A Clinical Decision Support System Promotes Shared Decision-Making and Cardiovascular Risk Factor Management

Background: CV Wizard is a web-based electronic health record-integrated point-of-care clinical decision support (CDS) system that presents personalized cardiovascular (CV) risk information to providers and patients in both a low numeracy visual format and a high numeracy quantitative format. Herein we report primary care provider perspectives on how this CDS system affected shared decision-making and CV risk factor management. Methods: Twenty clinics were randomized to either usual care or use of the CDS system for adults with diabetes, heart disease or high reversible CV risk. The CDS system targeted 20% of office visits and was used at 70%–80% of targeted visits over a 2-year period. Consented providers (n = 102) were surveyed at baseline and 18 months after implementation. Corrected survey response rates were 90% at baseline and 82% at follow-up. Generalized linear mixed models were used to compare usual care and CDS responses to common questions at baseline and follow-up, and CDS users were queried on their perceptions of the CDS system at follow-up only. Results: Compared to usual care providers, those in the CDS group reported increased follow-up rates of CV risk calculations while seeing patients (73% vs 28%, P = 0.006), being better prepared to discuss CV risk reduction priorities with patients (98% vs 78%, P = 0.03), providing accurate advice on aspirin for primary prevention (75% vs 48%, P = 0.02), and more often discussing CV risk reduction (60% vs 30%, P = 0.06). CDS users reported that the CDS system improved CV risk factor control (98%), saved time when talking to patients about CV risk reduction (93%), efficiently elicited patient treatment preferences (90%), was useful for shared decision-making (95%), influenced treatment recommendations (89%) and helped initiate CV risk discussions (94%); 85% of providers reported that their patients liked CV Wizard. Conclusion: The CV Wizard CDS system was successfully integrated into the workflow of primary care visits with high sustained use rates, high primary care provider satisfaction, high patient satisfaction, and positive impacts on provider-reported clinical processes related to CV risk factor management

Impact of Improving Diabetes Care on Quality-Adjusted Life Expectancy and Costs: A 40-Year Perspective

Background: There has been a trend toward better management of glucose, lipids, blood pressure, smoking and other aspects of diabetes care in the last decade. The goals of this study are to assess changes in quality of diabetes care over a 14-month period of time in a large, multispecialty U.S. medical group, to quantify treatment costs associated with the improved care, and to estimate the impact of care improvement on long-term costs and quality-adjusted life expectancy. Methods: Study subjects included 7,054 persons with diabetes, age 40–75 years, who at baseline had one or more of: systolic blood pressure \u3e 140 mmHg, low-density lipoprotein cholesterol \u3e 129 mg/dL, or current smoking status. We quantified their clinical status including A1c, blood pressure, lipids and smoking status both at baseline and after a median 14-month follow-up period. We similarly quantified visit frequency and medication use and associated costs in the year prior and year following the baseline visit. We employed these clinical risk factors and observed costs as data inputs into a log-term simulation model of diabetes outcomes –– the United Kingdom Prospective Diabetes Study Outcomes Model (Version 2) –– in order to estimate changes in quality-adjusted life years (QALYs) and costs associated with changes in clinical care, projected over a 40-year time period. We applied costs of complications that were derived from a previous study within this health system. We then estimated the cost per QALY gain for these adult diabetes subjects who are experiencing better clinical care over time. Results: Observed improvements in clinical care significantly increased expected QALY from 10.83 to 11.06, for a gain in 0.22 QALY. Incremental costs associated with outpatient visits and intensification of pharmacotherapy were $167 per year and$2,323 over the study period. Total costs increased by $4,453. Cost per QALY was estimated to be$19,866. Sensitivity analysis indicated that estimates of cost per QALY were more favorable in simulations with longer follow-up periods and in simulations that more narrowly targeted blood pressure control among those with high blood pressure at baseline. Conclusion: Observed improvements in diabetes care over a recent 14-month period of time are sufficient to significantly improve clinical and health outcomes. The cost-effectiveness of the slightly more intensive diabetes care provided appears to be satisfactory using standard thresholds for cost per QALY, both in the base case and across a range of sensitivity analysis scenarios. However, improvements in diabetes care are not cost saving from the point of view of the payer

Clinical Decision Support Impact on Overuse and Underuse of Aspirin for Primary Prevention of Cardiovascular Events

Background: The U.S. Preventive Services Task Force (USPSTF) recommends aspirin for primary prevention of atherosclerotic vascular disease (ASCVD) when the ASCVD benefit outweighs the risk of gastrointestinal hemorrhage. The complexity and time required to assess aspirin risks and benefits can result in overuse and underuse of aspirin. Methods: As part of a National Institutes of Health-funded study to lower ASCVD risk, we implemented electronic clinical decision support (CDS) algorithms to guide aspirin use based on USPSTF criteria and major bleeding risks. Baseline data was collected for whether aspirin was algorithmically recommended for all patients at their first eligible primary care encounter in 20 clinics over 2012–2014. The analysis excluded patients with congenital heart disease and included 6,651 adults with diabetes (mean age: 55.6 years; mean 10-year ASCVD risk: 27.8%) and 11,682 adults meeting prespecified criteria for high ASCVD risk without diabetes (mean age: 58.4 years; mean 10-year ASCVD risk: 24.7%). Overuse and underuse was determined by comparing concordance with (a) aspirin recommendations, and (b) documented aspirin use. Results: The CDS recommended aspirin for 4,139 (63.1%) patients with diabetes and 8,722 (74.7%) without diabetes. Among patients with aspirin recommended, aspirin was not used in 829 of 4,139 (20%) with diabetes and 6,493 of 8,722 (74.4%) without diabetes (underuse). Among patients for whom the CDS did not recommend aspirin, aspirin was used in 1,448 of 2,969 (59.8%) with diabetes and 1,021 of 2,960 (34.4%) without diabetes (overuse). Conclusion: Those with diabetes who were likely to benefit from aspirin use had higher aspirin use rates (less underuse) than similar high-cardiovascular-risk patients without diabetes. However, those with diabetes who were unlikely to benefit from aspirin based on USPSTF criteria and bleeding risks also had higher aspirin use rates (more overuse) than patients without diabetes. Strategies to ensure greater evidence-based use of aspirin, such as providing electronic clinical decision support, may help providers more accurately assess individualized risks and benefits of aspirin

Aspirin for Primary Prevention of Atherosclerotic Cardiovascular Disease: Challenges to Appropriate Use

Background: Aspirin use for primary prevention of atherosclerotic cardiovascular disease (ASCVD) should be highly individualized in order to accurately balance benefits and risks. There are now practical approaches for clinicians to calculate ASCVD and bleeding risks using web-based tools and mobile apps to facilitate good decision-making, but their lack of integration with the electronic health record (EHR) and need for extensive data input are barriers to use by busy clinicians. Methods: As part of a clinic randomized trial with 20 primary care clinics, we developed and tested an EHR-integrated web-based clinical decision support (CDS) system that provided individualized aspirin recommendations to patients and clinicians using risk-benefit calculations. During the 18-month intervention, aspirin recommendations were printed for patients and providers at 75% of eligible encounters. We evaluated the effects of the intervention on rates of appropriate primary prevention aspirin use among 3,958 patients with diabetes and 7,000 patients without diabetes, aged 40–75 years, with uncontrolled cardiovascular disease risk factors. Results: At baseline, among patients using aspirin, it was not recommended (overused) for 840 of 1,474 (57%) patients with diabetes and 564 of 1,659 (34%) without diabetes. Of patients not using aspirin, it was recommended (underused) by 522 of 2,484 (21%) patients with diabetes and 4,006 of 5,371 (75%) without diabetes. At the last follow-up visit, no significant differences were noted in aspirin use patterns for patients with diabetes. However, among patients without diabetes who were “underusing” aspirin at baseline, 12.9% were using aspirin in CDS clinics compared to 10.4% in control clinics (P = 0.03). Among patients who were “overusing” aspirin at baseline, 4.1% had discontinued using aspirin in CDS system clinics compared to 7.9% in control clinics (P = 0.06). Conclusion: Patterns of appropriate aspirin use are different among patients with and without diabetes, with overuse being more common in diabetes and underuse more common in those without diabetes. Our study results suggest that the use of accurate CDS by clinicians and patients improve overall concordance with aspirin. A better understanding of how best to present understandable risk-benefit information to providers and patients is needed

Understanding Healthcare Professionals\u27 Perspectives on Point-of-Care Testing

Point-of-care testing (POCT) is an emerging technology that provides crucial assistance in delivering healthcare. The COVID-19 pandemic led to the accelerated importance of POCT technology due to its in-home accessibility. While POCT use and implementation has increased, little research has been published about how healthcare professionals perceive these technologies. The objective of our study was to examine the current perspectives of healthcare professionals towards POCT. We surveyed healthcare professionals to quantify perceptions of POCT usage, adoption, benefits, and concerns between October 2020 and November 2020. Questions regarding POCT perception were assessed on a 5-point Likert Scale. We received a total of 287 survey responses. Of the respondents, 53.7% were male, 66.6% were white, and 30.7% have been in practice for over 20 years. We found that the most supported benefit was POCTs ability to improve patient management (92%) and that the most supported concern was that POCTs lead to over-testing (30%). This study provides a better understanding of healthcare workers\u27 perspectives on POCT. To improve patient outcomes through the usage of POCT, greater research is needed to assess the needs and concerns of industry and healthcare stakeholders

A Clinical Decision Support System Promotes Shared Decision-Making and Cardiovascular Risk Factor Management

Background/Aims: Cardiovascular (CV) Wizard is a web-based electronic health record-integrated point-of-care clinical decision support (CDS) system that presents personalized CV risk information to providers and patients in both a low-numeracy visual format and a high-numeracy quantitative format. We report primary care provider perspectives on how this CDS system affected shared decision-making and CV risk factor management. Methods: Twenty clinics were randomized to either usual care or use of the CDS system with diabetes, heart disease or high-reversible CV risk adults. The CDS system targeted 20% of office visits and was used at 70–80% of targeted visits over a 2-year period. Consented providers (N = 102) were surveyed at baseline and 18 months after implementation. Corrected survey response rates were 90% at baseline and 82% at follow-up. Generalized linear mixed models were used to compare usual care and CDS responses to common questions at baseline and follow-up, and CDS users were queried on their perceptions of the CDS system at follow-up only. Results: Compared to usual care providers, those in the CDS group reported increased follow-up rates of CV risk calculations while seeing patients (73% vs. 28%, P = 0.006), being better prepared to discuss CV risk reduction priorities with patients (98% vs. 78%, P = 0.03), providing accurate advice on aspirin for primary prevention (75% vs. 48%, P = 0.02) and more often discussing CV risk reduction (60% vs. 30%, P = 0.06). CDS users reported that the CDS system improved CV risk factor control (98%), saved time when talking to patients about CV risk reduction (93%), efficiently elicited patient treatment preferences (90%), was useful for shared decision-making (95%), influenced treatment recommendations (89%) and helped initiate CV risk discussions (94%); 85% of providers reported that their patients liked CV Wizard. Conclusion: The CV Wizard CDS system was successfully integrated into the workflow of primary care visits with high sustained use rates, high primary care provider satisfaction, high patient satisfaction and positive impacts on provider-reported clinical processes related to CV risk factor management

Overuse and Underuse of Aspirin for Primary Prevention of Cardiovascular Events in Primary Care

Background/Aims: The U.S. Preventive Services Task Force (USPSTF) currently recommends aspirin for primary prevention of coronary heart disease in men 45–79 years old and strokes in women 55–79 years old when the potential cardiovascular disease benefit outweighs the potential harm of gastrointestinal hemorrhage. The complexity and time required to assess risks and benefits for primary prevention can be a barrier for providers to giving patients USPSTF-consistent recommendations, resulting in potential overuse and underuse. Methods: As part of a National Institutes of Health-funded randomized trial to lower cardiovascular risk, we developed a sophisticated web-based electronic health record (EHR)-integrated tool to guide aspirin recommendations as determined by algorithms assessing USPSTF criteria and major bleeding risks. Baseline data was collected for whether aspirin was algorithmically indicated (or not) for all patients at their first eligible primary care encounter in 20 clinics over 18 months. The analysis included patients age 18–75 (mean 58.4) with elevated cardiovascular disease risk (mean 10-year ASCVD risk 24.7%) and excluded patients with congenital heart defects or diabetes. Aspirin overuse and underuse was determined by comparing concordance with: a) the algorithm’s aspirin recommendation, and b) EHR-medication documentation of aspirin. Results: Of the 11,682 patients meeting eligibility criteria at baseline, aspirin was indicated in 8,722 (74.7%) and not indicated in 2,960 (25.3%). Among patients with an aspirin indication, 6,493/8,722 (74.4%) did not have aspirin documented (underuse). Among patients without an aspirin indication, 1,021/2,960 (34.4%) had aspirin documented (overuse). Conclusion: Overall, 7,514/11,682 (64.3%) of patients who met study inclusion criteria for age and cardiovascular risk exhibited either potential overuse or underuse of aspirin for primary cardiovascular disease prevention. Despite expected missing documentation of aspirin due to its over-the-counter availability, which would result in measures of greater underuse and lower overuse than actuality, it is clear that patient aspirin use is very commonly inconsistent with USPSTF guidelines. The recommendation to consider colorectal benefits in the latest USPSTF draft could make decisions about aspirin appropriateness even more complex. EHR-based tools to help providers assess individualized risks and benefits of aspirin could greatly improve the quality of aspirin recommendations and potentially reduce costly cardiovascular disease events while simultaneously reducing rates of aspirin-related hazards

Effect of Improved Primary Care Access on Quality of Depression Care

PURPOSE We wanted to determine whether a major improvement in access to primary care during 2000 was associated with changes in the quality of care for patients with depression. METHODS Health plan administrative data were analyzed by multilevel regression to compare the quality of care received by patients with depression between 1999 and 2001, a time without major changes in depression care guidelines. Approximately 6,000 patients with depression who received all care in a large multispecialty medical group during any single year were subjects for this study. Thirteen different quality measures assessed process quality under the dimensions of effectiveness, timeliness, safety, and patient-centeredness. RESULTS The largest change was a reduction in the proportion of depressed patients with no follow-up visit in primary care after starting a new antidepressant medication: from 33.0% before a change in access to care to 15.4% afterward, P =.001. During the same period, continuity of care in primary care improved (>50% of primary care visits to 1 doctor increased from 67.3% to 74.0%, P = <.001), as did persistence of 6-month antidepressant medication (from 46.2% to 50.8%, P = <.001). Further analyses found that the latter change was primarily associated with the change in continuity of care. Measures of subspecialty mental health care worsened during this time. CONCLUSION Marked improvement in access to primary care for 1 year was associated with some improvement in primary care for patients with depression, but the mechanism appeared to be improved continuity. Those planning to implement advanced access to care need to do so in such a way that continuity of care is enhanced rather than harmed by the change

Impact of an Electronic Medical Record on Diabetes Quality of Care

PURPOSE This study was designed to evaluate the impact of electronic medical record (EMR) implementation on quality of diabetes care. METHODS We conducted a 5-year longitudinal study of 122 adults with diabetes mellitus at an intervention (EMR) clinic and a comparison (non-EMR) clinic. Clinics had similarly trained primary care physicians, similar patient populations, and used a common diabetes care guideline that emphasized the importance of glucose control. The EMR provided basic decision support, including prompts and reminders for diabetes care. Preintervention and postintervention frequency of testing for glycated hemoglobin (HbA(1c)) and low-density lipoprotein (LDL) levels were compared with and without adjustment for patient age, sex, comorbidity, and baseline HbA(1c) level. RESULTS Frequency of HbA(1c) tests increased at the EMR clinic compared with the frequency at the non-EMR clinic (P <.001). HbA(1c) levels improved in both clinics (P <.05) with no significant differences between clinics 2 years (P = .10) or 4 years (P = .27) after EMR implementation. Similar results were observed for LDL levels. CONCLUSIONS In this controlled study, EMR use led to an increased number of HbA(1c) and LDL tests but not to better metabolic control. If EMRs are to fulfill their promise as care improvement tools, improved implementation strategies and more sophisticated clinical decision support may be needed