Learning implementation of a guideline based decision support system to improve hypertension treatment in primary care in China: pragmatic cluster randomised controlled trial,The BMJ

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Learning implementation of a guideline based decision support system to improve hypertension treatment in primary care in China: pragmatic cluster randomised controlled trial
The BMJ ( IF 93.6 ) Pub Date : 2024-07-23 , DOI: 10.1136/bmj-2023-079143
Jiali Song ₁ , Xiuling Wang ₁ , Bin Wang ₁ , Yilan Ge ₁ , Lei Bi ₁ , Fuyu Jing ₁ , Huijun Jin ₁ , Teng Li ₁ , Bo Gu ₂ , Lili Wang ₁ , Jun Hao ₃ , Yanyan Zhao ₃ , Jiamin Liu ₁ , Haibo Zhang ₁ , Xi Li _{1,

2} , Jing Li ₁ , Wenjun Ma ₄ , Jiguang Wang ₅ , Sharon-Lise T Normand _{6,

7} , Jeph Herrin ₈ , Jane Armitage _{9,

10} , Harlan M Krumholz _{8,

11,

12} , Xin Zheng _{2,

13,

14,

15} ,

Affiliation

National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China.
National Clinical Research Centre for Cardiovascular Diseases, Shenzhen, Fuwai Shenzhen Hospital, Chinese Academy of Medical Sciences, Shenzhen, China.
Medical Research and Biometrics Centre, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
Hypertension Centre, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China.
The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
Centre for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA.
Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA.
National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
Coronary Artery Disease Ward 2, Fuwai Shenzhen Hospital, Chinese Academy of Medical Sciences, Shenzhen, China.
Clinical Trial Centre, Fuwai Shenzhen Hospital, Chinese Academy of Medical Sciences, Shenzhen, China.

Objective To evaluate the effectiveness of a clinical decision support system (CDSS) in improving the use of guideline accordant antihypertensive treatment in primary care settings in China. Design Pragmatic, open label, cluster randomised trial. Setting 94 primary care practices in four urban regions of China between August 2019 and July 2022: Luoyang (central China), Jining (east China), and Shenzhen (south China, including two regions). Participants 94 practices were randomised (46 to CDSS, 48 to usual care). 12 137 participants with hypertension who used up to two classes of antihypertensives and had a systolic blood pressure <180 mm Hg and diastolic blood pressure <110 mm Hg were included. Interventions Primary care practices were randomised to use an electronic health record based CDSS, which recommended a specific guideline accordant regimen for initiation, titration, or switching of antihypertensive (the intervention), or to use the same electronic health record without CDSS and provide treatment as usual (control). Main outcome measures The primary outcome was the proportion of hypertension related visits during which an appropriate (guideline accordant) treatment was provided. Secondary outcomes were the average reduction in systolic blood pressure and proportion of participants with controlled blood pressure (<140/90 mm Hg) at the last scheduled follow-up. Safety outcomes were patient reported antihypertensive treatment related events, including syncope, injurious fall, symptomatic hypotension or systolic blood pressure <90 mm Hg, and bradycardia. Results 5755 participants with 23 113 visits in the intervention group and 6382 participants with 27 868 visits in the control group were included. Mean age was 61 (standard deviation 13) years and 42.5% were women. During a median 11.6 months of follow-up, the proportion of visits at which appropriate treatment was given was higher in the intervention group than in the control group (77.8% (17 975/23 113) v 62.2% (17 328/27 868); absolute difference 15.2 percentage points (95% confidence interval (CI) 10.7 to 19.8); P<0.001; odds ratio 2.17 (95% CI 1.75 to 2.69); P<0.001). Compared with participants in the control group, those in the intervention group had a 1.6 mm Hg (95% CI −2.7 to −0.5) greater reduction in systolic blood pressure (−1.5 mm Hg v 0.3 mm Hg; P=0.006) and a 4.4 percentage point (95% CI −0.7 to 9.5) improvement in blood pressure control rate (69.0% (3415/4952) v 64.6% (3778/5845); P=0.07). Patient reported antihypertensive treatment related adverse effects were rare in both groups. Conclusions Use of a CDSS in primary care in China improved the provision of guideline accordant antihypertensive treatment and led to a modest reduction in blood pressure. The CDSS offers a promising approach to delivering better care for hypertension, both safely and efficiently. Trial registration ClinicalTrials.gov [NCT03636334][1]. Data described in the manuscript will not be made publicly available. Data collected for the study will be made available publicly upon reasonable request. For further detailed data access policy and procedure, contact zhengxin@fuwai.com. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT03636334&atom=%2Fbmj%2F386%2Fbmj-2023-079143.atom

更新日期：2024-07-23

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