『開好開滿』：運用臨床決策支援系統提升心臟衰竭病人指引導向藥物治療比率

Implementation of clinical decision support system to promote prescription of guideline-directed medical treatment drugs for congestive heart failure

前言：心衰竭病人使用腎素－血管張力素抑制劑、心速調節劑及醛固酮受體拮抗劑等指引導向藥物治療，可有效降低死亡率及再住院率，本團隊運用臨床決策支援系統，協助提升指引導向藥物治療比率。材料與方法：由資訊系統自動擷取病人的心衰竭診斷碼，於醫師記載病程紀錄時採『提示跳窗畫面』提醒指引導向藥物治療。當病人出院時仍有指引導向藥物未開立，則強制填具未使用之原因，以便後續分析檢討。結果：心衰竭臨床決策支援系統於2018年上線，系統建置前後指引導向藥物開立比率分別為腎素－血管張力素抑制劑：83.5％提升至95.7％（P=0.004）|心速調節劑：76.3％提升至93.6％（P=0.01）|和醛固酮受體拮抗劑：74.2％提升至78.6％（P=0.54）|心衰竭六個月內再住院率及住院死亡率分別從17.4％及9.2％下降至13.6％及3.4％。結論：臨床決策支援系統可以有效提升心衰竭病人之指引導向藥物處方率，進而改善六個月內再住院率及住院死亡率。

Background: Guideline-Directed Medical Treatment (GDMT) has been reported to be associated with a lower risk of in-hospital mortality and rehospitalization and is highly recommended in patients with congestive heart failure (CHF). Herein, we established the clinical decision support system (CDSS) to promote prescription of GDMT drugs for CHF with reduced left ventricular systolic function. Materials and Methods: A popout window was shown on the screen, with the help of capturing CHF-relevant coding by CDSS, to remind physicians to prescribe GDMT drugs every time when physicians were logging into the medical record system. The reasons why GDMT drugs were not given mandated to be checked and recorded before discharge. In 2018, the CDSS was established, by which the status of medications could be reported automatically and analyzed in patients with CHF. The prescription rates were compared before and after the establishment of the system. Results: The prescription rate of reninangiotensin system blockades, including angiotensin-converting-enzyme inhibitor, angiotensin II receptor antagonist or angiotensin receptor-neprilysin inhibitor was significantly increased from 83.5% to 95.7% (p=0.004)| the prescription rate of ratemodulating agents, including β-blocker or ivabradine, was significantly increased from 76.3% to 93.6% (p=0.01)| and the prescription rate of mineralocorticoid receptor antagonist was increased from 74.2% to 78.6% (p=0.54). The in-hospital mortality and 6-month rehospitalization rates were also improved. Conclusions: Our data showed that the adoption of the CDSS may probably improve the mortality and readmission rate of CHF by promoting the prescription rate of GDMT drugs for CHF.