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Protheroe J, Saunders B, Hill JC, Chudyk A, Foster NE, Bartlam B, Wathall S, Cooper V. Integrating clinician support with intervention design as part of a programme testing stratified care for musculoskeletal pain in general practice. BMC FAMILY PRACTICE 2021; 22:161. [PMID: 34311697 PMCID: PMC8312999 DOI: 10.1186/s12875-021-01507-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 07/01/2021] [Indexed: 11/23/2022]
Abstract
Background Stratified care involves subgrouping patients based on key characteristics, e.g. prognostic risk, and matching these subgroups to early treatment options. The STarT-MSK programme developed and tested a new stratified primary care intervention for patients with common musculoskeletal (MSK) conditions in general practice. Stratified care involves changing General Practitioners’ (GPs) behaviour, away from the current ‘stepped’ care approach to identifying early treatment options matched to patients’ risk of persistent pain. Changing healthcare practice is challenging, and to aid the successful delivery of stratified care, education and support for GPs was required. This paper details the iterative development of a clinician support package throughout the lifespan of the programme, to support GPs in delivering the stratified care intervention. We argue that clinician support is a crucial aspect of the intervention itself, which is often overlooked. Methods Qualitative research with patients and GPs identified barriers and facilitators to the adoption of stratified care, which were mapped onto the Theoretical Domains Framework (TDF). Identified domains were ‘translated’ into an educational paradigm, and an initial version of the support package developed. This was further refined following a feasibility and pilot RCT, and a finalised support package was developed for the main RCT. Results The clinician support package comprised face-to-face sessions combining adult-learning principles with behaviour change theory in a multimethod approach, which included group discussion, simulated consultations, patient vignettes and model consultation videos. Structured support for GPs was crucial to facilitate fidelity and, ultimately, a successful trial. Clinician support is a two-way process– the study team can learn from and adapt to specific local factors and issues not previously identified. The support from senior clinicians was required to ensure ‘buy in’. Monitoring of GP performance, provision of regular feedback and remedial support are important aspects of effective clinician support. Conclusion Designing effective clinician support from the onset of trial intervention design, in an evidence-based, theory-informed manner, is crucial to encourage active engagement and intervention fidelity within the trial, enabling the delivery of a robust and reliable proof-of-principle trial. We offer practical recommendations for future general practice interventions.
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Affiliation(s)
- Joanne Protheroe
- Primary Care Centre Versus Arthritis, Keele School of Medicine, Keele University, Staffordshire, ST5 5BG, UK
| | - Benjamin Saunders
- Primary Care Centre Versus Arthritis, Keele School of Medicine, Keele University, Staffordshire, ST5 5BG, UK.
| | - Jonathan C Hill
- Primary Care Centre Versus Arthritis, Keele School of Medicine, Keele University, Staffordshire, ST5 5BG, UK
| | - Adrian Chudyk
- Primary Care Centre Versus Arthritis, Keele School of Medicine, Keele University, Staffordshire, ST5 5BG, UK
| | - Nadine E Foster
- Primary Care Centre Versus Arthritis, Keele School of Medicine, Keele University, Staffordshire, ST5 5BG, UK.,STARS Research and Education Alliance, Surgical Treatment and Rehabilitation Service, The University of Queensland and Metro North Hospital and Health Service, Brisbane, QLD, Australia
| | - Bernadette Bartlam
- Primary Care Centre Versus Arthritis, Keele School of Medicine, Keele University, Staffordshire, ST5 5BG, UK
| | - Simon Wathall
- Primary Care Centre Versus Arthritis, Keele School of Medicine, Keele University, Staffordshire, ST5 5BG, UK
| | - Vincent Cooper
- Primary Care Centre Versus Arthritis, Keele School of Medicine, Keele University, Staffordshire, ST5 5BG, UK
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Okuyan B, Balta E, Ozcan V, Durak Albayrak O, Turker M, Sancar M. Turkish community pharmacists' behavioral determinants in provision of pharmaceutical care to elderly patients. Int J Clin Pharm 2021; 43:1024-1035. [PMID: 33411182 DOI: 10.1007/s11096-020-01211-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 11/26/2020] [Indexed: 11/30/2022]
Abstract
Background It is crucial to develop and implement community pharmacist-led pharmaceutical care services in primary care that could prevent and detect potentially inappropriate prescribing and promote medication adherence in older patients. Objective The aim of this study was to determine community pharmacists' perceived barriers and facilitators face during the provision of pharmaceutical care to older patients by using a theoretical domains framework. Method A cross-sectional online survey was conducted among community pharmacists in Turkey. A Turkish version of the 50-item Determinants of Implementation Behavior Questionnaire was developed to evaluate behavioral determinants of community pharmacists on delivering pharmaceutical care to older patients. Main outcome measures The behavioral determinants of community pharmacists. Results A total of 354 community pharmacists answered the questionnaire. The mean age was 43.2 (standard deviation = 11.1), and 227 (64%) of the pharmacists were female. Community pharmacists' positive opinions on pharmaceutical care service outcomes in older patients and feedback were regarded as facilitators. Community pharmacists' motivational level and emotions were additional determinant facilitators in delivering pharmaceutical care to older patients. Their negative opinions on the impact and action of pharmaceutical care in older patients were regarded as barriers. Conclusion In primary health care, a theory-based e-distant training program for community pharmacists and the guidelines for standard pharmaceutical care services led by community pharmacists could be designed by addressing barriers related to the impact and action of pharmaceutical care in older patients.
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Affiliation(s)
- Betul Okuyan
- Clinical Pharmacy Department, Faculty of Pharmacy, Marmara University, Maltepe, Istanbul, Turkey.
| | - Ecehan Balta
- Turkish Pharmacists' Association, Ankara, Turkey
| | - Vildan Ozcan
- Turkish Pharmacists' Association, Ankara, Turkey
| | | | | | - Mesut Sancar
- Clinical Pharmacy Department, Faculty of Pharmacy, Marmara University, Maltepe, Istanbul, Turkey
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3
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Moja L, Polo Friz H, Capobussi M, Kwag K, Banzi R, Ruggiero F, González-Lorenzo M, Liberati EG, Mangia M, Nyberg P, Kunnamo I, Cimminiello C, Vighi G, Grimshaw JM, Delgrossi G, Bonovas S. Effectiveness of a Hospital-Based Computerized Decision Support System on Clinician Recommendations and Patient Outcomes: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e1917094. [PMID: 31825499 PMCID: PMC6991299 DOI: 10.1001/jamanetworkopen.2019.17094] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Sophisticated evidence-based information resources can filter medical evidence from the literature, integrate it into electronic health records, and generate recommendations tailored to individual patients. OBJECTIVE To assess the effectiveness of a computerized clinical decision support system (CDSS) that preappraises evidence and provides health professionals with actionable, patient-specific recommendations at the point of care. DESIGN, SETTING, AND PARTICIPANTS Open-label, parallel-group, randomized clinical trial among internal medicine wards of a large Italian general hospital. All analyses in this randomized clinical trial followed the intent-to-treat principle. Between November 1, 2015, and December 31, 2016, patients were randomly assigned to the intervention group, in which CDSS-generated reminders were displayed to physicians, or to the control group, in which reminders were generated but not shown. Data were analyzed between February 1 and July 31, 2018. INTERVENTIONS Evidence-Based Medicine Electronic Decision Support (EBMEDS), a commercial CDSS covering a wide array of health conditions across specialties, was integrated into the hospital electronic health records to generate patient-specific recommendations. MAIN OUTCOMES AND MEASURES The primary outcome was the resolution rate, the rate at which medical problems identified and alerted by the CDSS were addressed by a change in practice. Secondary outcomes included the length of hospital stay and in-hospital all-cause mortality. RESULTS In this randomized clinical trial, 20 563 patients were admitted to the hospital. Of these, 6480 (31.5%) were admitted to the internal medicine wards (study population) and randomized (3242 to CDSS and 3238 to control). The mean (SD) age of patients was 70.5 (17.3) years, and 54.5% were men. In total, 28 394 reminders were generated throughout the course of the trial (median, 3 reminders per patient per hospital stay; interquartile range [IQR], 1-6). These messages led to a change in practice in approximately 4 of 100 patients. The resolution rate was 38.0% (95% CI, 37.2%-38.8%) in the intervention group and 33.7% (95% CI, 32.9%-34.4%) in the control group, corresponding to an odds ratio of 1.21 (95% CI, 1.11-1.32; P < .001). The length of hospital stay did not differ between the groups, with a median time of 8 days (IQR, 5-13 days) for the intervention group and a median time of 8 days (IQR, 5-14 days) for the control group (P = .36). In-hospital all-cause mortality also did not differ between groups (odds ratio, 0.95; 95% CI, 0.77-1.17; P = .59). Alert fatigue did not differ between early and late study periods. CONCLUSIONS AND RELEVANCE An international commercial CDSS intervention marginally influenced routine practice in a general hospital, although the change did not statistically significantly affect patient outcomes. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02577198.
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Affiliation(s)
- Lorenzo Moja
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Clinical Epidemiology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Orthopedic Institute Galeazzi, Milan, Italy
| | - Hernan Polo Friz
- Internal Medicine Division, Medical Department, Vimercate Hospital, Vimercate, Italy
| | - Matteo Capobussi
- Clinical Epidemiology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Orthopedic Institute Galeazzi, Milan, Italy
| | - Koren Kwag
- Medical School of International Health, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Rita Banzi
- IRCCS Mario Negri Institute for Pharmacological Research, Milan, Italy
| | - Francesca Ruggiero
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Clinical Epidemiology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Orthopedic Institute Galeazzi, Milan, Italy
| | - Marien González-Lorenzo
- Humanitas Clinical and Research Center, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Elisa G. Liberati
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, United Kingdom
| | | | - Peter Nyberg
- Duodecim Medical Publications Ltd, Helsinki, Finland
| | - Ilkka Kunnamo
- Duodecim Medical Publications Ltd, Helsinki, Finland
| | - Claudio Cimminiello
- Internal Medicine Division, Medical Department, Vimercate Hospital, Vimercate, Italy
| | - Giuseppe Vighi
- Internal Medicine Division, Medical Department, Vimercate Hospital, Vimercate, Italy
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and the Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Giovanni Delgrossi
- Internal Medicine Division, Medical Department, Vimercate Hospital, Vimercate, Italy
| | - Stefanos Bonovas
- Humanitas Clinical and Research Center, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Hamade N, Terry A, Malvankar-Mehta M. Interventions to improve the use of EMRs in primary health care: a systematic review and meta-analysis. BMJ Health Care Inform 2019; 26:0. [PMID: 31142493 PMCID: PMC7062324 DOI: 10.1136/bmjhci-2019-000023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 03/08/2019] [Accepted: 03/23/2019] [Indexed: 02/02/2023] Open
Abstract
Background Electronic medical record (EMR) adoption in primary care has grown exponentially since their introduction in the 1970s. However, without their proper use benefits cannot be achieved. This includes: 1) the complete and safe documentation of patient information; 2) improved coordination of care; 3) reduced errors and 4) more involved patients. The use of EMRs is defined by practitioners using EMRs and their features to perform daily practice functions. Objective The purpose of this systematic review was to identify interventions aimed at improving EMR use in primary healthcare settings. Methods Ten online databases were searched to identify studies conducted in primary healthcare settings aimed at implementing interventions to observe the use of EMRs and directly measure the use of EMR functions or outcomes effected by the use of EMR functions. Results Of 2098 identified studies, 12 were included in the review. Results showed that interventions focused on the use of EMR functions, including referrals, electronic communication, reminders, use of clinical decision support systems and workflow management support functions, were five times more likely to show improvements in EMR use compared with controls. Interventions focused on data quality were five and a half times more likely to show improvements in EMR use compared with controls. Conclusions Individuals in primary healthcare settings aiming to improve EMR use would benefit from implementing interventions focused on EMR feature add-ons such as clinical decision support systems and customised referral templates, and provisions of educational materials, or financial incentives targeted at improving the use of EMR functions and data quality.
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Affiliation(s)
- Noura Hamade
- Centre for Global Health, Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Amanda Terry
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich Interfaculty Program in Public Health, Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Monali Malvankar-Mehta
- Department of Ophthalmology, Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
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Keyworth C, Hart J, Armitage CJ, Tully MP. What maximizes the effectiveness and implementation of technology-based interventions to support healthcare professional practice? A systematic literature review. BMC Med Inform Decis Mak 2018; 18:93. [PMID: 30404638 PMCID: PMC6223001 DOI: 10.1186/s12911-018-0661-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 09/27/2018] [Indexed: 02/02/2023] Open
Abstract
Background Technological support may be crucial in optimizing healthcare professional practice and improving patient outcomes. A focus on electronic health records has left other technological supports relatively neglected. Additionally, there has been no comparison between different types of technology-based interventions, and the importance of delivery setting on the implementation of technology-based interventions to change professional practice. Consequently, there is a need to synthesise and examine intervention characteristics using a methodology suited to identifying important features of effective interventions, and the barriers and facilitators to implementation. Three aims were addressed: to identify interventions with a technological component that are successful at changing professional practice, to determine if and how such interventions are theory-based, and to examine barriers and facilitators to successful implementation. Methods A literature review informed by realist review methods was conducted involving a systematic search of studies reporting either: (1) behavior change interventions that included technology to support professional practice change; or (2) barriers and facilitators to implementation of technological interventions. Extracted data was quantitative and qualitative, and included setting, target professionals, and use of Behaviour Change Techniques (BCTs). The primary outcome was a change in professional practice. A thematic analysis was conducted on studies reporting barriers and facilitators of implementation. Results Sixty-nine studies met the inclusion criteria; 48 (27 randomized controlled trials) reported behavior change interventions and 21 reported practicalities of implementation. The most successful technological intervention was decision support providing healthcare professionals with knowledge and/or person-specific information to assist with patient management. Successful technologies were more likely to operationalise BCTs, particularly “instruction on how to perform the behavior”. Facilitators of implementation included aligning studies with organisational initiatives, ensuring senior peer endorsement, and integration into clinical workload. Barriers included organisational challenges, and design, content and technical issues of technology-based interventions. Conclusions Technological interventions must focus on providing decision support for clinical practice using recognized behavior change techniques. Interventions must consider organizational context, clinical workload, and have clearly defined benefits for improving practice and patient outcomes. Electronic supplementary material The online version of this article (10.1186/s12911-018-0661-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- C Keyworth
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Coupland 1 Building, Oxford Road, Manchester, M13 9PL, UK.
| | - J Hart
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Coupland 1 Building, Oxford Road, Manchester, M13 9PL, UK.,Division of Medical Education, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester, M13 9PL, UK
| | - C J Armitage
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Coupland 1 Building, Oxford Road, Manchester, M13 9PL, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester, UK
| | - M P Tully
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester, M13 9PL, UK
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Gillespie BM, Harbeck EL, Lavin J, Hamilton K, Gardiner T, Withers TK, Marshall AP. Evaluation of a patient safety programme on Surgical Safety Checklist Compliance: a prospective longitudinal study. BMJ Open Qual 2018; 7:e000362. [PMID: 30057963 PMCID: PMC6059267 DOI: 10.1136/bmjoq-2018-000362] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 06/02/2018] [Accepted: 06/14/2018] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Surgical Safety Checklists (SSC) have been implemented widely across 132 countries since 2008. Yet, despite associated reductions in postoperative complications and death rates, implementation of checklists in surgery remains a challenge. The aim of this study was to assess the impact of a patient safety programme over time on SSC use and incidence of clinical errors. DESIGN A prospective longitudinal design over three time points and a retrospective secondary analysis of clinical incident data was undertaken. METHODS We implemented a patient safety programme over 4 weeks to improve surgical teams' use of the SSC. We undertook structured observations to assess surgical teams' checklist use before and after programme implementation and conducted a retrospective audit of clinical incident data 12 months before and 12 months following implementation of the programme. RESULTS There were significant improvements in the observed use of the SSC across all phases, particularly in sign-out where completion rates ranged from 79.3% to 94.5% (p<0.0001) following programme implementation. Across clinical incident audit periods, 33 019 surgical procedures were performed. Based on a subsample of 64 cases, clinical incidents occurred in 22/16 264 (0.13%) before implementation and 42/16 755 (0.25%) cases after implementation. The most predominant incident after programme implementation was inadequate tissue specimen labelling (23/42, 54.8%). Clinical incidents resulted in minimal or no harm to the patient. CONCLUSIONS The benefit in using a surgical checklist lies in the potential to enhance team communications and the promotion of a team culture in which safety is the priority.
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Affiliation(s)
- Brigid M Gillespie
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
- Nursing & Midwifery Research & Education Unit, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- National Centre of Research Excellence in Nursing, Griffith University, Gold Coast, Queensland, Australia
| | - Emma L Harbeck
- National Centre of Research Excellence in Nursing, Griffith University, Gold Coast, Queensland, Australia
| | - Joanne Lavin
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
| | - Kyra Hamilton
- School of Applied Psychology, Griffith University, Mt Gravatt Campus, Mount Gravatt, Queensland, Australia
| | - Therese Gardiner
- Nursing and Midwifery Education and Research Unit, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Teresa K Withers
- Surgical and Procedural Services, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Andrea P Marshall
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
- Nursing & Midwifery Research & Education Unit, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- National Centre of Research Excellence in Nursing, Griffith University, Gold Coast, Queensland, Australia
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Van de Velde S, Kortteisto T, Spitaels D, Jamtvedt G, Roshanov P, Kunnamo I, Aertgeerts B, Vandvik PO, Flottorp S. Development of a Tailored Intervention With Computerized Clinical Decision Support to Improve Quality of Care for Patients With Knee Osteoarthritis: Multi-Method Study. JMIR Res Protoc 2018; 7:e154. [PMID: 29891466 PMCID: PMC6018233 DOI: 10.2196/resprot.9927] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 04/06/2018] [Accepted: 05/07/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Clinical practice patterns greatly diverge from evidence-based recommendations to manage knee osteoarthritis conservatively before resorting to surgery. OBJECTIVE This study aimed to tailor a guideline-based computerized decision support (CDS) intervention that facilitates the conservative management of knee osteoarthritis. METHODS Experts with backgrounds in clinical medicine, research, implementation, or health informatics suggested the most important recommendations for implementation, how to develop an implementation strategy, and how to form the CDS algorithms. In 6 focus group sessions, 8 general practitioners and 22 patients from Norway, Belgium, and Finland discussed the suggested CDS intervention and identified factors that would be most critical for the success of the intervention. The focus group moderators used the GUideline Implementation with DEcision Support checklist, which we developed to support consideration of CDS success factors. RESULTS The experts prioritized 9 out of 22 recommendations for implementation. We formed the concept for 6 CDS algorithms to support implementation of these recommendations. The focus group suggested 59 unique factors that could affect the success of the presented CDS intervention. Five factors (out of the 59) were prioritized by focus group participants in every country, including the perceived potential to address the information needs of both patients and general practitioners; the credibility of CDS information; the timing of CDS for patients; and the need for personal dialogue about CDS between the general practitioner and the patient. CONCLUSIONS The focus group participants supported the CDS intervention as a tool to improve the quality of care for patients with knee osteoarthritis through shared, evidence-based decision making. We aim to develop and implement the CDS based on these study results. Future research should address optimal ways to (1) provide patient-directed CDS, (2) enable more patient-specific CDS within the context of patient complexity, and (3) maintain user engagement with CDS over time.
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Affiliation(s)
- Stijn Van de Velde
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Oslo, Norway
| | - Tiina Kortteisto
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - David Spitaels
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Gro Jamtvedt
- Oslo and Akershus University College of Applied Sciences, Oslo, Norway
| | - Pavel Roshanov
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ilkka Kunnamo
- Duodecim, Scientific Society of Finnish Physicians, Helsinki, Finland
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Per Olav Vandvik
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Oslo, Norway.,Institute of Health and Society, University of Oslo, Oslo, Norway.,Making GRADE the Irresistible Choice (MAGIC), Oslo, Norway
| | - Signe Flottorp
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Oslo, Norway.,Institute of Health and Society, University of Oslo, Oslo, Norway
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Conway N, Adamson KA, Cunningham SG, Emslie Smith A, Nyberg P, Smith BH, Wales A, Wake DJ. Decision Support for Diabetes in Scotland: Implementation and Evaluation of a Clinical Decision Support System. J Diabetes Sci Technol 2018; 12:381-388. [PMID: 28905658 PMCID: PMC5851216 DOI: 10.1177/1932296817729489] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Automated clinical decision support systems (CDSS) are associated with improvements in health care delivery to those with long-term conditions, including diabetes. A CDSS was introduced to two Scottish regions (combined diabetes population ~30 000) via a national diabetes electronic health record. This study aims to describe users' reactions to the CDSS and to quantify impact on clinical processes and outcomes over two improvement cycles: December 2013 to February 2014 and August 2014 to November 2014. METHODS Feedback was sought via patient questionnaires, health care professional (HCP) focus groups, and questionnaires. Multivariable regression was used to analyze HCP SCI-Diabetes usage (with respect to CDSS message presence/absence) and case-control comparison of clinical processes/outcomes. Cases were patients whose HCP received a CDSS messages during the study period. Closely matched controls were selected from regions outside the study, following similar clinical practice (without CDSS). Clinical process measures were screening rates for diabetes-related complications. Clinical outcomes included HbA1c at 1 year. RESULTS The CDSS had no adverse impact on consultations. HCPs were generally positive toward CDSS and used it within normal clinical workflow. CDSS messages were generated for 5692 cases, matched to 10 667 controls. Following clinic, the probability of patients being appropriately screened for complications more than doubled for most measures. Mean HbA1c improved in cases and controls but more so in cases (-2.3 mmol/mol [-0.2%] versus -1.1 [-0.1%], P = .003). DISCUSSION AND CONCLUSIONS The CDSS was well received; associated with improved efficiencies in working practices; and large improvements in guideline adherence. These evidence-based, early interventions can significantly reduce costly and devastating complications.
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Affiliation(s)
- Nicholas Conway
- NHS Tayside, Ninewells Hospital Dundee, Dundee, UK
- University of Dundee, Ninewells Hospital Dundee, Dundee, UK
- Nicholas Conway, MACHS building, Tayside Children’s Hospital, Ninewells Hospital, Dundee, DD1 9SY, UK.
| | - Karen A. Adamson
- NHS Lothian, St John’s Hospital, Howden Road West, Howden, Livingston, UK
| | | | | | - Peter Nyberg
- Duodecim Medical Publications, Helsinki, Finland
| | - Blair H. Smith
- University of Dundee, Ninewells Hospital Dundee, Dundee, UK
| | - Ann Wales
- NHS Education for Scotland, Glasgow, UK
| | - Deborah J. Wake
- NHS Tayside, Ninewells Hospital Dundee, Dundee, UK
- University of Dundee, Ninewells Hospital Dundee, Dundee, UK
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Bashshur RL, Howell JD, Krupinski EA, Harms KM, Bashshur N, Doarn CR. The Empirical Foundations of Telemedicine Interventions in Primary Care. Telemed J E Health 2017; 22:342-75. [PMID: 27128779 DOI: 10.1089/tmj.2016.0045] [Citation(s) in RCA: 154] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION This article presents the scientific evidence for the merits of telemedicine interventions in primary care. Although there is no uniform and consistent definition of primary care, most agree that it occupies a central role in the healthcare system as first contact for patients seeking care, as well as gatekeeper and coordinator of care. It enables and supports patient-centered care, the medical home, managed care, accountable care, and population health. Increasing concerns about sustainability and the anticipated shortages of primary care physicians have sparked interest in exploring the potential of telemedicine in addressing many of the challenges facing primary care in the United States and the world. MATERIALS AND METHODS The findings are based on a systematic review of scientific studies published from 2005 through 2015. The initial search yielded 2,308 articles, with 86 meeting the inclusion criteria. Evidence is organized and evaluated according to feasibility/acceptance, intermediate outcomes, health outcomes, and cost. RESULTS The majority of studies support the feasibility/acceptance of telemedicine for use in primary care, although it varies significantly by demographic variables, such as gender, age, and socioeconomic status, and telemedicine has often been found more acceptable by patients than healthcare providers. Outcomes data are limited but overall suggest that telemedicine interventions are generally at least as effective as traditional care. Cost analyses vary, but telemedicine in primary care is increasingly demonstrated to be cost-effective. CONCLUSIONS Telemedicine has significant potential to address many of the challenges facing primary care in today's healthcare environment. Challenges still remain in validating its impact on clinical outcomes with scientific rigor, as well as in standardizing methods to assess cost, but patient and provider acceptance is increasingly making telemedicine a viable and integral component of primary care around the world.
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Affiliation(s)
- Rashid L Bashshur
- 1 University of Michigan Health System, University of Michigan , Ann Arbor, Michigan
| | - Joel D Howell
- 2 Department of Internal Medicine, University of Michigan , Ann Arbor, Michigan.,3 Department of History and Health Management and Policy, University of Michigan , Ann Arbor, Michigan
| | | | - Kathryn M Harms
- 5 Family Medicine, University of Michigan , Ann Arbor, Michigan
| | - Noura Bashshur
- 1 University of Michigan Health System, University of Michigan , Ann Arbor, Michigan
| | - Charles R Doarn
- 6 Department of Family and Community Medicine, University of Cincinnati , Cincinnati, Ohio
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Balikuddembe MS, Tumwesigye NM, Wakholi PK, Tylleskär T. Computerized Childbirth Monitoring Tools for Health Care Providers Managing Labor: A Scoping Review. JMIR Med Inform 2017; 5:e14. [PMID: 28619702 PMCID: PMC5491898 DOI: 10.2196/medinform.6959] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/11/2017] [Accepted: 04/11/2017] [Indexed: 11/24/2022] Open
Abstract
Background Proper monitoring of labor and childbirth prevents many pregnancy-related complications. However, monitoring is still poor in many places partly due to the usability concerns of support tools such as the partograph. In 2011, the World Health Organization (WHO) called for the development and evaluation of context-adaptable electronic health solutions to health challenges. Computerized tools have penetrated many areas of health care, but their influence in supporting health staff with childbirth seems limited. Objective The objective of this scoping review was to determine the scope and trends of research on computerized labor monitoring tools that could be used by health care providers in childbirth management. Methods We used key terms to search the Web for eligible peer-reviewed and gray literature. Eligibility criteria were a computerized labor monitoring tool for maternity service providers and dated 2006 to mid-2016. Retrieved papers were screened to eliminate ineligible papers, and consensus was reached on the papers included in the final analysis. Results We started with about 380,000 papers, of which 14 papers qualified for the final analysis. Most tools were at the design and implementation stages of development. Three papers addressed post-implementation evaluations of two tools. No documentation on clinical outcome studies was retrieved. The parameters targeted with the tools varied, but they included fetal heart (10 of 11 tools), labor progress (8 of 11), and maternal status (7 of 11). Most tools were designed for use in personal computers in low-resource settings and could be customized for different user needs. Conclusions Research on computerized labor monitoring tools is inadequate. Compared with other labor parameters, there was preponderance to fetal heart monitoring and hardly any summative evaluation of the available tools. More research, including clinical outcomes evaluation of computerized childbirth monitoring tools, is needed.
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Affiliation(s)
- Michael S Balikuddembe
- Center for International Health, University of Bergen, Bergen, Norway.,Department of Epidemiology and Biostatistics, Makerere University, Kampala, Uganda.,Department of Obstetrics & Gynaecology, Mulago National Referral and Teaching Hospital, Kampala, Uganda
| | - Nazarius M Tumwesigye
- School of Public Health, Department of Epidemiology & Biostatistics, Makerere University, Kampala, Uganda
| | - Peter K Wakholi
- School of Computing & Informatics Technology, Makerere University, Kampala, Uganda
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11
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Delvaux N, Van de Velde S, Aertgeerts B, Goossens M, Fauquert B, Kunnamo I, Van Royen P. Adapting a large database of point of care summarized guidelines: a process description. J Eval Clin Pract 2017; 23:21-28. [PMID: 28399329 PMCID: PMC5347856 DOI: 10.1111/jep.12426] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2015] [Indexed: 11/27/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Questions posed at the point of care (POC) can be answered using POC summarized guidelines. To implement a national POC information resource, we subscribed to a large database of POC summarized guidelines to complement locally available guidelines. Our challenge was in developing a sustainable strategy for adapting almost 1000 summarized guidelines. The aim of this paper was to describe our process for adapting a database of POC summarized guidelines. METHODS An adaptation process based on the ADAPTE framework was tailored to be used by a heterogeneous group of participants. Guidelines were assessed on content and on applicability to the Belgian context. To improve efficiency, we chose to first aim our efforts towards those guidelines most important to primary care doctors. RESULTS Over a period of 3 years, we screened about 80% of 1000 international summarized guidelines. For those guidelines identified as most important for primary care doctors, we noted that in about half of the cases, remarks were made concerning content. On the other hand, at least two-thirds of all screened guidelines required no changes when evaluating their local usability. CONCLUSIONS Adapting a large body of POC summarized guidelines using a formal adaptation process is possible, even when faced with limited resources. This can be done by creating an efficient and collaborative effort and ensuring user-friendly procedures. Our experiences show that even though in most cases guidelines can be adopted without adaptations, careful review of guidelines developed in a different context remains necessary. Streamlining international efforts in adapting international POC information resources and adopting similar adaptation processes may lessen duplication efforts and prove more cost-effective.
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Affiliation(s)
- Nicolas Delvaux
- Academic Centre for General Practice, Department of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Belgium.,EBMPracticeNet, Leuven, Belgium
| | - Stijn Van de Velde
- EBMPracticeNet, Leuven, Belgium.,Belgian Centre for Evidence Based Medicine (CEBAM), Leuven, Belgium
| | - Bert Aertgeerts
- Academic Centre for General Practice, Department of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Belgium.,EBMPracticeNet, Leuven, Belgium.,Belgian Centre for Evidence Based Medicine (CEBAM), Leuven, Belgium
| | - Martine Goossens
- Academic Centre for General Practice, Department of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Belgium.,EBMPracticeNet, Leuven, Belgium.,Belgian Centre for Evidence Based Medicine (CEBAM), Leuven, Belgium
| | - Benjamin Fauquert
- EBMPracticeNet, Leuven, Belgium.,Belgian Centre for Evidence Based Medicine (CEBAM), Leuven, Belgium
| | | | - Paul Van Royen
- Belgian Centre for Evidence Based Medicine (CEBAM), Leuven, Belgium.,Department of Primary and Interdisciplinary Care Antwerp, University of Antwerp, Antwerp, Belgium
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12
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Moja L, Passardi A, Capobussi M, Banzi R, Ruggiero F, Kwag K, Liberati EG, Mangia M, Kunnamo I, Cinquini M, Vespignani R, Colamartini A, Di Iorio V, Massa I, González-Lorenzo M, Bertizzolo L, Nyberg P, Grimshaw J, Bonovas S, Nanni O. Implementing an evidence-based computerized decision support system linked to electronic health records to improve care for cancer patients: the ONCO-CODES study protocol for a randomized controlled trial. Implement Sci 2016; 11:153. [PMID: 27884165 PMCID: PMC5123241 DOI: 10.1186/s13012-016-0514-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 10/24/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Computerized decision support systems (CDSSs) are computer programs that provide doctors with person-specific, actionable recommendations, or management options that are intelligently filtered or presented at appropriate times to enhance health care. CDSSs might be integrated with patient electronic health records (EHRs) and evidence-based knowledge. METHODS/DESIGN The Computerized DEcision Support in ONCOlogy (ONCO-CODES) trial is a pragmatic, parallel group, randomized controlled study with 1:1 allocation ratio. The trial is designed to evaluate the effectiveness on clinical practice and quality of care of a multi-specialty collection of patient-specific reminders generated by a CDSS in the IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) hospital. We hypothesize that the intervention can increase clinician adherence to guidelines and, eventually, improve the quality of care offered to cancer patients. The primary outcome is the rate at which the issues reported by the reminders are resolved, aggregating specialty and primary care reminders. We will include all the patients admitted to hospital services. All analyses will follow the intention-to-treat principle. DISCUSSION The results of our study will contribute to the current understanding of the effectiveness of CDSSs in cancer hospitals, thereby informing healthcare policy about the potential role of CDSS use. Furthermore, the study will inform whether CDSS may facilitate the integration of primary care in cancer settings, known to be usually limited. The increasing use of and familiarity with advanced technology among new generations of physicians may support integrated approaches to be tested in pragmatic studies determining the optimal interface between primary and oncology care. TRIAL REGISTRATION ClinicalTrials.gov, NCT02645357.
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Affiliation(s)
- Lorenzo Moja
- Department of Biomedical Sciences for Health, University of Milan, Via Pascal 36, 20133 Milan, Italy
- Clinical Epidemiology Unit, IRCCS Orthopedic Institute Galeazzi, Via Galeazzi 4, 20161 Milan, Italy
| | - Alessandro Passardi
- Medical Oncology Unit, IRST Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy
| | - Matteo Capobussi
- School of Specialization in Hygiene and Preventive Medicine, University of Milan, Milan, Italy
| | - Rita Banzi
- IRCCS Mario Negri Institute for Pharmacological Research, Via La Masa 19, 20156 Milan, Italy
| | - Francesca Ruggiero
- Clinical Epidemiology Unit, IRCCS Orthopedic Institute Galeazzi, Via Galeazzi 4, 20161 Milan, Italy
| | - Koren Kwag
- Clinical Epidemiology Unit, IRCCS Orthopedic Institute Galeazzi, Via Galeazzi 4, 20161 Milan, Italy
| | - Elisa Giulia Liberati
- Cambridge Centre for Health Services Research (CCHSR), Department of Public Health and Primary Care, Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
| | | | - Ilkka Kunnamo
- Duodecim Medical Publications Ltd, Kaivokatu 10 A, 00101 Helsinki, Finland
| | - Michela Cinquini
- IRCCS Mario Negri Institute for Pharmacological Research, Via La Masa 19, 20156 Milan, Italy
| | - Roberto Vespignani
- Medical Oncology Unit, IRST Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy
| | - Americo Colamartini
- Medical Oncology Unit, IRST Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy
| | - Valentina Di Iorio
- Medical Oncology Unit, IRST Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy
| | - Ilaria Massa
- Medical Oncology Unit, IRST Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy
| | - Marien González-Lorenzo
- Department of Biomedical Sciences for Health, University of Milan, Via Pascal 36, 20133 Milan, Italy
- Clinical Epidemiology Unit, IRCCS Orthopedic Institute Galeazzi, Via Galeazzi 4, 20161 Milan, Italy
| | - Lorenzo Bertizzolo
- School of Specialization in Hygiene and Preventive Medicine, University of Milan, Milan, Italy
| | - Peter Nyberg
- Duodecim Medical Publications Ltd, Kaivokatu 10 A, 00101 Helsinki, Finland
| | - Jeremy Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8 L6 Canada
| | - Stefanos Bonovas
- Humanitas Clinical and Research Center, Via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Oriana Nanni
- Medical Oncology Unit, IRST Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy
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Kersting C, Weltermann B. Electronic reminders to facilitate longitudinal care: a mixed-methods study in general practices. BMC Med Inform Decis Mak 2016; 16:148. [PMID: 27881130 PMCID: PMC5122020 DOI: 10.1186/s12911-016-0387-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 11/10/2016] [Indexed: 11/10/2022] Open
Abstract
Background Longitudinal, patient-centered care represents a challenge for general practitioners (GPs), and in this context, reminder systems can offer targeted support. This study aimed to identify details of such reminders: (1) contents of care addressed, (2) their mode of display in the electronic health record (EHR), (3) their visual appearance, (4) personnel responsibilities for editing and applying reminders, and (5) use of reminders for patient recall. Methods This mixed-methods study comprised (1) a cross-sectional survey among 185 GP practices from a German university network, and (2) structured observations of reminder utilization in six practices based on a clinical vignette describing a multimorbid senior with 26 care needs. Descriptive statistics were performed for survey data. The practice observations were analyzed by portraying different types of reminders. Results Seventy-three of 185 practices completed the survey (39.5%): 98.6% reported using reminders in the EHR. Frequent care contents addressed were allergies/adverse drug events (95.8%), preventive measures (93.1%), participation in disease management programs (87.5%), chronic diseases (75.0%), and upcoming vaccinations (68.1%). Practice observations showed a variety of mainly self-configured reminders. In a patients’ EHR, information was displayed (1) compiled in a separate field, (2) scattered throughout the EHR, and/or (3) in a pop-up window. The visual appearance of electronic reminders varied: (1) colored fields with short text, (2) EHR entries and/or billing codes in pre-defined colors, (3) abbreviations within the treatment documentation, (4) symbols within the treatment documentation, (5) symbols linked to free text fields, and (6) traffic light schemes. Five practices self-designed reminders ‘as needed’; one practice applied an EHR-embedded, pre-defined reminder system. Practices used reminders for a mean of 13.3 of the 26 aspects of care detailed in the clinical vignette (range: 9–21; standard deviation (SD): 4.3). Practices needed 20–35 min (mean: 27.5; SD: 6.1) to retrieve the information requested. Conclusions Most GP practices use self-designed, visual reminders for some aspects of care, yet data-based, sophisticated solutions are needed to improve longitudinal care. Trial registration German Clinical Trials Register, unique identifying number: DRKS00008777 (date of registration: 06/19/2015). Electronic supplementary material The online version of this article (doi:10.1186/s12911-016-0387-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christine Kersting
- Institute for General Medicine, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Birgitta Weltermann
- Institute for General Medicine, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
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14
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Moja L, Polo Friz H, Capobussi M, Kwag K, Banzi R, Ruggiero F, González-Lorenzo M, Liberati EG, Mangia M, Nyberg P, Kunnamo I, Cimminiello C, Vighi G, Grimshaw J, Bonovas S. Implementing an evidence-based computerized decision support system to improve patient care in a general hospital: the CODES study protocol for a randomized controlled trial. Implement Sci 2016; 11:89. [PMID: 27389248 PMCID: PMC4936265 DOI: 10.1186/s13012-016-0455-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 06/18/2016] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Computerized decision support systems (CDSSs) are information technology-based software that provide health professionals with actionable, patient-specific recommendations or guidelines for disease diagnosis, treatment, and management at the point-of-care. These messages are intelligently filtered to enhance the health and clinical care of patients. CDSSs may be integrated with patient electronic health records (EHRs) and evidence-based knowledge. METHODS/DESIGN We designed a pragmatic randomized controlled trial to evaluate the effectiveness of patient-specific, evidence-based reminders generated at the point-of-care by a multi-specialty decision support system on clinical practice and the quality of care. We will include all the patients admitted to the internal medicine department of one large general hospital. The primary outcome is the rate at which medical problems, which are detected by the decision support software and reported through the reminders, are resolved (i.e., resolution rates). Secondary outcomes are resolution rates for reminders specific to venous thromboembolism (VTE) prevention, in-hospital all causes and VTE-related mortality, and the length of hospital stay during the study period. DISCUSSION The adoption of CDSSs is likely to increase across healthcare systems due to growing concerns about the quality of medical care and discrepancy between real and ideal practice, continuous demands for a meaningful use of health information technology, and the increasing use of and familiarity with advanced technology among new generations of physicians. The results of our study will contribute to the current understanding of the effectiveness of CDSSs in primary care and hospital settings, thereby informing future research and healthcare policy questions related to the feasibility and value of CDSS use in healthcare systems. This trial is seconded by a specialty trial randomizing patients in an oncology setting (ONCO-CODES). TRIAL REGISTRATION ClinicalTrials.gov, https://clinicaltrials.gov/ct2/show/NCT02577198?term=NCT02577198&rank=1.
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Affiliation(s)
- Lorenzo Moja
- Department of Biomedical Sciences for Health, University of Milan, Via Pascal 36, 20133 Milan, Italy
- Clinical Epidemiology Unit, IRCCS Orthopedic Institute Galeazzi, Via Galeazzi 4, 20161 Milan, Italy
| | - Hernan Polo Friz
- Internal Medicine Division, Medical Department, Vimercate Hospital, Via Santi Cosma e Damiano 10, 20871 Vimercate, Italy
| | - Matteo Capobussi
- School of Specialization in Hygiene and Preventive Medicine, University of Milan, Milan, Italy
| | - Koren Kwag
- Clinical Epidemiology Unit, IRCCS Orthopedic Institute Galeazzi, Via Galeazzi 4, 20161 Milan, Italy
| | - Rita Banzi
- IRCCS Mario Negri Institute for Pharmacological Research, Via La Masa 19, 20156 Milan, Italy
| | - Francesca Ruggiero
- Clinical Epidemiology Unit, IRCCS Orthopedic Institute Galeazzi, Via Galeazzi 4, 20161 Milan, Italy
| | - Marien González-Lorenzo
- Department of Biomedical Sciences for Health, University of Milan, Via Pascal 36, 20133 Milan, Italy
| | - Elisa Giulia Liberati
- Department of Health Science, Centre for Medicine, University of Leicester, University Road, Leicester, LE1 7RH UK
| | | | - Peter Nyberg
- Duodecim Medical Publications Ltd, Kaivokatu 10 A, 00101 Helsinki, Finland
| | - Ilkka Kunnamo
- Duodecim Medical Publications Ltd, Kaivokatu 10 A, 00101 Helsinki, Finland
| | - Claudio Cimminiello
- Internal Medicine Division, Medical Department, Vimercate Hospital, Via Santi Cosma e Damiano 10, 20871 Vimercate, Italy
| | - Giuseppe Vighi
- Internal Medicine Division, Medical Department, Vimercate Hospital, Via Santi Cosma e Damiano 10, 20871 Vimercate, Italy
| | - Jeremy Grimshaw
- Ottawa Hospital Research Institute & Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Stefanos Bonovas
- Humanitas Clinical and Research Center, Via Manzoni 56, 20089 Rozzano Milan, Italy
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15
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Moja L, Kwag KH. Point of care information services: a platform for self-directed continuing medical education for front line decision makers. Postgrad Med J 2016; 91:83-91. [PMID: 25655251 PMCID: PMC4345919 DOI: 10.1136/postgradmedj-2014-132965] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The structure and aim of continuing medical education (CME) is shifting from the passive transmission of knowledge to a competency-based model focused on professional development. Self-directed learning is emerging as the foremost educational method for advancing competency-based CME. In a field marked by the constant expansion of knowledge, self-directed learning allows physicians to tailor their learning strategy to meet the information needs of practice. Point of care information services are innovative tools that provide health professionals with digested evidence at the front line to guide decision making. By mobilising self-directing learning to meet the information needs of clinicians at the bedside, point of care information services represent a promising platform for competency-based CME. Several points, however, must be considered to enhance the accessibility and development of these tools to improve competency-based CME and the quality of care.
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Affiliation(s)
- Lorenzo Moja
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy Clinical Epidemiology Unit, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | - Koren Hyogene Kwag
- Clinical Epidemiology Unit, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
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16
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Sönnichsen A, Trampisch US, Rieckert A, Piccoliori G, Vögele A, Flamm M, Johansson T, Esmail A, Reeves D, Löffler C, Höck J, Klaassen-Mielke R, Trampisch HJ, Kunnamo I. Polypharmacy in chronic diseases-Reduction of Inappropriate Medication and Adverse drug events in older populations by electronic Decision Support (PRIMA-eDS): study protocol for a randomized controlled trial. Trials 2016; 17:57. [PMID: 26822311 PMCID: PMC5526277 DOI: 10.1186/s13063-016-1177-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 01/15/2016] [Indexed: 01/10/2023] Open
Abstract
Background Multimorbidity is increasing in aging populations with a corresponding increase in polypharmacy as well as inappropriate prescribing. Depending on definitions, 25-50 % of patients aged 75 years or older are exposed to at least five drugs. Evidence is increasing that polypharmacy, even when guidelines advise the prescribing of each drug individually, can potentially cause more harm than benefit to older patients, due to factors such as drug-drug and drug-disease interactions. Several approaches reducing polypharmacy and inappropriate prescribing have been proposed, but evidence showing a benefit of these measures regarding clinically relevant endpoints is scarce. There is an urgent need to implement more effective strategies. We therefore set out to develop an evidence-based electronic decision support (eDS) tool to aid physicians in reducing inappropriate prescribing and test its effectiveness in a large-scale cluster-randomized controlled trial. Methods The “Polypharmacy in chronic diseases–Reduction of Inappropriate Medication and Adverse drug events in older populations” (PRIMA)-eDS tool is a tool comprising an indication check and recommendations for the reduction of polypharmacy and inappropriate prescribing based on systematic reviews and guidelines, the European list of inappropriate medications for older people, the SFINX-database of interactions, the PHARAO-database on adverse effects, and the RENBASE-database on renal dosing. The tool will be evaluated in a cluster-randomized controlled trial involving 325 general practitioners (GPs) and around 3500 patients across five study centres in the United Kingdom, Germany, Austria and Italy. GP practices will be asked to recruit 11 patients aged 75 years or older who are taking at least eight medications and will be cluster-randomized after completion of patient recruitment. Intervention GPs will have access to the PRIMA-eDS tool, while control GPs will treat their patients according to current guidelines (usual care) without access to the PRIMA-eDS tool. After an observation time of 2 years, intervention and control groups will be compared regarding the primary composite endpoint of first non-elective hospitalization or death. Discussion The principal hypothesis is that reduction of polypharmacy and inappropriate prescribing can improve the clinical composite outcome of hospitalization or death. A positive result of the trial will contribute substantially to the improvement of care in multimorbidity. The trial is necessary to investigate not only whether the reduction of polypharmacy improves outcome, but also whether GPs and patients are willing to follow the recommendations of the PRIMA-eDS tool. Trial registration This trial has been registered with Current Controlled Trials Ltd. on 31 July 2014 (ISRCTN10137559). Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1177-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andreas Sönnichsen
- Institute of General Practice and Family Medicine, Witten/Herdecke University, Alfred-Herrhausen-Str. 50, 58448, Witten, Germany.
| | - Ulrike S Trampisch
- Institute of General Practice and Family Medicine, Witten/Herdecke University, Alfred-Herrhausen-Str. 50, 58448, Witten, Germany
| | - Anja Rieckert
- Institute of General Practice and Family Medicine, Witten/Herdecke University, Alfred-Herrhausen-Str. 50, 58448, Witten, Germany
| | | | - Anna Vögele
- South Tyrolian Academy of General Practice, Bolzano, Italy
| | - Maria Flamm
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Tim Johansson
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Aneez Esmail
- Centre of Primary Care, University of Manchester, Manchester, UK
| | - David Reeves
- Centre of Primary Care, University of Manchester, Manchester, UK
| | - Christin Löffler
- Institute of General Practice, Rostock University Medical Centre, Rostock, Germany
| | - Jennifer Höck
- Institute of General Practice, Rostock University Medical Centre, Rostock, Germany
| | - Renate Klaassen-Mielke
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University, Bochum, Germany
| | - Hans Joachim Trampisch
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University, Bochum, Germany
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17
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Kwag KH, González-Lorenzo M, Banzi R, Bonovas S, Moja L. Providing Doctors With High-Quality Information: An Updated Evaluation of Web-Based Point-of-Care Information Summaries. J Med Internet Res 2016; 18:e15. [PMID: 26786976 PMCID: PMC4738183 DOI: 10.2196/jmir.5234] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 11/19/2015] [Accepted: 11/20/2015] [Indexed: 01/18/2023] Open
Abstract
Background The complexity of modern practice requires health professionals to be active information-seekers. Objective Our aim was to review the quality and progress of point-of-care information summaries—Web-based medical compendia that are specifically designed to deliver pre-digested, rapidly accessible, comprehensive, and periodically updated information to health care providers. We aimed to evaluate product claims of being evidence-based. Methods We updated our previous evaluations by searching Medline, Google, librarian association websites, and conference proceedings from August 2012 to December 2014. We included Web-based, regularly updated point-of-care information summaries with claims of being evidence-based. We extracted data on the general characteristics and content presentation of products, and we quantitatively assessed their breadth of disease coverage, editorial quality, and evidence-based methodology. We assessed potential relationships between these dimensions and compared them with our 2008 assessment. Results We screened 58 products; 26 met our inclusion criteria. Nearly a quarter (6/26, 23%) were newly identified in 2014. We accessed and analyzed 23 products for content presentation and quantitative dimensions. Most summaries were developed by major publishers in the United States and the United Kingdom; no products derived from low- and middle-income countries. The main target audience remained physicians, although nurses and physiotherapists were increasingly represented. Best Practice, Dynamed, and UptoDate scored the highest across all dimensions. The majority of products did not excel across all dimensions: we found only a moderate positive correlation between editorial quality and evidence-based methodology (r=.41, P=.0496). However, all dimensions improved from 2008: editorial quality (P=.01), evidence-based methodology (P=.015), and volume of diseases and medical conditions (P<.001). Conclusions Medical and scientific publishers are investing substantial resources towards the development and maintenance of point-of-care summaries. The number of these products has increased since 2008 along with their quality. Best Practice, Dynamed, and UptoDate scored the highest across all dimensions, while others that were marketed as evidence-based were less reliable. Individuals and institutions should regularly assess the value of point-of-care summaries as their quality changes rapidly over time.
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Affiliation(s)
- Koren Hyogene Kwag
- Clinical Epidemiology Unit, IRCCS Galeazzi Orthopedic Institute, Milan, Italy
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