Computerized clinical decision support systems for chronic disease management: A decision-maker-researcher partnership systematic review

<p>Abstract</p> <p>Background</p> <p>The use of computerized clinical decision support systems (CCDSSs) may improve chronic disease management, which requires recurrent visits to multiple health professionals, ongoing disease and treatment monitoring, and patient behavior modification. The objective of this review was to determine if CCDSSs improve the processes of chronic care (such as diagnosis, treatment, and monitoring of disease) and associated patient outcomes (such as effects on biomarkers and clinical exacerbations).</p> <p>Methods</p> <p>We conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid's EBM Reviews database, Inspec, and reference lists for potentially eligible articles published up to January 2010. We included randomized controlled trials that compared the use of CCDSSs to usual practice or non-CCDSS controls. Trials were eligible if at least one component of the CCDSS was designed to support chronic disease management. We considered studies 'positive' if they showed a statistically significant improvement in at least 50% of relevant outcomes.</p> <p>Results</p> <p>Of 55 included trials, 87% (n = 48) measured system impact on the process of care and 52% (n = 25) of those demonstrated statistically significant improvements. Sixty-five percent (36/55) of trials measured impact on, typically, non-major (surrogate) patient outcomes, and 31% (n = 11) of those demonstrated benefits. Factors of interest to decision makers, such as cost, user satisfaction, system interface and feature sets, unique design and deployment characteristics, and effects on user workflow were rarely investigated or reported.</p> <p>Conclusions</p> <p>A small majority (just over half) of CCDSSs improved care processes in chronic disease management and some improved patient health. Policy makers, healthcare administrators, and practitioners should be aware that the evidence of CCDSS effectiveness is limited, especially with respect to the small number and size of studies measuring patient outcomes.</p

Can computerized clinical decision support systems improve practitioners' diagnostic test ordering behavior? A decision-maker-researcher partnership systematic review

<p>Abstract</p> <p>Background</p> <p>Underuse and overuse of diagnostic tests have important implications for health outcomes and costs. Decision support technology purports to optimize the use of diagnostic tests in clinical practice. The objective of this review was to assess whether computerized clinical decision support systems (CCDSSs) are effective at improving ordering of tests for diagnosis, monitoring of disease, or monitoring of treatment. The outcome of interest was effect on the diagnostic test-ordering behavior of practitioners.</p> <p>Methods</p> <p>We conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid's EBM Reviews database, Inspec, and reference lists for eligible articles published up to January 2010. We included randomized controlled trials comparing the use of CCDSSs to usual practice or non-CCDSS controls in clinical care settings. Trials were eligible if at least one component of the CCDSS gave suggestions for ordering or performing a diagnostic procedure. We considered studies 'positive' if they showed a statistically significant improvement in at least 50% of test ordering outcomes.</p> <p>Results</p> <p>Thirty-five studies were identified, with significantly higher methodological quality in those published after the year 2000 (<it>p </it>= 0.002). Thirty-three trials reported evaluable data on diagnostic test ordering, and 55% (18/33) of CCDSSs improved testing behavior overall, including 83% (5/6) for diagnosis, 63% (5/8) for treatment monitoring, 35% (6/17) for disease monitoring, and 100% (3/3) for other purposes. Four of the systems explicitly attempted to reduce test ordering rates and all succeeded. Factors of particular interest to decision makers include costs, user satisfaction, and impact on workflow but were rarely investigated or reported.</p> <p>Conclusions</p> <p>Some CCDSSs can modify practitioner test-ordering behavior. To better inform development and implementation efforts, studies should describe in more detail potentially important factors such as system design, user interface, local context, implementation strategy, and evaluate impact on user satisfaction and workflow, costs, and unintended consequences.</p

A New Paradigm of Cardiovascular Risk Factor Modification

Atherosclerotic cardiovascular diseases (CVDs) are the leading cause of death and disability in the United States. While multiple studies have demonstrated that modification of atherosclerotic cardiovascular risk factors (CVRFs) significantly reduces morbidity and mortality rates, clinical control of CVDs and CVRFs remains poor. By 2010, the American Heart Association seeks to reduce coronary heart disease, stroke, and risk by 25%. To meet this goal, clinical practitioners must establish new treatment paradigms for CVDs and CVRFs. This paper discusses one such treatment model – a comprehensive atherosclerosis program run by physician extenders (under physician supervision), which incorporates evidence-based CVD and CVRF interventions to achieve treatment goals

Impact of Implementing a Dyslipidemia Management Guideline on Cholesterol Control for Secondary Prevention of Ischemic Heart Disease in Primary Care

Cardiovascular diseases (CVD) are the main cause of death worldwide. The control of CVD risk factors, such as dyslipidemia, reduces their mortality rate. Nonetheless, fewer than 50% of patients with ischemic heart disease (IHD) have good cholesterol control. Our objective is to assess whether the level of participation of general practitioners (GPs) in activities to implement a dyslipidemia management guideline, and the characteristics of the patient and physician are associated with cholesterol control in IHD patients. We undertook a quasi-experimental, uncontrolled, before-and-after study of 1151 patients. The intervention was carried out during 2010 and 2011, and consisted of a face-to-face training and online course phase (Phase 1), and another of face-to-face feedback (Phase 2). The main outcome variable was the low-density lipoprotein cholesterol (LDL-C) control, whereby values of <100 mg/dL (2.6 mmol/L) were set as a good level of control, according to the recommendations of the guidelines in force in 2009. After Phase 1, 6.7% more patients demonstrated good cholesterol control. With respect to patient characteristics, being female and being older were found to be risk factors of poor control. Being diabetic and having suffered a stroke were protective factors. Of the GPs' characteristics, being tutor in a teaching center for GP residents and having completed the online course were found to be protective factors. We concluded that cholesterol control in IHD patients was influenced by the type of training activity undertook by physicians during the implementation of the GPC, and patient and physician characteristics. We highlight that if we apply the recent targets of the European guideline, which establish a lower level of LDL-C control, the percentage of good control could be worse than the observed in this study

Stavovi obiteljskih liječnika o elektroničkim alatima i dostupnosti, uporabi i pridržavanju smjernica za prevenciju kardiovaskularnih bolesti u Hrvatskoj

Family physicians are burdened with a great number of guidelines considering different conditions they treat. We analyzed opinions of family physicians on electronic tools which help managing chronic conditions and their influence on patient care by cardiovascular disease (CVD) prevention guideline availability, usage and adherence. A descriptive study was performed on a convenient sample of 417 (response rate 56.0%) Croatian family physicians. Data on physician characteristics and availability, usage and adherence to CVD prevention guidelines were analyzed. The χ2-test was used for comparisons. Significance was defined as p<0.05. Family physicians who used additional electronic tools in Electronic Health Record software on more than 80% of their patients had CVD prevention guidelines more available (p<0.01) and used them more frequently (p<0.01). A group who used electronic tools on more than 80% of their patients had CVD prevention guidelines available to them frequently and used them on more than 60% of their patients, also strictly adhering to the guidelines (p<0.01). Physicians who used CVD prevention guidelines on more than 60% of their patients spent more time doing patient education (p=0.036). Using electronic tools helps Croatian family physicians in terms of availability, usage and adherence to the guidelines and quality improvement.Obiteljski liječnici su u radu opterećeni velikim brojem smjernica za različite bolesti. Analizirali smo njihovo mišljenje o elektroničkim alatima koji im pomažu u skrbi za bolesnike s kroničnim bolestima i njihovom utjecaju na dostupnost, uporabu i pridržavanje smjernica za prevenciju kardiovaskularnih bolesti (KVB). Provedeno je opisno istraživanje na uzorku od 417 (stopa odgovora 56,0%) hrvatskih obiteljskih liječnika. Analizirani su podaci o značajkama liječnika, dostupnosti, upotrebi i pridržavanju smjernica za prevenciju KVB. Za usporedbe je primijenjen χ2-test. Statistička značajnost je definirana kao p<0,05. Obiteljski liječnici koji su rabili dodatne elektroničke alate za više od 80% svojih bolesnika imali su dostupnije smjernice za prevenciju KVB (p<0,01) i više su ih upotrebljavali (p<0,01). Liječnici koji su istodobno rabili elektroničke alate na više od 80% svojih bolesnika često su imali na raspolaganju smjernice za prevenciju KVB i upotrebljavali su ih na više od 60% svojih bolesnika, a ujedno su se strogo pridržavali smjernica (p<0,01). Liječnici koji su rabili smjernice za prevenciju KVB na više od 60% svojih bolesnika proveli su i više vremena obrazujući svoje bolesnike (p=0,036). Primjena elektroničkih alata pomaže obiteljskim liječnicima u Hrvatskoj u pogledu dostupnosti, upotrebe i pridržavanja smjernica te unaprjeđenju kvalitete skrbi

Primary Stroke Prevention: 3-hydroxy-3-methyl-glutaryl-Coenzyme A (HMG-CoA) Reductase Inhibitor (statin) Use in the Diabetic Patient

Purpose: The primary objective for this retrospective chart review was to evaluate provider adherence to the 2011 AHA/ASA Primary Stroke Prevention guideline of prescribing a statin to all diabetic patients for primary prevention of stroke, regardless of dyslipidemia. A second aim of this study is to identify provider facilitators and barriers to prescribing a statin therapy for primary prevention. Methods: Using a retrospective study design, a random sample of 100 medical records of diabetic patients presenting to a university women’s health clinic within the previous year were reviewed for statin use and rationale. Results: Of the 100 diabetic patients sampled, only 69% were currently prescribed a statin therapy. Furthermore, only one patient had a diabetic rationale for statin use. Primary stroke prevention counseling and therapy aimed at prevention of primary stroke will be completed at a future date. Conclusion: In this clinic setting there is no documentation of adherence to the 2011 AHA/ASA Primary Stroke Prevention Guideline recommendation that statin therapy be used as a primary prevention in the diabetic population

Use of m-Health Technology for Preventive Interventions to Tackle Cardiometabolic Conditions and Other Non-Communicable Diseases in Latin America- Challenges and Opportunities

In Latin America, cardiovascular disease (CVD) mortality rates will increase by an estimated 145% from 1990 to 2020. Several challenges related to social strains, inadequate public health infrastructure, and underfinanced healthcare systems make cardiometabolic conditions and non-communicable diseases (NCDs) difficult to prevent and control. On the other hand, the region has high mobile phone coverage, making mobile health (mHealth) particularly attractive to complement and improve strategies toward prevention and control of these conditions in low- and middle-income countries. In this article, we describe the experiences of three Centers of Excellence for prevention and control of NCDs sponsored by the National Heart, Lung, and Blood Institute with mHealth interventions to address cardiometabolic conditions and other NCDs in Argentina, Guatemala, and Peru. The nine studies described involved the design and implementation of complex interventions targeting providers, patients and the public. The rationale, design of the interventions, and evaluation of processes and outcomes of each of these studies are described, together with barriers and enabling factors associated with their implementation.Fil: Beratarrechea, Andrea Gabriela. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Diez Canseco, Francisco. Universidad Peruana Cayetano Heredia; PerúFil: Irazola, Vilma. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Miranda, Jaime. Universidad Peruana Cayetano Heredia; PerúFil: Ramirez Zea, Manuel. Institute of Nutrition of Central America and Panama; GuatemalaFil: Rubinstein, Adolfo Luis. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentin

Diabetes Guidelines Implementation Toolkit

Diabetes Guidelines Implementation Toolkit is a capstone project aimed to help the Grady North Fulton Health Center to implement the American Diabetes Association (ADA) “Standards in Medical Care in Diabetes, 2011” guidelines. This toolkit can also be used to implement the diabetes guidelines in any other primary or community healthcare facility to improve diabetes care. Diabetes can affect many parts of the body and can lead to serious complications such as blindness, kidney damage, and lower-limb amputations. Working together, people with diabetes, their support network, and their health care providers can reduce the occurrence of these and other diabetes complications by controlling the levels of blood glucose, blood pressure, blood lipids, and by receiving other preventive care practices in a timely manner. Once the decision to put into practice the evidence-based diabetes guidelines has been made, this implementation toolkit will serve as a guide to help go through the process of implementation. The toolkit will suggest practical ways to implement the use of the guidelines using a stepwise approach, resources and template materials such as information handouts, flow sheets, referral forms, sample patient letters, etc. will be provided in the toolkit to facilitate the implementation. The final goal of the implementations is to improve the delivery of effective preventive health care services and promote diabetes preventive behaviors in order to prevent diabetes, its complications and disabilities, and the burden associated with the disease

Dyslipidemia Screening in Children between the Ages of 9 and 11 Years: An Evidence-Based Approach

PURPOSE: The purpose of this study is to examine the outcome of healthcare provider education on the incidence of dyslipidemia screening in a pediatric primary care clinic. METHODS: The design of this study was a descriptive pre and post design to evaluate if dyslipidemia screening rates, knowledge, and self-efficacy of healthcare providers changed following an education series at a general pediatric clinic in Lexington, KY. The rates of dyslipidemia screening were calculated prior to providing provider education as well as afterwards to see whether there was an improvement in screening rates. Provider’s knowledge and confidence before the education series was also assessed via a survey. The sample of this study consisted of 11 pediatric healthcare providers at a general pediatric clinic. The secondary sample of this study were the medical records of children between the ages of 9 and 11 years who presented to a general pediatric clinic for an annual well-child exam. The sample consisted of 256 medical records during the pre-education time period, June 2018 to August 2018, and 65 medical records during the post-education time period, September 10, 2018 to October 19, 2018. RESULTS: The Chi-square test of association was used to compare dyslipidemia screening rates before and after the educational intervention was given in the pediatric primary care clinic. The Chi-square test was also used after the educational burst e-mail was sent to all healthcare providers three weeks after the start of the study. Three months prior to the educational intervention being implemented, 17.2% of providers performed routine dyslipidemia screening on children between the ages of 9-11 years during annual well-child exams. Post-educational intervention, dyslipidemia screening rates increased to 24.6% (P=0.1701). An e-mail serving as an educational burst was sent to all providers at the clinic three weeks after the start of the study, regardless of whether they received education, reminding them of the evidence-based guidelines and the need to screen. Dyslipidemia screening rates increased from 18.75% prior to the e-mail to 26.53% after the e-mail was sent (P=0.7409). Lastly, descriptive statistics including means and standard deviations were used to summarize healthcare provider’s confidence and knowledge in dyslipidemia screening. The results yielded that many healthcare providers do not feel confident in the evidence-based guidelines regarding dyslipidemia screening and management in the pediatric primary care population nor feel comfortable treating. CONCLUSION: Dyslipidemia screening rates improved from 17.2% to 24.6%, an increase of 43% between the two percentages, at a general pediatric clinic after the educational intervention was implemented. This is a significant improvement and evidence that education on the current AAP guidelines was needed. Of the providers that participated, 81.8% strongly agreed that they felt more confident in when and how to screen, diagnose, and manage dyslipidemia in children between the ages of 9 and 11 years after they received education. Providing quality, evidence-based care is of utmost importance in the clinic. This intervention will likely lead to improved early diagnoses and treatment of dyslipidemia in the pediatric population and reduce morbidity and mortality in adulthood