An innovative implementation strategy to improve the use of Dutch guidelines on hypertensive disorders in pregnancy: A randomized controlled trial

Clinical decision support systems for maternity care: a systematic review and meta-analysis

Background

The use of Clinical Decision Support Systems (CDSS) is increasing throughout healthcare and may be able to improve safety and outcomes in maternity care, but maternity care has key differences to other disciplines that complicate the use of CDSS. We aimed to identify evaluated CDSS and synthesise evidence of their impact on maternity care.

Methods

We conducted a systematic review for articles published before 24th May 2024 that described i) CDSS that ii) investigated the impact of their use iii) in maternity settings. Medline, CINAHL, CENTRAL and HMIC were searched for articles relating to evaluations of CDSS in maternity settings, with forward- and backward-citation tracing conducted for included articles. Risk of bias was assessed using the Mixed Methods Assessment Tool, and CDSS were described according to the clinical problem, purpose, design, and technical environment. Quantitative results from articles reporting appropriate data were meta-analysed to estimate odds of a CDSS achieving its desired outcome using a multi-level random effects model, first by individual CDSS and then across all CDSS. PROSPERO ID: CRD42022348157.

Findings

We screened 12,039 papers and included 87 articles describing 47 unique CDSS. 24 articles (28%) described randomised controlled trials, 30 (34%) described non-randomised interventional studies, 10 (11%) described mixed methods studies, 10 (11%) described qualitative studies, 7 (8%) described quantitative descriptive studies, and 7 (8%) described economic evaluations. 49 (56%) were in High-Income Countries and 38 (44%) in Low- and Middle-Income countries, with no CDSS trialled in both income categories. Meta-analysis of 35 included studies found an odds ratio for improved outcomes of 1.69 (95% confidence interval 1.24-2.30). There was substantial variation in effects, aims, CDSS types, context, study designs, and outcomes.

Interpretation

Most CDSS evaluations showed improvements in outcomes, but there was heterogeneity in all aspects of design and evaluation of systems. CDSS are increasingly important in delivering healthcare, and Electronic Health Records and mHealth will increase their availability, but traditional epidemiological methods may be limited in guiding design and demonstrating effectiveness due to rapid CDSS development lifecycles and the complex systems in which they are embedded. Development methods that are attentive to context, such as Human Centred Design, will help to meet this need.

Funding

None.

[Digitalization and clinical decision tools]

Digitalization in cardiovascular emergencies is rapidly evolving, analogous to the development in medicine, driven by the increasingly broader availability of digital structures and improved networks, electronic health records and the interconnectivity of systems. The potential use of digital health in patients with acute chest pain starts even in the prehospital phase with the transmission of a digital electrocardiogram (ECG) as well as telemedical support and digital emergency management, which facilitate optimization of the rescue pathways and reduce critical time intervals. The increasing dissemination and acceptance of guideline apps and clinical decision support tools as well as integrated calculators and electronic scores are anticipated to improve guideline adherence, translating into a better quality of treatment and improved outcomes. Implementation of artificial intelligence to support image analysis and also the prediction of coronary artery stenosis requiring interventional treatment or impending cardiovascular events, such as heart attacks or death, have an enormous potential especially as conventional instruments frequently yield suboptimal results; however, there are barriers to the rapid dissemination of corresponding decision aids, such as the regulatory rules related to approval as a medical product, data protection issues and other legal liability aspects, which must be considered.

[Evidence synthesis and recommendations: clinical practice guidelines on drug treatment for hypertension in pregnancySíntese de evidências e recomendações: diretrizes de prática clínica para o tratamento farmacológico da hipertensão arterial na gravidez]

Introduction

Hypertensive disorders during pregnancy are a major cause of severe morbidity, long-term disability, and death. Appropriate pharmacological treatment is essential in the management of these disorders.

Objectives

Synthesize the recommendations developed by the World Health Organization (WHO) to improve the quality of care and health outcomes of adults with high blood pressure, and address aspects of how to implement these recommendations.

Methods

A synthesis was conducted of WHO recommendations: drug treatment for severe hypertension in pregnancy and WHO recommendations: drug treatment for non-severe hypertension in pregnancy. The WHO recommendations follow the GRADE methodology (Grading of Recommendations, Assessment, Development, and Evaluation) for the preparation of guidelines, as described in the WHO Handbook for Guideline Development. In addition, a systematic search for studies carried out in the Region of the Americas was conducted in PubMed, Lilacs, Health Systems Evidence, Epistemonikos, and gray literature to identify barriers, facilitators, and implementation strategies.

Results

Four recommendations were formulated for women with hypertensive disorders. Implementation barriers and facilitators were identified, and indicators were created to assess adherence and outcomes.

Conclusions

The formulated recommendations provide guidance on how to approach drug treatment of hypertension in pregnancy, with considerations for implementation in Latin America and the Caribbean.

Trends in guideline implementation: an updated scoping review

Background

Guidelines aim to support evidence-informed practice but are inconsistently used without implementation strategies. Our prior scoping review revealed that guideline implementation interventions were not selected and tailored based on processes known to enhance guideline uptake and impact. The purpose of this study was to update the prior scoping review.

Methods

We searched MEDLINE, EMBASE, AMED, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews for studies published from 2014 to January 2021 that evaluated guideline implementation interventions. We screened studies in triplicate and extracted data in duplicate. We reported study and intervention characteristics and studies that achieved impact with summary statistics.

Results

We included 118 studies that implemented guidelines on 16 clinical topics. With regard to implementation planning, 21% of studies referred to theories or frameworks, 50% pre-identified implementation barriers, and 36% engaged stakeholders in selecting or tailoring interventions. Studies that employed frameworks (n=25) most often used the theoretical domains framework (28%) or social cognitive theory (28%). Those that pre-identified barriers (n=59) most often consulted literature (60%). Those that engaged stakeholders (n=42) most often consulted healthcare professionals (79%). Common interventions included educating professionals about guidelines (44%) and information systems/technology (41%). Most studies employed multi-faceted interventions (75%). A total of 97 (82%) studies achieved impact (improvements in one or more reported outcomes) including 10 (40% of 25) studies that employed frameworks, 28 (47.45% of 59) studies that pre-identified barriers, 22 (52.38% of 42) studies that engaged stakeholders, and 21 (70% of 30) studies that employed single interventions.

Conclusions

Compared to our prior review, this review found that more studies used processes to select and tailor interventions, and a wider array of types of interventions across the Mazza taxonomy. Given that most studies achieved impact, this might reinforce the need for implementation planning. However, even studies that did not plan implementation achieved impact. Similarly, even single interventions achieved impact. Thus, a future systematic review based on this data is warranted to establish if the use of frameworks, barrier identification, stakeholder engagement, and multi-faceted interventions are associated with impact.

Trial registration

The protocol was registered with Open Science Framework (https://osf.io/4nxpr) and published in JBI Evidence Synthesis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01223-6.

Clinical decision support in cardiovascular medicine

Despite considerable progress in tackling cardiovascular disease over the past 50 years, many gaps in the quality of care for cardiovascular disease remain. Multiple missed opportunities have been identified at every step in the prevention and treatment of cardiovascular disease, such as failure to make risk factor modifications, failure to diagnose cardiovascular disease, and failure to use proper evidence based treatments. With the digital transformation of medicine and advances in health information technology, clinical decision support (CDS) tools offer promise to enhance the efficiency and effectiveness of delivery of cardiovascular care. However, to date, the promise of CDS delivering scalable and sustained value for patient care in clinical practice has not been realized. This article reviews the evidence on key emerging questions around the development, implementation, and regulation of CDS with a focus on cardiovascular disease. It first reviews evidence on the effectiveness of CDS on healthcare process and clinical outcomes related to cardiovascular disease and design features associated with CDS effectiveness. It then reviews the barriers encountered during implementation of CDS in cardiovascular care, with a focus on unintended consequences and strategies to promote successful implementation. Finally, it reviews the legal and regulatory environment of CDS with specific examples for cardiovascular disease.

The effects of clinical decision support system for prescribing medication on patient outcomes and physician practice performance: a systematic review and meta-analysis

Background

Clinical Decision Support Systems (CDSSs) for Prescribing are one of the innovations designed to improve physician practice performance and patient outcomes by reducing prescription errors. This study was therefore conducted to examine the effects of various CDSSs on physician practice performance and patient outcomes.

Methods

This systematic review was carried out by searching PubMed, Embase, Web of Science, Scopus, and Cochrane Library from 2005 to 2019. The studies were independently reviewed by two researchers. Any discrepancies in the eligibility of the studies between the two researchers were then resolved by consulting the third researcher. In the next step, we performed a meta-analysis based on medication subgroups, CDSS-type subgroups, and outcome categories. Also, we provided the narrative style of the findings. In the meantime, we used a random-effects model to estimate the effects of CDSS on patient outcomes and physician practice performance with a 95% confidence interval. Q statistics and I² were then used to calculate heterogeneity.

Results

On the basis of the inclusion criteria, 45 studies were qualified for analysis in this study. CDSS for prescription drugs/COPE has been used for various diseases such as cardiovascular diseases, hypertension, diabetes, gastrointestinal and respiratory diseases, AIDS, appendicitis, kidney disease, malaria, high blood potassium, and mental diseases. In the meantime, other cases such as concurrent prescribing of multiple medications for patients and their effects on the above-mentioned results have been analyzed. The study shows that in some cases the use of CDSS has beneficial effects on patient outcomes and physician practice performance (std diff in means = 0.084, 95% CI 0.067 to 0.102). It was also statistically significant for outcome categories such as those demonstrating better results for physician practice performance and patient outcomes or both. However, there was no significant difference between some other cases and traditional approaches. We assume that this may be due to the disease type, the quantity, and the type of CDSS criteria that affected the comparison. Overall, the results of this study show positive effects on performance for all forms of CDSSs.

Conclusions

Our results indicate that the positive effects of the CDSS can be due to factors such as user-friendliness, compliance with clinical guidelines, patient and physician cooperation, integration of electronic health records, CDSS, and pharmaceutical systems, consideration of the views of physicians in assessing the importance of CDSS alerts, and the real-time alerts in the prescription.

Composite adverse outcomes in obstetric studies: a systematic review

BACKGROUND

Composite outcomes are increasingly being used in obstetric trials. The aim of this systematic review is to critically appraise the use of composite outcomes in obstetric RCTs with an intention of identifying limitations and providing potential solutions for future research.

METHODS

The study protocol was prospectively registered. Medline, Embase, Cochrane Databases and www.clinicaltrials.gov were searched for randomized controlled trials (RCTs) published in English between 1999 and 2019, using search terms related to pregnancy and composite outcomes.

STUDY ELIGIBILITY CRITERIA

RCTs involving an obstetric condition that reported on a composite outcome.

STUDY APPRAISAL AND SYNTHESIS METHODS

Screening and data extraction were performed in duplicate, and a descriptive synthesis and critical appraisal of composite obstetric outcomes, is presented.

RESULTS

Of the 4170 results screened, we identified 156 RCTs, reporting on 181 composite outcomes. Of these, 158 composite outcomes related to general morbidity and mortality, either exclusively maternal (n=20), fetal-neonatal [perinatal] (n=116) or maternal and perinatal (n=22) were included in the final analysis. Obstetric composite outcomes included between two and 16 components. Components that comprised these composite outcomes were often dissimilar in terms of severity and frequency of occurrence, unlikely to have similar relative risk reductions and sometimes unrelated to the study's primary objective - important pre-requisites to consider while constructing composite outcomes. In addition, composite adverse obstetric outcomes often do not incorporate the perspectives of pregnant persons, embrace a holistic view of health or consider outcomes related to both members of the mother-fetus dyad.

CONCLUSIONS

Composite outcomes are being increasingly used as primary outcomes in obstetric RCTs, based on which study conclusions are drawn and clinical recommendations made. However, there is a lack of consistency with regard to what components should be included within a composite adverse obstetric outcome and how these components should be measured. The use of novel research methods such as concept mapping may be able to address some of the limitations with the development of composite adverse obstetric outcomes, to inform future research.