瑞士伯尔尼大学Sven Streit团队对优化老年人多病多药的处方进行了一项聚类随机临床试验。该研究于2023年5月24日发表在《英国医学杂志》上。

为了研究以电子临床决策支持系统（eCDSS）为中心的初级保健药物审查干预对患有多种疾病和服用多种药物的老年人的药物适当性和处方遗漏数量的影响，并与药物治疗符合常规护理的讨论进行比较，研究组设计了一项集群随机临床试验。

2018年12月至2021年2月，研究组在瑞士初级保健机构招募年龄≥65岁的患者，有三种及以上慢性病和服用五种及以上长期药物。以eCDSS为中心的优化药物治疗的干预由全科医生进行，随后全科医生和患者共同决策，并与患者和全科医生之间关于药物与常规护理一致的讨论进行了比较。主要结局是12个月时药物适当性指数（MAI）和利用不足评估（AOU）的改善。次要结局包括用药次数、跌倒、骨折和生活质量。

在43个全科医生集群中，共招募了323名患者（中位年龄77岁；45%（n=146）为女性）。21名全科医生160名患者被分配到干预组，22名全科医师163名患者被分到对照组。平均而言，据报告，每位患者都会执行一项停止或开始服药的建议。

在12个月时，对药物适当性改善的意向治疗分析结果（比值比为1.05）和处方遗漏次数（0.90）未有结论。按方案分析也是如此。在12个月的随访中，未发现明确证据表明安全性结局存在差异，但在6个月和12个月时，干预组报告的安全性事件少于对照组。

在这项针对全科医生和老年人的随机试验中，与关于符合常规护理药物的讨论相比，围绕eCDSS的使用进行的药物审查干预是否在12个月时提高了药物的适当性或减少了处方遗漏，结果尚不确定。尽管如此，干预措施可以安全地进行，不会对患者造成任何伤害。

附：英文原文

Title: Optimising prescribing in older adults with multimorbidity and polypharmacy in primary care (OPTICA): cluster randomised clinical trial

Author: Katharina Tabea Jungo, Anna-Katharina Ansorg, Carmen Floriani, Zsofia Rozsnyai, Nathalie Schwab, Rahel Meier, Fabio Valeri, Odile Stalder, Andreas Limacher, Claudio Schneider, Michael Bagattini, Sven Trelle, Marco Spruit, Matthias Schwenkglenks, Nicolas Rodondi, Sven Streit

Issue&Volume: 2023/05/24

Abstract:

Objective To study the effects of a primary care medication review intervention centred around an electronic clinical decision support system (eCDSS) on appropriateness of medication and the number of prescribing omissions in older adults with multimorbidity and polypharmacy compared with a discussion about medication in line with usual care.

Design Cluster randomised clinical trial.

Setting Swiss primary care, between December 2018 and February 2021.

Participants Eligible patients were ≥65 years of age with three or more chronic conditions and five or more long term medications.

Intervention The intervention to optimise pharmacotherapy centred around an eCDSS was conducted by general practitioners, followed by shared decision making between general practitioners and patients, and was compared with a discussion about medication in line with usual care between patients and general practitioners.

Main outcome measures Primary outcomes were improvement in the Medication Appropriateness Index (MAI) and the Assessment of Underutilisation (AOU) at 12 months. Secondary outcomes included number of medications, falls, fractures, and quality of life.

Results In 43 general practitioner clusters, 323 patients were recruited (median age 77 (interquartile range 73-83) years; 45% (n=146) women). Twenty one general practitioners with 160 patients were assigned to the intervention group and 22 general practitioners with 163 patients to the control group. On average, one recommendation to stop or start a medication was reported to be implemented per patient. At 12 months, the results of the intention-to-treat analysis of the improvement in appropriateness of medication (odds ratio 1.05, 95% confidence interval 0.59 to 1.87) and the number of prescribing omissions (0.90, 0.41 to 1.96) were inconclusive. The same was the case for the per protocol analysis. No clear evidence was found for a difference in safety outcomes at the 12 month follow-up, but fewer safety events were reported in the intervention group than in the control group at six and 12 months.

Conclusions In this randomised trial of general practitioners and older adults, the results were inconclusive as to whether the medication review intervention centred around the use of an eCDSS led to an improvement in appropriateness of medication or a reduction in prescribing omissions at 12 months compared with a discussion about medication in line with usual care. Nevertheless, the intervention could be safely delivered without causing any harm to patients.

DOI: 10.1136/bmj-2022-074054

Source: https://www.bmj.com/content/381/bmj-2022-074054