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Tlili NE, Robert L, Gerard E, Lemaitre M, Vambergue A, Beuscart JB, Quindroit P. A systematic review of the value of clinical decision support systems in the prescription of antidiabetic drugs. Int J Med Inform 2024; 191:105581. [PMID: 39106772 DOI: 10.1016/j.ijmedinf.2024.105581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 07/23/2024] [Accepted: 07/28/2024] [Indexed: 08/09/2024]
Abstract
INTRODUCTION The management of chronic diabetes mellitus and its complications demands customized glycaemia control strategies. Polypharmacy is prevalent among people with diabetes and comorbidities, which increases the risk of adverse drug reactions. Clinical decision support systems (CDSSs) may constitute an innovative solution to these problems. The aim of our study was to conduct a systematic review assessing the value of CDSSs for the management of antidiabetic drugs (AD). MATERIALS AND METHODS We systematically searched the scientific literature published between January 2010 and October 2023. The retrieved studies were categorized as non-specific or AD-specific. The studies' quality was assessed using the Mixed Methods Appraisal Tool. The review's results were reported in accordance with the PRISMA guidelines. RESULTS Twenty studies met our inclusion criteria. The majority of AD-specific studies were conducted more recently (2020-2023) compared to non-specific studies (2010-2015). This trend hints at growing interest in more specialized CDSSs tailored for prescriptions of ADs. The nine AD-specific studies focused on metformin and insulin and demonstrated positive impacts of the CDSSs on different outcomes, including the reduction in the proportion of inappropriate prescriptions of ADs and in hypoglycaemia events. The 11 nonspecific studies showed similar trends for metformin and insulin prescriptions, although the CDSSs' impacts were not significant. There was a predominance of metformin and insulin in the studied CDSSs and a lack of studies on ADs such as sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists. CONCLUSION The limited number of studies, especially randomized clinical trials, interested in evaluating the application of CDSS in the management of ADs underscores the need for further investigations. Our findings suggest the potential benefit of applying CDSSs to the prescription of ADs particularly in primary care settings and when targeting clinical pharmacists. Finally, establishing core outcome sets is crucial for ensuring consistent and standardized evaluation of these CDSSs.
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Affiliation(s)
- Nour Elhouda Tlili
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France.
| | - Laurine Robert
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France; Institut de Pharmacie, CHU Lille, F-59000 Lille, France
| | - Erwin Gerard
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France; Institut de Pharmacie, CHU Lille, F-59000 Lille, France
| | - Madleen Lemaitre
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France; CHU Lille, Department of Diabetology, Endocrinology, Metabolism and Nutrition, Lille University Hospital, F-59000, Lille, France
| | - Anne Vambergue
- CHU Lille, Department of Diabetology, Endocrinology, Metabolism and Nutrition, Lille University Hospital, F-59000, Lille, France; European Genomic Institute for Diabetes, Lille University School of Medicine, F-59000 Lille, France
| | - Jean-Baptiste Beuscart
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France
| | - Paul Quindroit
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France
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Kullgren JT, Kim HM, Slowey M, Colbert J, Soyster B, Winston SA, Ryan K, Forman JH, Riba M, Krupka E, Kerr EA. Using Behavioral Economics to Reduce Low-Value Care Among Older Adults: A Cluster Randomized Clinical Trial. JAMA Intern Med 2024; 184:281-290. [PMID: 38285565 PMCID: PMC10825788 DOI: 10.1001/jamainternmed.2023.7703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/22/2023] [Indexed: 01/31/2024]
Abstract
Importance Use of low-value care is common among older adults. It is unclear how to best engage clinicians and older patients to decrease use of low-value services. Objective To test whether the Committing to Choose Wisely behavioral economic intervention could engage primary care clinicians and older patients to reduce low-value care. Design, Setting, and Participants Stepped-wedge cluster randomized clinical trial conducted at 8 primary care clinics of an academic health system and a private group practice between December 12, 2017, and September 4, 2019. Participants were primary care clinicians and older adult patients who had diabetes, insomnia, or anxiety or were eligible for prostate cancer screening. Data analysis was performed from October 2019 to November 2023. Intervention Clinicians were invited to commit in writing to Choosing Wisely recommendations for older patients to avoid use of hypoglycemic medications to achieve tight glycemic control, sedative-hypnotic medications for insomnia or anxiety, and prostate-specific antigen tests to screen for prostate cancer. Committed clinicians had their photographs displayed on clinic posters and received weekly emails with alternatives to these low-value services. Educational handouts were mailed to applicable patients before scheduled visits and available at the point of care. Main Outcomes and Measures Patient-months with a low-value service across conditions (primary outcome) and separately for each condition (secondary outcomes). For patients with diabetes, or insomnia or anxiety, secondary outcomes were patient-months in which targeted medications were decreased or stopped (ie, deintensified). Results The study included 81 primary care clinicians and 8030 older adult patients (mean [SD] age, 75.1 [7.2] years; 4076 men [50.8%] and 3954 women [49.2%]). Across conditions, a low-value service was used in 7627 of the 37 116 control patient-months (20.5%) and 7416 of the 46 381 intervention patient-months (16.0%) (adjusted odds ratio, 0.79; 95% CI, 0.65-0.97). For each individual condition, there were no significant differences between the control and intervention periods in the odds of patient-months with a low-value service. The intervention increased the odds of deintensification of hypoglycemic medications for diabetes (adjusted odds ratio, 1.85; 95% CI, 1.06-3.24) but not sedative-hypnotic medications for insomnia or anxiety. Conclusions and Relevance In this stepped-wedge cluster randomized clinical trial, the Committing to Choose Wisely behavioral economic intervention reduced low-value care across 3 common clinical situations and increased deintensification of hypoglycemic medications for diabetes. Use of scalable interventions that nudge patients and clinicians to achieve greater value while preserving autonomy in decision-making should be explored more broadly. Trial Registration ClinicalTrials.gov Identifier: NCT03411525.
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Affiliation(s)
- Jeffrey T. Kullgren
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
- University of Michigan Center for Bioethics and Social Sciences in Medicine, Ann Arbor
| | - H. Myra Kim
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
| | - Megan Slowey
- Center for Health and Research Transformation, Ann Arbor, Michigan
| | - Joseph Colbert
- University of Michigan Center for Bioethics and Social Sciences in Medicine, Ann Arbor
| | - Barbara Soyster
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | | | - Kerry Ryan
- University of Michigan Center for Bioethics and Social Sciences in Medicine, Ann Arbor
| | - Jane H. Forman
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Melissa Riba
- Center for Health and Research Transformation, Ann Arbor, Michigan
| | - Erin Krupka
- University of Michigan School of Information, Ann Arbor
| | - Eve A. Kerr
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
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Persell SD, Petito LC, Lee JY, Meeker D, Doctor JN, Goldstein NJ, Fox CR, Rowe TA, Linder JA, Chmiel R, Peprah YA, Brown T. Reducing Care Overuse in Older Patients Using Professional Norms and Accountability : A Cluster Randomized Controlled Trial. Ann Intern Med 2024; 177:324-334. [PMID: 38315997 DOI: 10.7326/m23-2183] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Effective strategies are needed to curtail overuse that may lead to harm. OBJECTIVE To evaluate the effects of clinician decision support redirecting attention to harms and engaging social and reputational concerns on overuse in older primary care patients. DESIGN 18-month, single-blind, pragmatic, cluster randomized trial, constrained randomization. (ClinicalTrials.gov: NCT04289753). SETTING 60 primary care internal medicine, family medicine and geriatrics practices within a health system from 1 September 2020 to 28 February 2022. PARTICIPANTS 371 primary care clinicians and their older adult patients from participating practices. INTERVENTION Behavioral science-informed, point-of-care, clinical decision support tools plus brief case-based education addressing the 3 primary clinical outcomes (187 clinicians from 30 clinics) were compared with brief case-based education alone (187 clinicians from 30 clinics). Decision support was designed to increase salience of potential harms, convey social norms, and promote accountability. MEASUREMENTS Prostate-specific antigen (PSA) testing in men aged 76 years and older without previous prostate cancer, urine testing for nonspecific reasons in women aged 65 years and older, and overtreatment of diabetes with hypoglycemic agents in patients aged 75 years and older and hemoglobin A1c (HbA1c) less than 7%. RESULTS At randomization, mean clinic annual PSA testing, unspecified urine testing, and diabetes overtreatment rates were 24.9, 23.9, and 16.8 per 100 patients, respectively. After 18 months of intervention, the intervention group had lower adjusted difference-in-differences in annual rates of PSA testing (-8.7 [95% CI, -10.2 to -7.1]), unspecified urine testing (-5.5 [CI, -7.0 to -3.6]), and diabetes overtreatment (-1.4 [CI, -2.9 to -0.03]) compared with education only. Safety measures did not show increased emergency care related to urinary tract infections or hyperglycemia. An HbA1c greater than 9.0% was more common with the intervention among previously overtreated diabetes patients (adjusted difference-in-differences, 0.47 per 100 patients [95% CI, 0.04 to 1.20]). LIMITATION A single health system limits generalizability; electronic health data limit ability to differentiate between overtesting and underdocumentation. CONCLUSION Decision support designed to increase clinicians' attention to possible harms, social norms, and reputational concerns reduced unspecified testing compared with offering traditional case-based education alone. Small decreases in diabetes overtreatment may also result in higher rates of uncontrolled diabetes. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Stephen D Persell
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago; and Center for Primary Care Innovation, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.D.P., J.A.L.)
| | - Lucia C Petito
- Division of Biostatistics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (L.C.P.)
| | - Ji Young Lee
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (J.Y.L., T.A.R., Y.A.P., T.B.)
| | | | - Jason N Doctor
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California (J.N.D.)
| | - Noah J Goldstein
- UCLA Anderson School of Management, UCLA Geffen School of Medicine, Los Angeles, California (N.J.G., C.R.F.)
| | - Craig R Fox
- UCLA Anderson School of Management, UCLA Geffen School of Medicine, Los Angeles, California (N.J.G., C.R.F.)
| | - Theresa A Rowe
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (J.Y.L., T.A.R., Y.A.P., T.B.)
| | - Jeffrey A Linder
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago; and Center for Primary Care Innovation, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.D.P., J.A.L.)
| | - Ryan Chmiel
- Information Services, Northwestern Memorial HealthCare, Chicago, Illinois (R.C.)
| | - Yaw Amofa Peprah
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (J.Y.L., T.A.R., Y.A.P., T.B.)
| | - Tiffany Brown
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (J.Y.L., T.A.R., Y.A.P., T.B.)
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Morse B, Anstett T, Mistry N, Porter S, Pincus S, Lin CT, Novins-Montague S, Ho PM. User-Centered Design to Reduce Inappropriate Blood Transfusion Orders. Appl Clin Inform 2023; 14:28-36. [PMID: 36630999 PMCID: PMC9833954 DOI: 10.1055/s-0042-1759866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND To improve blood transfusion practices, we applied user-centered design (UCD) to evaluate potential changes to blood transfusion orders. OBJECTIVES The aim of the study is to build effective transfusion orders with different designs to improve guideline adherence. METHODS We developed three different versions of transfusion orders that varied how information was presented to clinicians ordering blood transfusions. We engaged 14 clinicians (residents, advanced practice providers [APPs], and attending physicians) from different specialties. We used the think aloud technique and rapid qualitative analysis to generate themes to incorporate into our modified orders. RESULTS Most end-users who participated in the semi-structured interviews preferred the interruptive alert design plus behavioral nudges (n = 8/14, 57%). The predominant rationale was that the in-line alert was not visually effective in capturing the end-user's attention, while the interruptive alert forced a brief stop in the workflow to consider the guidelines. All users supported the general improvements, though for different reasons, and as a result, the general improvements remained in the designs for the forthcoming trial. CONCLUSION The user experience uncovered through the think aloud approach produced a clear and rich understanding of potentially confounding factors in the initial design of different intervention versions. Input from end-users guided the creation of all three designs so each was addressing human factors with parity, which ensured that the results of our study reflected differences in interruptive properties of the alerts and not differences in design.
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Affiliation(s)
- Brad Morse
- Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States,Address for correspondence Brad Morse, PhD, MA Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine1890 N Revere Ct, Aurora, CO 80045United States
| | - Tyler Anstett
- Department of Medicine, Division Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Neelam Mistry
- Department of Medicine, Division Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Samuel Porter
- Department of Medicine, Division Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Sharon Pincus
- Adult & Child Center for Outcomes Research & Delivery Science/The NavLab, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Chen-Tan Lin
- Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Sylvie Novins-Montague
- Adult & Child Center for Outcomes Research & Delivery Science/The NavLab, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - P. Michael Ho
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, United States
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