本文由小咖机器人翻译整理

期刊来源：Ann Intern Med

原文链接：https://doi.org/10.7326/M23-2183

摘要内容如下：

背景

需要有效的战略来减少可能导致伤害的过度使用。

客观

评估临床医生决策支持的影响，将注意力转移到危害上，并将社会和声誉问题纳入老年初级保健患者的过度使用。

设计

18个月，单盲，实用，整群随机试验，限制随机化。（ClinicalTrials.gov：NCT04289753）

设置

2020年9月1日至2022年2月28日，在卫生系统内开展60项初级保健内科、家庭医学和老年病学实践。

参与者

参与实践的371名初级保健临床医生及其老年患者。

干预

行为科学知情，护理点，临床决策支持工具加上简短的基于病例的教育，解决3个主要临床结果（来自30个诊所的187名临床医生），与单独的简短的基于病例的教育（来自30个诊所的187名临床医生）进行比较。决策支持旨在提高潜在危害的显著性，传达社会规范，并促进问责制。

测量

对76岁及以上既往无前列腺癌的男性进行前列腺特异性抗原（PSA）检测，对65岁及以上的女性进行非特异性原因的尿液检测，对75岁及以上且糖化血红蛋白（HbA1c）低于7%的患者过度使用降糖药治疗糖尿病。

结果

在随机分组时，平均临床年度PSA检测、不明原因尿液检测和糖尿病过度治疗率分别为每100名患者24.9、23.9和16.8。干预18个月后，干预组的PSA检测年率（-8.7[95%CI，-10.2至-7.1]）、不明原因尿液检测年率（-5.5[CI，-7.0至-3.6]）和糖尿病过度治疗年率（-1.4[CI，-2.9至-0.03]）的调整后差异中的差异低于仅接受教育组。安全措施并未显示与尿路感染或高血糖相关的紧急护理增加。在既往接受过度治疗的糖尿病患者中，干预后HbA1c高于9.0%的情况更为常见（调整后的倍差，每100名患者0.47[95%CI，0.04至1.20]）。

局限性

单一的卫生系统限制了推广能力；电子健康数据限制了区分过度测试和记录不足的能力。

结论

与单独提供传统的基于病例的教育相比，旨在提高临床医生对可能的危害、社会规范和声誉问题的关注的决策支持减少了未指定的测试。糖尿病过度治疗的小幅下降也可能导致更高的糖尿病未控率。

主要资金来源

国家老龄化研究所。

英文原文如下：

Abstracts

BACKGROUND  Effective strategies are needed to curtail overuse that may lead to harm.

OBJECTIVE  To evaluate the effects of clinician decision support redirecting attention to harms and engaging social and reputational concerns on overuse in older primary care patients.

DESIGN  18-month, single-blind, pragmatic, cluster randomized trial, constrained randomization. (ClinicalTrials.gov: NCT04289753).

SETTING  60 primary care internal medicine, family medicine and geriatrics practices within a health system from 1 September 2020 to 28 February 2022.

PARTICIPANTS  371 primary care clinicians and their older adult patients from participating practices.

INTERVENTION  Behavioral science-informed, point-of-care, clinical decision support tools plus brief case-based education addressing the 3 primary clinical outcomes (187 clinicians from 30 clinics) were compared with brief case-based education alone (187 clinicians from 30 clinics). Decision support was designed to increase salience of potential harms, convey social norms, and promote accountability.

MEASUREMENTS  Prostate-specific antigen (PSA) testing in men aged 76 years and older without previous prostate cancer, urine testing for nonspecific reasons in women aged 65 years and older, and overtreatment of diabetes with hypoglycemic agents in patients aged 75 years and older and hemoglobin A1c (HbA1c) less than 7%.

RESULTS  At randomization, mean clinic annual PSA testing, unspecified urine testing, and diabetes overtreatment rates were 24.9, 23.9, and 16.8 per 100 patients, respectively. After 18 months of intervention, the intervention group had lower adjusted difference-in-differences in annual rates of PSA testing (-8.7 [95% CI, -10.2 to -7.1]), unspecified urine testing (-5.5 [CI, -7.0 to -3.6]), and diabetes overtreatment (-1.4 [CI, -2.9 to -0.03]) compared with education only. Safety measures did not show increased emergency care related to urinary tract infections or hyperglycemia. An HbA1c greater than 9.0% was more common with the intervention among previously overtreated diabetes patients (adjusted difference-in-differences, 0.47 per 100 patients [95% CI, 0.04 to 1.20]).

LIMITATION  A single health system limits generalizability; electronic health data limit ability to differentiate between overtesting and underdocumentation.

CONCLUSION  Decision support designed to increase clinicians' attention to possible harms, social norms, and reputational concerns reduced unspecified testing compared with offering traditional case-based education alone. Small decreases in diabetes overtreatment may also result in higher rates of uncontrolled diabetes.

PRIMARY FUNDING SOURCE  National Institute on Aging.

-----------分割线---------

点击链接：https://www.mediecogroup.com/community/user/vip/categories/ ，成为医咖会员，获取12项专属权益。

现在购买可享受最大优惠（买一年送三个月，买两年送一年），2024年2月10日起将不再享有该优惠。