use disorder (2787 intervention arm, 2260 usual care arm) under the care of 599 attending physicians (340 intervention arm, 259 usual care arm) for analysis. Buprenorphine was initiated in 347 (12.5%) patients in the intervention arm and in 271 (12.0%) patients in the usual care arm (adjusted generalized estimating equations odds ratio 1.22, 95% confidence interval 0.61 to 2.43, P=0.58). Buprenorphine was initiated at least once by 151 (44.4%) physicians in the intervention arm and by 88 (34.0%) in the usual care arm (1.83, 1.16 to 2.89, P=0.01).

Conclusions User centered clinical decision support did not increase patient level rates of initiating buprenorphine in the emergency department. Although streamlining and automating electronic health record workflows can potentially increase adoption of complex, unfamiliar evidence based practices, more interventions are needed to look at other barriers to the treatment of addiction and increase the rate of initiating buprenorphine in the emergency department in patients with opioid use disorder.

DOI: 10.1136/bmj-2021-069271

Source: https://www.bmj.com/content/377/bmj-2021-069271

BMJ-British Medical Journal:《英国医学杂志》，创刊于1840年。隶属于BMJ出版集团，最新IF：93.333
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