A Clinical Reminder Order Check Intervention to Improve Guideline-concordant Imaging Practices for Men With Prostate Cancer: A Pilot Study

Features and functions of decision support systems for appropriate diagnostic imaging: a scoping review

BACKGROUND

Diagnostic imaging decision support (DI-DS) systems could be effective tools for reducing inappropriate diagnostic imaging examinations. Since effective design and evaluation of these systems requires in-depth understanding of their features and functions, the present study aims to map the existing literature on DI-DS systems to identify features and functions of these systems.

METHODS

The search was performed using Scopus, Embase, PubMed, Web of Science, and Cochrane Central Registry of Controlled Trials (CENTRAL) and was limited to 2000 to 2021. Analytical studies, descriptive studies, reviews and book chapters that explicitly addressed the functions or features of DI-DS systems were included.

RESULTS

A total of 6,046 studies were identified. Out of these, 55 studies met the inclusion criteria. From these, 22 functions and 22 features were identified. Some of the identified features were: visibility, content chunking/grouping, deployed as a multidisciplinary program, clinically valid and relevant feedback, embedding current evidence, and targeted recommendations. And, some of the identified functions were: displaying an appropriateness score, recommending alternative or more appropriate imaging examination(s), providing recommendations for next diagnostic steps, and providing safety alerts.

CONCLUSIONS

The set of features and functions obtained in the present study can provide a basis for developing well-designed DI-DS systems, which could help to improve adherence to diagnostic imaging guidelines, minimize unnecessary costs, and improve the outcome of care through appropriate diagnosis and on-time care delivery.

Evaluation of clinical decision support systems in oncology: An updated systematic review

With increasing reliance on technology in oncology, the impact of digital clinical decision support (CDS) tools needs to be examined. A systematic review update was conducted and peer-reviewed literature from 2016 to 2022 were included if CDS tools were used for live decision making and comparatively assessed quantitative outcomes. 3369 studies were screened and 19 were included in this updated review. Combined with a previous review of 24 studies, a total of 43 studies were analyzed. Improvements in outcomes were observed in 42 studies, and 34 of these were of statistical significance. Computerized physician order entry and clinical practice guideline systems comprise the greatest number of evaluated CDS tools (13 and 10 respectively), followed by those that utilize patient-reported outcomes (8), clinical pathway systems (8) and prescriber alerts for best-practice advisories (4). Our review indicates that CDS can improve guideline adherence, patient-centered care, and care delivery processes in oncology.

Increasing the value of PSA through improved implementation

Low-value testing and treatment contribute to billions of dollars in waste to the United States health care system annually. High frequency, low-cost testing, including prostate-specific antigen (PSA) testing, is a major contributor to this inefficient health care delivery. Despite decreasing mortality of prostate cancer over the last few decades, the reputation of prostate specific antigen (PSA) for prostate cancer screening has fluctuated over the last decade due to lack of clarity of the benefits of screening and high risk for overtreatment. The value of PSA could be improved by efficient implementation of smarter testing strategies that reduce the harms and increase the benefits.

Improved guideline adherence in oncology through clinical decision-support systems: still hindered by current health IT infrastructures?

PURPOSE OF REVIEW

Despite several efforts to enhance guideline adherence in cancer management, the rate of adherence remains often dissatisfactory in clinical routine. Clinical decision-support systems (CDSS) have been developed to support the management of cancer patients by providing evidence-based recommendations. In this review, we focus on both current evidence supporting the beneficial effects of CDSS on guideline adherence as well as technical and structural requirements for CDSS implementation in clinical routine.

RECENT FINDINGS

Some studies have demonstrated a significant improvement of guideline adherence by CDSSs in oncologic diseases such as breast cancer, colon cancer, cervical cancer, prostate cancer, and hepatocellular carcinoma as well as in the management of cancer pain. However, most of these studies were rather small and designs rather simple. One reason for this limited evidence might be that CDSSs are only occasionally implemented in clinical routine. The main limitations for a broader implementation might lie in the currently existing clinical data infrastructures that do not sufficiently allow CDSS interoperability as well as in some CDSS tools themselves, if handling is hampered by poor usability.

SUMMARY

In principle, CDSSs improve guideline adherence in clinical cancer management. However, there are some technical und structural obstacles to overcome to fully implement CDSSs in clinical routine.

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.

Improving Guideline Adherence in Urology

CONTEXT

Clinical practice guidelines (CPGs) distil an evidence base into recommendations. CPG adherence is associated with better patient outcomes. However, preparation and dissemination of CPGs are a costly task involving multiple skilled personnel. Furthermore, dissemination alone does not ensure CPG adherence. Reasons for nonadherence are often complex, but understanding practice variations and reasons for nonadherence is key to improving CPG adherence and harmonising clinically appropriate and cost-effective care.

OBJECTIVE

To overview approaches to improving guideline adherence, to provide urology-specific examples of knowledge-practice gaps, and to highlight potential solutions informed by implementation science.

EVIDENCE ACQUISITION

Three common approaches to implementation science (the Knowledge-To-Action framework, the Consolidated Framework for Implementation Research, and the Behaviour Change Wheel), are summarised.

EVIDENCE SYNTHESIS

Three implementation problems in urology are illustrated: underuse of single instillation of intravesical chemotherapy in non-muscle-invasive bladder cancer, overuse of androgen deprivation therapy in localised prostate cancer, and guideline-discordant imaging in prostate cancer. Research using implementation science approaches to address these implementation problems is discussed.

CONCLUSIONS

Urologists, patients, health care providers, funders, and other key stakeholders must commit to reliably capturing and reporting data on patient outcomes, practice variations, guideline adherence, and the impact of adherence on outcomes. Leverage of implementation science frameworks is a sound next step towards improving guideline adherence and the associated benefits of evidence-based care.

PATIENT SUMMARY

Clinical practice guideline documents are created by expert panels. These documents provide overviews of the evidence for the tests and treatments used in patient care. They also provide recommendations and it is expected that in most circumstances clinicians will follow these recommendations. Sometimes, health care professionals cannot or do not follow these recommendations and it is not always clear why. In this review article we look at some examples of research approaches to addressing this problem of nonadherence and we provide some examples specific to urology.