Characteristics and impact of interventions to support healthcare providers’ compliance with guideline recommendations for breast cancer: a systematic literature review

BackgroundBreast cancer clinical practice guidelines (CPGs) offer evidence-based recommendations to improve quality of healthcare for patients. Suboptimal compliance with breast cancer guideline recommendations remains frequent, and has been associated with a decreased survival. The aim of this systematic review was to characterize and determine the impact of available interventions to support healthcare providers' compliance with CPGs recommendations in breast cancer healthcare.MethodsWe searched for systematic reviews and primary studies in PubMed and Embase (from inception to May 2021). We included experimental and observational studies reporting on the use of interventions to support compliance with breast cancer CPGs. Eligibility assessment, data extraction and critical appraisal was conducted by one reviewer, and cross-checked by a second reviewer. Using the same approach, we synthesized the characteristics and the effects of the interventions by type of intervention (according to the EPOC taxonomy), and applied the GRADE framework to assess the certainty of evidence.ResultsWe identified 35 primary studies reporting on 24 different interventions. Most frequently described interventions consisted in computerized decision support systems (12 studies); educational interventions (seven), audit and feedback (two), and multifaceted interventions (nine). There is low quality evidence that educational interventions targeted to healthcare professionals may improve compliance with recommendations concerning breast cancer screening, diagnosis and treatment. There is moderate quality evidence that reminder systems for healthcare professionals improve compliance with recommendations concerning breast cancer screening. There is low quality evidence that multifaceted interventions may improve compliance with recommendations concerning breast cancer screening. The effectiveness of the remaining types of interventions identified have not been evaluated with appropriate study designs for such purpose. There is very limited data on the costs of implementing these interventions.ConclusionsDifferent types of interventions to support compliance with breast cancer CPGs recommendations are available, and most of them show positive effects. More robust trials are needed to strengthen the available evidence base concerning their efficacy. Gathering data on the costs of implementing the proposed interventions is needed to inform decisions about their widespread implementation

Supporting Clinical Decision Making in Cancer Care Delivery

Background: Cancer treatment and management require complicated clinical decision making to provide the highest quality of care for an individual patient. This is facilitated in part with ever-increasing availability of medications and treatments but hindered due to barriers such as access to care, cost of medications, clinician knowledge, and patient preferences or clinical factors. Although guidelines for cancer treatment and many symptoms have been developed to inform clinical practice, implementation of these guidelines into practice is often delayed or does not occur. Informatics-based approaches, such as clinical decision support, may be an effective tool to improve guideline implementation by delivering patient-specific and evidence-based knowledge to the clinician at the point of care to allow shared decision making with a patient and their family. The large amount of data in the electronic health record can be utilized to develop, evaluate, and implement automated approaches; however, the quality of the data must first be examined and evaluated. Methods: This dissertation addresses gaps the literature about clinical decision making for cancer care delivery. Specifically, following an introduction and review of the literature for relevant topics to this dissertation, the researcher presents three studies. In Study One, the researcher explores the use of clinical decision support in cancer therapeutic decision making by conducting a systematic review of the literature. In Study Two, the researcher conducts a quantitative study to describe the rate of guideline concordant care provided for prevention of acute chemotherapy-induced nausea and vomiting (CINV) and to identify predictors of receiving guideline concordant care. In Study Three, the researcher conducts a mixed-methods study to evaluate the completeness, concordance, and heterogeneity of clinician documentation of CINV. The final chapter of this dissertation is comprised of key findings of each study, the strengths and limitations, clinical and research implications, and future research. Results: In Study One, the systematic review, the researcher identified ten studies that prospectively studied clinical decision support systems or tools in a cancer setting to guide therapeutic decision making. There was variability in these studies, including study design, outcomes measured, and results. There was a trend toward benefit, both in process and patient-specific outcomes. Importantly, few studies were integrated into the electronic health record. In Study Two, of 180 patients age 26 years or less, 36% received guideline concordant care as defined by pediatric or adult guidelines, as appropriate. Factors associated with receiving guideline concordant care included receiving a cisplatin-based regimen, being treated in adult oncology compared to pediatric oncology, and solid tumor diagnosis. In Study Three, of the 127 patient records reviewed for the documentation of chemotherapy-induced nausea and vomiting, 75% had prescriber assessment documented and 58% had nursing assessment documented. Of those who had documented assessments by both prescriber and nurse, 72% were in agreement of the presence/absence of chemotherapy-induced nausea and vomiting. After mapping the concept through the United Medical Language System and developing a post-coordinated expression to identify chemotherapy-induced nausea and vomiting in the text, 85% of prescriber documentation and 100% of nurse documentation could be correctly categorized as present/absent. Further descriptors of the symptoms, such as severity or temporality, however, were infrequently reported. Conclusion: In summary, this dissertation provides new knowledge about decision making in cancer care delivery. Specifically, in Study One the researcher describes that clinical decision support, one potential implementation strategy to improve guideline concordant care, is understudied or under published but a promising potential intervention. In Study Two, I identified factors that were associated with receipt of guideline concordant care for CINV, and these should be further explored to develop interventions. Finally, in Study Three, I report on the limitations of the data quality of CINV documentation in the electronic health record. Future work should focus on validating these results on a multi-institutional level

Coupling computer-interpretable guidelines with a drug-database through a web-based system – The PRESGUID project

BACKGROUND: Clinical Practice Guidelines (CPGs) available today are not extensively used due to lack of proper integration into clinical settings, knowledge-related information resources, and lack of decision support at the point of care in a particular clinical context. OBJECTIVE: The PRESGUID project (PREScription and GUIDelines) aims to improve the assistance provided by guidelines. The project proposes an online service enabling physicians to consult computerized CPGs linked to drug databases for easier integration into the healthcare process. METHODS: Computable CPGs are structured as decision trees and coded in XML format. Recommendations related to drug classes are tagged with ATC codes. We use a mapping module to enhance computerized guidelines coupling with a drug database, which contains detailed information about each usable specific medication. In this way, therapeutic recommendations are backed up with current and up-to-date information from the database. RESULTS: Two authoritative CPGs, originally diffused as static textual documents, have been implemented to validate the computerization process and to illustrate the usefulness of the resulting automated CPGs and their coupling with a drug database. We discuss the advantages of this approach for practitioners and the implications for both guideline developers and drug database providers. Other CPGs will be implemented and evaluated in real conditions by clinicians working in different health institutions

Modélisation ontologique des recommandations de pratique clinique pour une aide à la décision à niveaux d'abstraction variables

Clinical practice guidelines (CPGs) are elaborated according to evidence-based medicine principles in order to improve healthcare quality. However, even when they are integrated into clinical decision support systems, recommendations are poorly implemented by physicians. Indeed, CPGs are often criticized for their lack of flexibility, and their inability to handle the singularity of patients encountered in clinical practice. In particular, CPGs are usually elaborated for a single pathology whereas patients usually suffer from multiple pathologies and comorbidities. We have proposed a method based on an ontological reasoning to enable the reconciliation of single-pathology CPGs to support the flexible management of patients with multiple pathologies. Knowledge bases are made of decision rules that formalize the content of single-pathology CPGs. Patient criteria are organized by a domain ontology, which allows the generation of a generalization-ordered graph of clinical patient profiles. The ontological reasoning allows to reason at different levels of abstraction to process clinical cases described with different levels of completeness. This method has been implemented in a decision support system called GO-DSS, and applied to the management of patients suffering from both arterial hypertension and type 2 diabetes, on the basis of CPGs produced by the VIDAL company (VIDAL Recos). The prototype and its user interfaces have been qualitatively evaluated by a sample of users including both computer scientists with medical knowledge and physicians with computer skills.Conformément aux principes de la médecine factuelle, les guides de bonne pratique clinique (GBPC) sont élaborés dans un but d'amélioration de la qualité des soins. Pourtant, le suivi des recommandations par les médecins reste faible, même lorsqu'elles sont intégrées dans des systèmes informatisés d'aide à la décision. En effet, elles sont souvent critiquées pour leur manque de flexibilité, et leur incapacité à gérer la singularité des patients rencontrés en pratique clinique. En particulier, leur orientation monopathologique est en inadéquation avec la réalité de patients bien souvent polypathologiques. Nos travaux portent sur la proposition d'une méthode basée sur un raisonnement ontologique pour permettre la conciliation de GBPC pour la prise en charge flexible de patients polypathologiques au sein d'un système d'aide à la décision. Les bases de connaissances reposent sur des règles construites par formalisation des recommandations, dont les critères patients sont organisés par une ontologie du domaine, permettant de produire un graphe des profils cliniques structuré par généralisation. Le raisonnement ontologique permet une juste adaptation des connaissances aux niveaux d'abstraction variables de la description du patient. Cette méthode a été implémentée dans un système d'aide à la décision, appelé GO-DSS, et appliquée à la prise en charge de patients diabétiques et hypertendus, à partir des GBPC produits par la société VIDAL (VIDAL Recos). Le prototype et ses interfaces ont été évalués qualitativement par un échantillon d'utilisateurs comprenant à la fois des informaticiens avec des connaissances médicales et des médecins avec des compétences en informatique

Front-Line Physicians' Satisfaction with Information Systems in Hospitals

Day-to-day operations management in hospital units is difficult due to continuously varying situations, several actors involved and a vast number of information systems in use. The aim of this study was to describe front-line physicians' satisfaction with existing information systems needed to support the day-to-day operations management in hospitals. A cross-sectional survey was used and data chosen with stratified random sampling were collected in nine hospitals. Data were analyzed with descriptive and inferential statistical methods. The response rate was 65 % (n = 111). The physicians reported that information systems support their decision making to some extent, but they do not improve access to information nor are they tailored for physicians. The respondents also reported that they need to use several information systems to support decision making and that they would prefer one information system to access important information. Improved information access would better support physicians' decision making and has the potential to improve the quality of decisions and speed up the decision making process.Peer reviewe