利用基于网络的临床决策支持系统改善英国初级保健中的肌肉骨骼护理质量：混合方法整群随机对照试验。
完整摘要 · 中文译文
背景：在英国，肌肉骨骼（MSK）疾病占全科咨询量的七分之一。尽管有国家指南，次优诊疗仍然普遍存在。数字临床决策支持系统（CDSS）为提高诊疗质量提供了一条有前景的途径，但尚未在肌肉骨骼初级医疗中得到充分评估。 目的：本研究旨在评估一种用于英国全科医疗肌肉骨骼咨询的临床决策支持系统（CrossCover）的有效性、临床疗效和成本效益、碳减排、安全性及其实施情况。 方法：我们在2024年2月至7月期间，在19家全科诊所开展了一项混合方法、整群随机对照试验。诊所按1：1比例随机分组，并按名单规模进行分层。干预组诊所接受了培训，并可使用基于网络的临床决策支持系统3个月。我们分析了匿名电子健康记录，以识别所有成人肌肉骨骼咨询。主要结局为包含12项预设非循证管理选项中一项或多项的患者记录比例，通过盲法临床审查120份患者记录（每组60份）进行评估。审查员对两组患者完整3个月的记录进行评估；在干预组中，仅在使用了临床决策支持系统的咨询中出现次优管理时才予以计数。次要结局包括意向性治疗比较中的自我管理建议、处方、转诊和影像学检查。此外，还评估了临床医生的参与度、安全性、环境和经济学模型，以及来自半结构化访谈的临床医生经验。 评估者设盲；临床医生未设盲。 结果：在10182名符合条件的肌肉骨骼（MSK）疾病患者中（4268名干预组；5914名对照组），CDSS在365例（8.6%）患者病例中被使用。意向性治疗分析显示，干预措施仅增加了自我管理建议。符合方案分析显示，当CDSS被使用时，CDSS引导的咨询中出现次优照护的比例为3%（2/60），而对照咨询中为25%（15/60）（调整后的比值比为12.30，95%置信区间2.52-59.9；P=0.002）。该措施还增加了自我管理建议和社区转诊，并减少了处方开具和病假条使用。安全性问题在6.6%（24/365）的使用案例中被记录，未发现高风险问题。环境模型估计，若该干预措施得以推广，碳排放将减少18%，年度成本节省10%。访谈（n=18）强调了对CDSS内容和安全网措施的良好评价，但指出了整合方面的挑战。 结论：当使用时，CrossCover CDSS显著减少了初级保健中肌肉骨骼疾病管理的次优照护。然而，尽管安全性和临床医生反馈良好，总体参与度有限，这凸显了改善数字整合、工作流程协调和实施支持的必要性。
完整摘要 · 英文原文
BACKGROUND: Musculoskeletal (MSK) conditions account for one in seven general practice consultations in the United Kingdom. Despite national guidelines, suboptimal care remains common. Digital clinical decision support systems (CDSSs) offer a promising route to improve care quality but have not been robustly evaluated in MSK primary care. OBJECTIVE: This study aimed to evaluate the efficacy, clinical effectiveness and cost-effectiveness, carbon reduction, safety, and implementation of a CDSS (CrossCover) for MSK consultations in UK general practice. METHODS: We conducted a mixed methods, cluster-randomized controlled trial in 19 general practices between February and July 2024. Practices were randomized 1:1, stratified by list size. Intervention practices received training and access to the web-based CDSS for 3 months. We analyzed anonymized electronic health records to identify all adult MSK consultations. The primary outcome was the proportion of patient records containing one or more of 12 predefined non-evidence-based management options, assessed by blinded clinical review of 120 patient records (60 per arm). Reviewers assessed the complete 3-month record in both arms; in the intervention arm, suboptimal management was counted only where it occurred at a consultation in which the CDSS was used. Secondary outcomes included intention-to-treat treatment comparisons of self-management advice, prescriptions, referrals, and imaging. Clinician engagement, safety, environmental and economic modeling, and clinician experiences from semistructured interviews were evaluated. Outcome assessors were blinded; clinicians were not. RESULTS: Among 10,182 eligible patients with MSK conditions (4268 intervention; 5914 control), the CDSS was used in 365 (8.6%) patient cases. Intention-to-treat analysis identified that the intervention increased self-management alone. Per-protocol analysis demonstrated that when used, suboptimal care arose in 3% (2/60) of CDSS-guided consultations vs 25% (15/60) of control consultations (adjusted odds ratio 12.30, 95% CI 2.52-59.9; P=.002). It also increased self-management advice and community referrals, and it reduced prescribing and fit-note use. Safety concerns were logged in 6.6% (24/365) of uses with no high-risk issues identified. Environmental modeling estimated an 18% reduction in carbon emissions and 10% annual cost savings if the intervention were scaled. Interviews (n=18) highlighted positive perceptions of the CDSS's content and safety netting but noted challenges in integration. CONCLUSIONS: When used, the CrossCover CDSS significantly reduced suboptimal primary care MSK management. However, while safety and clinician feedback were favorable, overall engagement was limited, underscoring the need for improved digital integration, workflow alignment, and implementation support.