Modalités d'interaction avec des systèmes d'aide à la décision médicale par alerte ou à la demande pour délivrer des recommandations : une étude préliminaire dans le cadre de la prise en charge de l'hypertension

Classiquement développés comme des systèmes d'alertes produisant automatiquement des thérapeutiques centrées patient, les systèmes d'aide à la décision médicale sont appréciés par les médecins utilisateurs de façon variable selon les études. Nous pensons que ce mode d'interaction n'est pertinent que dans les cas simples où le médecin pense a priori qu'il n'a pas besoin d'être aidé. Une approche " à la demande " nous semble, par ailleurs, adaptée dans les cas plus compliqués. Nous avons testé cette hypothèse avec le système ASTI développé de façon à proposer deux modes d'interaction. Dédié aux cas simples, le mode " critique ", entièrement automatique, produit des alertes lorsque la prescription médicamenteuse du médecin n'est pas conforme aux recommandations. Au contraire, le mode " guidé " est utilisé de façon volontaire par le médecin qui, au cours d'une navigation active au sein d'une base de connaissances, accède dans les cas complexes aux recommandations thérapeutiques. Un score de complexité des cas cliniques a été proposé. Une étude préliminaire a été conduite sur 15 cas cliniques et 10 généralistes qui valide notre hypothèse de travail

Simultaneously authoring and modeling clinical practice guidelines: a case study in the therapeutic management of type 2 diabetes in France.

By providing patient-specific advice, clinical decision support systems (CDSSs) are expected to promote the implementation of clinical practice guidelines (CPGs) to improve the quality of care. However, produced as texts, often incomplete and ambiguous, CPGs are difficult to translate into the formal knowledge bases (KBs) of CDSSs. The French National Authority for Health (HAS) decided to update CPGs on the management of type 2 diabetes. This work illustrates the simultaneous development of the text and its formal counterpart in a CDSS named RecosDiab. CPGs were elaborated by a working group according to the guideline development methodology. Textual recommendations were graded, either as evidence-based when evidence existed or as consensus-based when acknowledge by the working group. Knowledge modeling was performed following the steps of de-abstraction, disambiguation, and verification of completeness. This last step generated clinical situations not explicitly mentioned in the text and were graded as expert-based. The resulting KB provides therapeutic advice for 805 clinical situations, among which 2 are graded as evidence-based, 37 are consensus-based, and 766 are expert-based. However, because of the amount of expert-based propositions, the HAS did not endorse the system

Using visual demonstrations in young adults to promote smoking cessation: Preliminary findings from a French pilot study

Background: A personalised, smoking cessation message was successfully delivered in Australian community pharmacies to motivate behavioural change in young smoking adults. Objective: The purpose of this pilot study was to test the acceptability and effectiveness of the innovative, proven smoking cessation intervention to another population of young adults with a higher prevalence of smoking and associated morbidities. Methods: Ninety eight university students in Paris, France were recruited to a pilot study (50 intervention: 48 control). All students received smoking cessation counselling sessions and half also received a visual demonstration of themselves, both as a lifelong smoker and non-smoker. Results: There was no statistical significant difference between the groups in smoking dependence at recruitment. At the three month follow-up, the proportion who had attempted to quit smoking were 37% (control) vs 46% (intervention). These percentages suggested a positive result for the intervention, although the difference was not statistically significant (p = 0.39). Conclusion: This is one of the first studies conducted in France using visual demonstrations combined with healthcare counselling to promote smoking cessation amongst young adult smokers. Further research, recruiting from the general French public, is needed to better understand if the innovative personalised health message can motivate young French adult smokers to quit

Design factors for success or failure of guideline-based decision support systems: an hypothesis involving case complexity.

Computer-based decision support systems (CDSSs) are currently mostly reminder systems. However, the effectiveness of such systems to modify physician behavior is not always observed. We assume that this approach is appropriate when physicians think they know how to prescribe and consider they don't need to be helped, i.e. for simple clinical cases. On the opposite, on-demand approaches allowing for flexibility in the interpretation of patient conditions are more appropriate for more complex cases, e.g. in chronic disease management. ASTI is a CDSS operating in two modes, a critiquing mode working as a reminder-based system and a user-initiated guiding mode. Using a clinical case complexity score, a pre/post-intervention experiment with 10 GPs and 15 cases of hypertensive patients has been performed. Preliminary results tend to indicate that reminder-based interaction is appropriate for simple cases and that physicians are willing to use on-demand systems as clinical situations become complex, making both modes complementary

Using knowledge modelling to measure how clinical practice could actually be evidence-based: a preliminary analysis with arterial hypertension management.

ASTI is a guideline-based decision support system to be used in primary care. We analyzed the knowledge modelling carried out in the development of ASTI knowledge base (KB) from French clinical practice guidelines (CPGs) on arterial hypertension management to evaluate the evidence status of therapeutic propositions issued by the system. We defined three status: "evidence-based" (EB) when propositions are graded A, B, or C, "consensus-based" (CB) when propositions are explicitly mentioned in CPGs but supported by professional agreement (grade D), and "non-supported" (NS) when propositions are expert-based and provided by a domain specialist. We compared the distributions of evidence status on the 44,571 theoretical patient profiles extracted from ASTI KB, and on a data set of 435 actual hypertensive patients. Only 8.3% of actual patients, managed by 0.5% of the KB, have an EB profile and 46.9% of patients, managed by 12.6% of the KB, have a CB profile. Thus, there is no CPG recommendation for nearly half of the patients (44.8% have a NS profile)

Role of physicians’ reactance in e-iatrogenesis: a case study with ASTI guiding mode on the management of hypertension

Clinical decision support systems (CDSSs) have the potential to increase guideline adherence, but factors of success are not yet understood. ASTI guiding mode (ASTI-GM) is an on-demand guideline-based CDSS where the user navigates in a knowledge base to get the best treatment for a given patient. We conducted a web-based evaluation of ASTI-GM, carried out as a before-after study, where general practitioners (GPs) were asked to solve 5 clinical cases, first without ASTI-GM, then using the system. Of the 136 GPs that resolved the case on the management of hypertension, compliance with best practices increased from 69.1% to 80.9% with ASTI-GM. When the navigation matched the set of patient parameters described in the clinical case, the increase was even higher and reached 92.9%. E-iatrogenesis has been measured at 19.1%, with 5.1% of commission errors, 8.1% of negative reactance, and 5.9% of neutral reactance. Role of physicians’ reactance in noncompliance with guideline-based CDSSs should be further investigated