Arriba-lib: evaluation of an electronic library of decision aids in primary care physicians

Workload and workflow implications associated with the use of electronic clinical decision support tools used by health professionals in general practice: a scoping review

BACKGROUND

Electronic clinical decision support tools (eCDS) are increasingly available to assist General Practitioners (GP) with the diagnosis and management of a range of health conditions. It is unclear whether the use of eCDS tools has an impact on GP workload. This scoping review aimed to identify the available evidence on the use of eCDS tools by health professionals in general practice in relation to their impact on workload and workflow.

METHODS

A scoping review was carried out using the Arksey and O'Malley methodological framework. The search strategy was developed iteratively, with three main aspects: general practice/primary care contexts, risk assessment/decision support tools, and workload-related factors. Three databases were searched in 2019, and updated in 2021, covering articles published since 2009: Medline (Ovid), HMIC (Ovid) and Web of Science (TR). Double screening was completed by two reviewers, and data extracted from included articles were analysed.

RESULTS

The search resulted in 5,594 references, leading to 95 full articles, referring to 87 studies, after screening. Of these, 36 studies were based in the USA, 21 in the UK and 11 in Australia. A further 18 originated from Canada or Europe, with the remaining studies conducted in New Zealand, South Africa and Malaysia. Studies examined the use of eCDS tools and reported some findings related to their impact on workload, including on consultation duration. Most studies were qualitative and exploratory in nature, reporting health professionals' subjective perceptions of consultation duration as opposed to objectively-measured time spent using tools or consultation durations. Other workload-related findings included impacts on cognitive workload, "workflow" and dialogue with patients, and clinicians' experience of "alert fatigue".

CONCLUSIONS

The published literature on the impact of eCDS tools in general practice showed that limited efforts have focused on investigating the impact of such tools on workload and workflow. To gain an understanding of this area, further research, including quantitative measurement of consultation durations, would be useful to inform the future design and implementation of eCDS tools.

Validation of Cardiovascular Risk Prediction by the Arriba Instrument

BACKGROUND

It is recommended in cardiovascular prevention guidelines that treatment should be based on overall cardiovascular risk. The arriba instrument has been widely used for this purpose in Germany. The aim of this study is to validate risk prediction by arriba with the aid of morbidity and mortality data from the population- based Study of Health in Pomerania.

METHODS

In a longitudinal analysis, the arriba instrument was used to calculate the 10-year overall cardiovascular risk at baseline for subjects who had not sustained any prior cardiovascular event. Cardiovascular event rates were determined from follow-up data, and discrimination and calibration measures for the risk determination algorithm were calculated.

RESULTS

Data from 1973 subjects (mean age 51 ± 13 years, 48% men) were included in the analysis. After a median follow-up of 10.9 years, cardiovascular events had occurred in 196 subjects, or 9.8%. The ratio of predicted to observed event rate was 0.8 (95% confidence interval: [0.5; 1.1]), 1.3 [1.0; 1.8], and 1.1 [0.8; 1.4] for subjects at low, intermediate, and high cardiovascular risk, respectively. Arriba underestimated cardiovascular event rates in women and overestimated them in persons aged 30-44 and 45-59. The area under curve was 0.84 [95% CI 0.81; 0.86].

CONCLUSION

The discrimination scores of the arriba instrument resemble those of SCORE-Germany and PROCAM, but a better adjustment to the target population would be desirable. The results support the recommendation of the German Guideline for Cardiovascular Risk Counseling in General Practice for the use of the arriba instrument. An unresolved problem is the failure to consider intervention effects, resulting in an overall mild overestimation of risk.

Decision aids to facilitate decision making around behavior change in the field of health promotion: A scoping review

OBJECTIVE

To broadly synthesize literature regarding decision aids (DAs) supporting decision making about diet, physical activity, sleeping and substance use a scoping review was performed.

METHODS

Multiple sources were used: (1) Scientific literature searches, (2) excluded references from a Cochrane review regarding DAs for treatments and screenings, and (3) results from additional searches. Interventions had to (1) support informed decision making and (2) provide information and help to choose between at least two options. Two researchers screened titles and abstracts. Relevant information was extracted descriptively.

RESULTS

Thirty-five scientific articles and four DAs (grey literature) were included. Results were heterogeneous. Twenty-nine (94%) studies described substance use DAs. All DAs offered information and value and/or preference clarification. Many other elements were included (e.g., goal-setting). DA's effects were mixed. Few studies used standardized measures, e.g., decisional conflict (n = 4, 13%). Some positive behavioral effects were reported: e.g., smoking abstinence (n = 1).

CONCLUSIONS

This research shows only some positive behavioral effects of DAs. However, studies reported heterogeneous results/outcomes, impeding knowledge synthesis. Areas of improvement were identified, e.g., establishing which intervention elements are effective regarding health behavior decision making.

PRACTICE IMPLICATIONS

DAs can potentially be beneficial in supporting people to change health behaviors - especially regarding smoking.

Reduction of the long-term use of proton pump inhibitors by a patient-oriented electronic decision support tool (arriba-PPI): study protocol for a randomized controlled trial

BACKGROUND

Proton pump inhibitors (PPIs) are increasingly being prescribed, although long-term use is associated with multiple side effects. Therefore, an electronic decision support tool with the aim of reducing the long-term use of PPIs in a shared decision-making process between general practitioners (GPs) and their patients has been developed. The developed tool is a module that can be added to the so-called arriba decision support tool, which is already used by GPs in Germany in routine care. In this large-scale cluster-randomized controlled trial we evaluate the effectiveness of this arriba-PPI tool.

METHODS

The arriba-PPI tool is an electronic decision support system that supports shared decision-making and evidence-based decisions around the long-term use of PPIs at the point of care. The tool will be evaluated in a cluster-randomized controlled trial involving 210 GP practices and 3150 patients in Germany. GP practices will be asked to recruit 20 patients aged ≥ 18 years regularly taking PPIs for ≥ 6 months. After completion of patient recruitment, each GP practice with enrolled patients will be cluster-randomized. Intervention GP practices will get access to the software arriba-PPI, whereas control GPs will treat their patients as usual. After an observation period of six months, GP practices will be compared regarding the reduction of cumulated defined daily doses of PPI prescriptions per patient.

DISCUSSION

Our principal hypothesis is that the application of the arriba-PPI tool can reduce PPI prescribing in primary care by at least 15% compared to conventional strategies used by GPs. A positive result implies the implementation of the arriba-PPI tool in routine care.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00016364. Registered on 31 January 2019.

The impact and utility of encounter patient decision aids: Systematic review, meta-analysis and narrative synthesis

OBJECTIVE

To determine the effect of encounter patient decision aids (PDAs) as evaluated in randomized controlled trials (RCTs) and conduct a narrative synthesis of non-randomized studies assessing feasibility, utility and their integration into clinical workflows.

METHODS

Databases were systematically searched for RCTs of encounter PDAs to enable the conduct of a meta-analysis. We used a framework analysis approach to conduct a narrative synthesis of non-randomized studies.

RESULTS

We included 23 RCTs and 30 non-randomized studies. Encounter PDAs significantly increased knowledge (SMD = 0.42; 95% CI 0.30, 0.55), lowered decisional conflict (SMD= -0.33; 95% CI -0.56, -0.09), increased observational-based assessment of shared decision making (SMD = 0.94; 95% CI 0.40, 1.48) and satisfaction with the decision-making process (OR = 1.78; 95% CI 1.19, 2.66) without increasing visit durations (SMD= -0.06; 95% CI -0.29, 0.16). The narrative synthesis showed that encounter tools have high utility for patients and clinicians, yet important barriers to implementation exist (i.e. time constraints) at the clinical and organizational level.

CONCLUSION

Encounter PDAs have a positive impact on patient-clinician collaboration, despite facing implementation barriers.

PRACTICAL IMPLICATIONS

The potential utility of encounter PDAs requires addressing the systemic and structural barriers that prevent adoption in clinical practice.

The Optimizing-Risk-Communication (OptRisk) randomized trial - impact of decision-aid-based consultation on adherence and perception of cardiovascular risk

BACKGROUND

Shared decision-making is a well-established approach to increasing patient participation in medical decisions. Increasingly, using lifetime-risk or time-to-event (TTE) formats has been suggested, as these might have advantages in comparison with a 10-year risk prognosis, particularly for younger patients, whose lifetime risk for some events may be considerably greater than their 10-year risk. In this study, a randomized trial, the most popular 10-year risk illustration in the decision-aid software Arriba (emoticons), is compared with a newly developed TTE illustration, which is based on a Markov model. The study compares the effect of these two methods of presenting cardiovascular risk to patients on their subsequent adherence to intervention.

METHODS

A total of 294 patients were interviewed 3 months after they had had a consultation with their GP on cardiovascular risk prevention. Adherence to behavioral change or medication intervention was measured as the primary outcome. The latter was expressed as a generated score. Furthermore, different secondary outcomes were measured, ie, patient perception of risk and self-rated importance of avoiding a cardiovascular event, as well as patient numeracy, which was used as a proxy for patient health literacy.

RESULTS

Overall, no significant difference in patient adherence was found depending on risk representation. In the emoticon group, the number of interventions had a significant impact on the adherence score (P=0.025). Perception of risk was significantly higher in patients counseled with the TTE risk display, whereas the importance of avoiding a cardiovascular event was rated equally highly in both groups and actually increased over time.

CONCLUSION

The TTE format is an appropriate means for counseling patients. Adherence is a very complex construct, which cannot be fully explained by our findings. The study results support our call for considering TTE illustrations as a valuable alternative to current decision-support tools covering cardiovascular prevention. Nevertheless, further research is needed to shed light on patient motivation and adherence with regard to cardiovascular risk prevention.

TRIAL REGISTRATION

The study was registered at the German Clinical Trials Register and at the WHO International Clinical Trials Register Platform (ICTRP, ID DRKS00004933); registered February 2, 2016 (retrospectively registered).

Time-to-event versus ten-year-absolute-risk in cardiovascular risk prevention - does it make a difference? Results from the Optimizing-Risk-Communication (OptRisk) randomized-controlled trial

Background

The concept of shared-decision-making is a well-established approach to increase the participation of patients in medical decisions. Using lifetime risk or time-to-event (TTE) formats has been increasingly suggested as they might have advantages, e.g. in younger patients, to better show consequences of unhealthy behaviour. In this study, the most-popular ten-year risk illustration in the decision-aid-software arriba^TM (emoticons), is compared within a randomised trial to a new-developed TTE illustration, which is based on a Markov model.

Methods

Thirty-two General Practitioners (GPs) took part in the study. A total of 304 patients were recruited and counseled by their GPs with arriba^TM, and randomized to either the emoticons or the TTE illustration, followed by a patient questionnaire to figure out the degree of shared-decision-making (PEF-FB9, German questionnaire to measure the participation in the shared decision-making process, primary outcome), as well as the decisional conflict, perceived risk, accessibility and the degree of information, which are all secondary outcomes.

Results

Regarding our primary outcome PEF-FB9 the new TTE illustration is not inferior compared to the well-established emoticons taking the whole study population into account. Furthermore, the non-inferiority of the innovative TTE could be confirmed for all secondary outcome variables. The explorative analysis indicates even advantages in younger patients (below 46 years of age).

Conclusion

The TTE format seems to be as useful as the well-established emoticons. For certain patient populations, especially younger patients, the TTE may be even superior to demonstrate a cardiovascular risk at early stages. Our results suggest that time-to-event illustrations should be considered for current decision support tools covering cardiovascular prevention.

Trial registration

The study was registered at the German Clinical Trials Register and at the WHO International Clinical Trials Register Platform (ICTRP, ID DRKS00004933); registered 2 February 2016 (retrospectively registered).

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0393-1) contains supplementary material, which is available to authorized users.

An informed shared decision making programme on the prevention of myocardial infarction for patients with type 2 diabetes in primary care: protocol of a cluster randomised, controlled trial

Background

International and national societies claim a patient centred approach including shared decision making (SDM) in diabetes care. In a previous project, a SDM programme on the prevention of myocardial infarction has been developed. It is aimed at supporting patients with type 2 diabetes to make informed choices on preventive options, to share the decision making process with the health care team, and to improve adherence to the chosen treatment. In this study, the programme will be implemented and evaluated in primary care practices.

Methods/Design

A cluster randomised, controlled trial will be conducted to compare the SDM programme with standard care enrolling patients with type 2 diabetes (N = 306) from primary care practices (N = 24). The intervention programme comprises a six hours provider training, a patient decision aid including evidence-based information, a 90 minutes structured teaching session provided by medical assistants, a sheet to document the patients’ individual treatment goals, and a structured consultation with the general practitioner for sharing information, setting treatment goals, and for adapting treatment regimens if necessary. Patients in the control group receive a brief extract of recommendations of the German National Disease Management Guideline on the treatment of patients with type 2 diabetes. Primary outcome measure is adherence to blood pressure treatment and statin treatment at 6 months follow-up. Secondary outcome measures comprise informed choice and the achievement of patients’ treatment goals. Analyses will be carried out on intention-to-treat basis. Concurrent qualitative methods will be used to explore the implementation processes.

Discussion

At the end of this study, information on the efficacy of the SDM programme in the primary care context will be available. In addition, processes that might interfere with or that might promote a successful implementation will be identified.

Trial registration

ISRCTN77300204.

Development and validation of a generic questionnaire for the implementation of complex medical interventions

Introduction: The implementation of complex medical interventions in daily practice is often fraught with difficulties. According to the iterative phase model proposed by the British Medical Research Council (MRC), the development, implementation and evaluation of complex interventions should be theory-driven. A conceptual model that seems to be a promising framework is the Theory of planned behaviour (TPB). In our study we aimed to develop and validate a generic and multifaceted questionnaire based on the TPB to detect physicians’ willingness to implement complex medical interventions and the factors influencing this willingness.

Methods: The questionnaire was developed according to the literature and was informed by previous qualitative research of our department. It was validated on the example of an electronic library of decision aids, arriba-lib. The sample consisted of 181 General Practitioners (GPs) who received a training regarding arriba-lib and subsequently filled in the questionnaire, assessing the TPB variables attitude, subjective norm, perceived behaviour control and intention. Follow-up assessments were conducted after two (assessing retest reliability) and eight weeks (assessing target behaviour). We performed a confirmatory factor analysis investigating the factorial structure of our questionnaire according to the TPB. Beside the calculation of the questionnaire’s psychometric properties we conducted a structural equation model and an ordinal regression to predict actual behaviour regarding the installation and application of arriba-lib.

Results: The postulated three factorial model (attitude, subjective norm, perceived behaviour control) of our questionnaire based on the TPB was rejected. A two factorial model with a combined factor subjective norm/perceived behaviour control was accepted. The explained variance in the ordinal regression was low (Nagelkerke’s R²=.12). Neither attitude nor intention were able to predict the use or non-use of arriba-lib (attitude: p=.68, intention: p=.44). For the combined factor subjective norm/perceived behaviour control a significant, but small effect (p=.03) was shown.

Conclusions: The TPB is not an adequate theoretical framework to guide the development of a generic questionnaire in the context of the implementation of complex interventions. To enable the successful implementation of complex medical interventions evaluators have to go through the whole development and evaluation process according to the MRC-model, without short cuts. Further, it has to be discussed if a generic instrument can be valid and useful. Regarding the TPB a publication bias regarding the theory’s applicability might have to be considered.

Physician behaviors surrounding the implementation of decision and communication AIDS in a breast cancer clinic: a qualitative analysis of staff intern perceptions

The aim of this paper is to examine how physician behavior facilitated or impeded our implementation of decision and communication aids in a breast cancer clinic. Staff interns provided decision and communication aids to patients and wrote up case notes for each patient they served. We used grounded theory to code our staff interns' case notes. We then identified barriers and facilitators to our program's implementation from each category we generated in the coding. Facilitators included physicians reading patient questions and then bringing the staff interns to the consultation. Barriers included physicians forgetting to bring the staff interns to the appointments and discouraging interns from speaking during the consultation. Physicians vary in their cooperation with our program. Our next steps will be to inquire directly with physicians about how to adapt our program design. We will also seek to position the staff interns as mentees to increase physician commitment to our program.