1
|
Gupta R, Xie BE, Zhu M, Segal JB. Randomized Experiments to Reduce Overuse of Health Care: A Scoping Review. Med Care 2024; 62:263-269. [PMID: 38315879 PMCID: PMC10939761 DOI: 10.1097/mlr.0000000000001978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
OBJECTIVE Health care overuse is pervasive in countries with advanced health care delivery systems. We hypothesize that effective interventions to reduce low-value care that targets patients or clinicians are mediated by psychological and cognitive processes that change behaviors and that interventions targeting these processes are varied. Thus, we performed a scoping review of experimental studies of interventions, including the interventions' objectives and characteristics, to reduce low-value care that targeted psychological and cognitive processes. METHODS We systematically searched databases for experimental studies of interventions to change cognitive orientations and affective states in the setting of health care overuse. Outcomes included observed overuse or a stated intention to use services. We used existing frameworks for behavior change and mechanisms of change to categorize the interventions and the mediating processes. RESULTS Twenty-seven articles met the inclusion criteria. Sixteen studied the provision of information to patients or clinicians, with most providing cost information. Six studies used educational interventions, including the provision of feedback about individual practice. Studies rarely used counseling, behavioral nudges, persuasion, and rewards. Mechanisms for behavior change included gain in knowledge or confidence and motivation by social norms. CONCLUSIONS In this scoping review, we found few experiments testing interventions that directly target the psychological and cognitive processes of patients or clinicians to reduce low-value care. Most studies provided information to patients or clinicians without measuring or considering mediating factors toward behavior change. These findings highlight the need for process-driven experimental designs, including trials of behavioral nudges and persuasive language involving a trusting patient-clinician relationship, to identify effective interventions to reduce low-value care.
Collapse
Affiliation(s)
- Ravi Gupta
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | | | - Meng Zhu
- Johns Hopkins Carey Business School, Baltimore, MD
- Pamplin College of Business, Virgina Tech, Blacksburg, VA
| | - Jodi B. Segal
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| |
Collapse
|
2
|
Ingvarsson S, Hasson H, von Thiele Schwarz U, Nilsen P, Powell BJ, Lindberg C, Augustsson H. Strategies for de-implementation of low-value care-a scoping review. Implement Sci 2022; 17:73. [PMID: 36303219 PMCID: PMC9615304 DOI: 10.1186/s13012-022-01247-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/13/2022] [Indexed: 11/27/2022] Open
Abstract
Background The use of low-value care (LVC) is a persistent problem that calls for knowledge about strategies for de-implementation. However, studies are dispersed across many clinical fields, and there is no overview of strategies that can be used to support the de-implementation of LVC. The extent to which strategies used for implementation are also used in de-implementing LVC is unknown. The aim of this scoping review is to (1) identify strategies for the de-implementation of LVC described in the scientific literature and (2) compare de-implementation strategies to implementation strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and strategies added by Perry et al. Method A scoping review was conducted according to recommendations outlined by Arksey and O’Malley. Four scientific databases were searched, relevant articles were snowball searched, and the journal Implementation Science was searched manually for peer-reviewed journal articles in English. Articles were included if they were empirical studies of strategies designed to reduce the use of LVC. Two reviewers conducted all abstract and full-text reviews, and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data-charting form. The strategies were first coded inductively and then mapped onto the ERIC compilation of implementation strategies. Results The scoping review identified a total of 71 unique de-implementation strategies described in the literature. Of these, 62 strategies could be mapped onto ERIC strategies, and four strategies onto one added category. Half (50%) of the 73 ERIC implementation strategies were used for de-implementation purposes. Five identified de-implementation strategies could not be mapped onto any of the existing strategies in ERIC. Conclusions Similar strategies are used for de-implementation and implementation. However, only a half of the implementation strategies included in the ERIC compilation were represented in the de-implementation studies, which may imply that some strategies are being underused or that they are not applicable for de-implementation purposes. The strategies assess and redesign workflow (a strategy previously suggested to be added to ERIC), accountability tool, and communication tool (unique new strategies for de-implementation) could complement the existing ERIC compilation when used for de-implementation purposes. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01247-y.
Collapse
Affiliation(s)
- Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,Unit for implementation and evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Per Nilsen
- Department of Health, Medicine and Caring Sciences, Division of Public Health, Linköping University, Linköping, Sweden
| | - Byron J Powell
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, St. Louis, MO, USA.,Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, St. Louis, MO, USA.,Division of Infectious Diseases, John T. Milliken Department of Medicine, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Clara Lindberg
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden
| | - Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,Unit for implementation and evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
| |
Collapse
|
3
|
Raudasoja AJ, Falkenbach P, Vernooij RWM, Mustonen JMJ, Agarwal A, Aoki Y, Blanker MH, Cartwright R, Garcia-Perdomo HA, Kilpeläinen TP, Lainiala O, Lamberg T, Nevalainen OPO, Raittio E, Richard PO, Violette PD, Komulainen J, Sipilä R, Tikkinen KAO. Randomized controlled trials in de-implementation research: a systematic scoping review. Implement Sci 2022; 17:65. [PMID: 36183140 PMCID: PMC9526943 DOI: 10.1186/s13012-022-01238-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Healthcare costs are rising, and a substantial proportion of medical care is of little value. De-implementation of low-value practices is important for improving overall health outcomes and reducing costs. We aimed to identify and synthesize randomized controlled trials (RCTs) on de-implementation interventions and to provide guidance to improve future research. METHODS MEDLINE and Scopus up to May 24, 2021, for individual and cluster RCTs comparing de-implementation interventions to usual care, another intervention, or placebo. We applied independent duplicate assessment of eligibility, study characteristics, outcomes, intervention categories, implementation theories, and risk of bias. RESULTS Of the 227 eligible trials, 145 (64%) were cluster randomized trials (median 24 clusters; median follow-up time 305 days), and 82 (36%) were individually randomized trials (median follow-up time 274 days). Of the trials, 118 (52%) were published after 2010, 149 (66%) were conducted in a primary care setting, 163 (72%) aimed to reduce the use of drug treatment, 194 (85%) measured the total volume of care, and 64 (28%) low-value care use as outcomes. Of the trials, 48 (21%) described a theoretical basis for the intervention, and 40 (18%) had the study tailored by context-specific factors. Of the de-implementation interventions, 193 (85%) were targeted at physicians, 115 (51%) tested educational sessions, and 152 (67%) multicomponent interventions. Missing data led to high risk of bias in 137 (60%) trials, followed by baseline imbalances in 99 (44%), and deficiencies in allocation concealment in 56 (25%). CONCLUSIONS De-implementation trials were mainly conducted in primary care and typically aimed to reduce low-value drug treatments. Limitations of current de-implementation research may have led to unreliable effect estimates and decreased clinical applicability of studied de-implementation strategies. We identified potential research gaps, including de-implementation in secondary and tertiary care settings, and interventions targeted at other than physicians. Future trials could be improved by favoring simpler intervention designs, better control of potential confounders, larger number of clusters in cluster trials, considering context-specific factors when planning the intervention (tailoring), and using a theoretical basis in intervention design. REGISTRATION OSF Open Science Framework hk4b2.
Collapse
Affiliation(s)
- Aleksi J Raudasoja
- Faculty of Medicine, University of Helsinki, Helsinki, Finland. .,Finnish Medical Society Duodecim, Helsinki, Finland.
| | - Petra Falkenbach
- Finnish Coordinating Center for Health Technology Assessment, Oulu University Hospital, Oulu, Finland.,University of Oulu, Oulu, Finland
| | - Robin W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Arnav Agarwal
- Division of General Internal Medicine, Department of Medicine and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Yoshitaka Aoki
- Department of Urology, University of Fukui Faculty of Medical Sciences, Fukui, Japan
| | - Marco H Blanker
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Rufus Cartwright
- Department of Gynaecology, Chelsea & Westminster NHS Foundation Trust, London, UK.,Department of Epidemiology & Biostatistics, Imperial College London, London, UK
| | - Herney A Garcia-Perdomo
- Division of Urology/Uro-oncology, Department of Surgery, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Tuomas P Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Olli Lainiala
- Department of Radiology, Tampere University Hospital and Faculty of Medicine and Health Technologies, Tampere University, Tampere, Finland
| | | | - Olli P O Nevalainen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Hatanpää Health Center, City of Tampere, Finland.,Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Eero Raittio
- Oral Health Care, Tampere, Finland.,Institute of Dentistry, University of Eastern Finland, Kuopio, Finland.,Nordic Healthcare Group Ltd., Helsinki, Finland
| | - Patrick O Richard
- Division of Urology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Philippe D Violette
- Departments of Surgery and Health Research Methods Evidence and Impact, McMaster University, Hamilton, Canada
| | | | - Raija Sipilä
- Finnish Medical Society Duodecim, Helsinki, Finland
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
| |
Collapse
|
4
|
Latifi N, Redberg RF, Grady D. The Next Frontier of Less Is More-From Description to Implementation. JAMA Intern Med 2022; 182:103-105. [PMID: 34870674 DOI: 10.1001/jamainternmed.2021.6908] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Niloofar Latifi
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rita F Redberg
- Department of Medicine, University of California, San Francisco.,Editor, JAMA Internal Medicine
| | - Deborah Grady
- Department of Medicine, University of California, San Francisco.,Deputy Editor, JAMA Internal Medicine
| |
Collapse
|
5
|
Gamstätter T. [The problem of medical overuse : Finding a definition and solutions]. Internist (Berl) 2021; 62:343-353. [PMID: 33580822 DOI: 10.1007/s00108-021-00957-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2021] [Indexed: 11/30/2022]
Abstract
High-quality medical care including the concepts of "patient-centered medicine" and "precision medicine" imply medical awareness of measures that are "too much" and thus not appropriate for certain patients in a certain context. Physicians occupy a central role as stewards of limited social resources. Numerous influencing factors can cause a cascading into medical overuse. How to identify and avoid overuse? When is "less medicine" the better medicine for an individual patient?
Collapse
Affiliation(s)
- T Gamstätter
- Deutsche Gesellschaft für Innere Medizin e. V. (DGIM), Irenenstr. 1, 65189, Wiesbaden, Deutschland.
| |
Collapse
|
6
|
Lillo S, Larsen TR, Pennerup L, Antonsen S. The impact of interventions applied in primary care to optimize the use of laboratory tests: a systematic review. Clin Chem Lab Med 2021; 59:1336-1352. [PMID: 33561910 DOI: 10.1515/cclm-2020-1734] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/26/2021] [Indexed: 11/15/2022]
Abstract
Laboratory tests are important tools in primary care, but their use is sometimes inappropriate. The aim of this review is to give an overview of interventions applied in primary care to optimize the use of laboratory tests. A search for studies was made in the MEDLINE and EMBASE databases. We also extracted studies from two previous reviews published in 2015. Studies were included if they described application of an intervention aiming to optimize the use of laboratory tests. We also evaluated the overall risk of bias of the studies. We included 24 studies. The interventions were categorized as: education, feedback reports and computerized physician order entry (CPOE) strategies. Most of the studies were classified as medium or high risk of bias while only three studies were evaluated as low risk of bias. The majority of the studies aimed at reducing the number of tests, while four studies investigated interventions aiming to increase the use of specific tests. Despite the studies being heterogeneous, we made results comparable by transforming the results into weighted relative changes in number of tests when necessary. Education changed the number of tests consistently, and these results were supported by the low risk of bias of the papers. Feedback reports have mainly been applied in combination with education, while when used alone the effect was minimal. The use of CPOE strategies seem to produce a marked change in the number of test requests, however the studies were of medium or high risk of bias.
Collapse
Affiliation(s)
- Serena Lillo
- Biochemistry Department, Odense University Hospital (OUH) and Svendborg Hospital, Svendborg, Denmark.,Department of Clinical Research, University of Southern Denmark (SDU), Odense, Denmark
| | - Trine Rennebod Larsen
- Biochemistry Department, Odense University Hospital (OUH) and Svendborg Hospital, Svendborg, Denmark.,Department of Clinical Research, University of Southern Denmark (SDU), Odense, Denmark
| | - Leif Pennerup
- Biochemistry Department, Odense University Hospital (OUH) and Svendborg Hospital, Svendborg, Denmark
| | - Steen Antonsen
- Biochemistry Department, Odense University Hospital (OUH) and Svendborg Hospital, Svendborg, Denmark
| |
Collapse
|
7
|
Burton CR, Williams L, Bucknall T, Fisher D, Hall B, Harris G, Jones P, Makin M, Mcbride A, Meacock R, Parkinson J, Rycroft-Malone J, Waring J. Theory and practical guidance for effective de-implementation of practices across health and care services: a realist synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background
Health-care systems across the globe are facing increased pressures to balance the efficient use of resources and at the same time provide high-quality care. There is greater requirement for services to be evidence based, but practices that are of limited clinical effectiveness or cost-effectiveness still occur.
Objectives
Our objectives included completing a concept analysis of de-implementation, surfacing decision-making processes associated with de-implementing through stakeholder engagement, and generating an evidence-based realist programme theory of ‘what works’ in de-implementation.
Design
A realist synthesis was conducted using an iterative stakeholder-driven four-stage approach. Phase 1 involved scoping the literature and conducting stakeholder interviews to develop the concept analysis and an initial programme theory. In Phase 2, systematic searches of the evidence were conducted to test and develop this theory, expressed in the form of contingent relationships. These are expressed as context–mechanism–outcomes to show how particular contexts or conditions trigger mechanisms to generate outcomes. Phase 3 consisted of validation and refinement of programme theories through stakeholder interviews. The final phase (i.e. Phase 4) formulated actionable recommendations for service leaders.
Participants
In total, 31 stakeholders (i.e. user/patient representatives, clinical managers, commissioners) took part in focus groups and telephone interviews.
Data sources
Using keywords identified during the scoping work and concept analysis, searches of bibliographic databases were conducted in May 2018. The databases searched were the Cochrane Library, Campbell Collaboration, MEDLINE (via EBSCOhost), the Cumulative Index to Nursing and Allied Health Literature (via EBSCOhost), the National Institute for Health Research Journals Library and the following databases via the ProQuest platform: Applied Social Sciences Index and Abstracts, Social Services Abstracts, International Bibliography of the Social Sciences, Social Sciences Database and Sociological Abstracts. Alerts were set up for the MEDLINE database from May 2018 to December 2018. Online sources were searched for grey literature and snowballing techniques were used to identify clusters of evidence.
Results
The concept analysis showed that de-implementation is associated with five main components in context and over time: (1) what is being de-implemented, (2) the issues driving de-implementation, (3) the action characterising de-implementation, (4) the extent that de-implementation is planned or opportunistic and (5) the consequences of de-implementation. Forty-two papers were synthesised to identify six context–mechanism–outcome configurations, which focused on issues ranging from individual behaviours to organisational procedures. Current systems can perpetuate habitual decision-making practices that include low-value treatments. Electronic health records can be designed to hide or remove low-value treatments from choice options, foregrounding best evidence. Professionals can be made aware of their decision-making strategies through increasing their attention to low-value practice behaviours. Uncertainty about diagnosis or patients’ expectations for certain treatments provide opportunities for ‘watchful waiting’ as an active strategy to reduce inappropriate investigations and prescribing. The emotional component of clinician–patient relationships can limit opportunities for de-implementation, requiring professional support through multimodal educational interventions. Sufficient alignment between policy, public and professional perspectives is required for de-implementation success.
Limitations
Some specific clinical issues (e.g. de-prescribing) dominate the de-implementation evidence base, which may limit the transferability of the synthesis findings. Any realist inquiry generates findings that are essentially cumulative and should be developed through further investigation that extends the range of sources into, for example, clinical research and further empirical studies.
Conclusions
This review contributes to our understanding of how de-implementation of low-value procedures and services can be improved within health-care services, through interventions that make professional decision-making more accountable and the prominence of a whole-system approach to de-implementation. Given the whole-system context of de-implementation, a range of different dissemination strategies will be required to engage with different stakeholders, in different ways, to change practice and policy in a timely manner.
Study registration
This study is registered as PROSPERO CRD42017081030.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Christopher R Burton
- School of Allied and Public Health Professions, Canterbury Christ Church University, Canterbury, UK
| | - Lynne Williams
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Tracey Bucknall
- School of Nursing and Midwifery, Deakin University, Melbourne, VIC, Australia
| | - Denise Fisher
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Beth Hall
- Library and Archives Services, Bangor University, Bangor, UK
| | - Gill Harris
- Betsi Cadwaladr University Health Board, Bangor, UK
| | - Peter Jones
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Matthew Makin
- North Manchester Care Organisation, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Anne Mcbride
- Alliance Manchester Business School, The University of Manchester, Manchester, UK
| | - Rachel Meacock
- Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - John Parkinson
- School of Psychology, College of Human Sciences, Bangor University, Bangor, UK
| | | | - Justin Waring
- School of Social Policy, University of Birmingham, Birmingham, UK
| |
Collapse
|
8
|
Reducing vitamin D requests in a primary care cohort: a quality improvement study. BJGP Open 2020; 4:bjgpopen20X101090. [PMID: 33144362 PMCID: PMC7880195 DOI: 10.3399/bjgpopen20x101090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 01/06/2020] [Indexed: 11/16/2022] Open
Abstract
Background Since 2000, vitamin D requests have increased 2–6 fold with no evidence of a corresponding improvement in the health of the population. The ease of vitamin D requesting may contribue to the rapid rise in its demand and, hence, pragmatic interventions to reduce vitamin D test ordering are warranted. Aim To study the effect on vitamin D requests following a redesign of the electronic forms used in primary care. In addition, any potential harms were studied and the potential cost-savings associated with the intervention were evaluated. Design & setting An interventional study took place within primary care across Leicestershire, England. Method The intervention was a redesign of the electronic laboratory request form for primary care practitioners across the county. Data were collected on vitamin D requests for a 6-month period prior to the change (October 2016 to March 2017) and the corresponding 6-month period post-intervention (October 2017 to March 2018), data were also collected on vitamin D, calcium, and phosphate levels. Results The number of requests for vitamin D decreased by 14 918 (36.2%) following the intervention. Changes in the median calcium and phosphate were not clinically significant. Cost-modelling suggested that if such an intervention was implemented across primary care in the UK, there would be a potential annual saving to the NHS of £38 712 606. Conclusion A simple pragmatic redesign of the electronic request form for vitamin D test led to a significant reduction in vitamin D requests without any adverse effect on the quality of care.
Collapse
|
9
|
Anderson TS, Lin GA. Testing Cascades-A Call to Move From Descriptive Research to Deimplementation Science. JAMA Intern Med 2020; 180:984-985. [PMID: 32511685 DOI: 10.1001/jamainternmed.2020.1588] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Grace A Lin
- Division of General Internal Medicine, University of California, San Francisco.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| |
Collapse
|
10
|
Ibarz M, Cadamuro J, Sumarac Z, Guimaraes JT, Kovalevskaya S, Nybo M, Cornes MP, Vermeersch P, Simundic AM, Lippi G. Clinicians' and laboratory medicine specialists' views on laboratory demand management: a survey in nine European countries. ACTA ACUST UNITED AC 2020; 8:111-119. [PMID: 31990661 DOI: 10.1515/dx-2019-0081] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/05/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Laboratory tests are an essential aspect of current medical practice and their use has grown exponentially. Several studies however have demonstrated inappropriate use of laboratory testing. This inappropriateness can lead to delayed or wrong diagnosis, negatively impacting patient safety and an increase in health care expenditure. The aim of the present small-scale survey was to obtain information on the current status of demand management in European laboratories, as well as the opinions of laboratory and clinical professionals in this regard. METHODS Two surveys were developed, one for laboratory specialists and one for clinicians, covering information on current use, knowledge and opinions on the possible impact of different demand management strategies on patient outcome and health care costs. Additionally, we asked for the current state and willingness on collaboration of laboratory specialists and clinicians. RESULTS One hundred and fifty responses, 72 laboratory specialists and 78 clinicians, from nine countries were received. Developing local ordering protocols/profiles in collaboration with clinicians was the most used strategy (80.3% of laboratories). Of clinicians, 85.6% considered measures to ensure appropriate use of tests necessary and 100% were interested in advice/information about their indication. Of the laboratory specialists 97.2% were either already participating or willing to participate in multidisciplinary groups on the appropriateness of test demand as were 60.3% of clinicians, and 85.9% of clinicians were interested in attending activities about laboratory test demand management. CONCLUSIONS The results of our survey show that tools to improve the appropriate use of laboratory tests are already regularly used today. Laboratory medicine specialists as well as clinicians are willing to undertake additional shared activities aimed at improving patient-centered laboratory diagnostic workup.
Collapse
Affiliation(s)
- Mercedes Ibarz
- Department of Clinical Laboratory, University Hospital Arnau de Vilanova, IRBLleida, Rovira Roure 80, 25198 Lleida, Spain
| | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Zorica Sumarac
- Center for Medical Biochemistry, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Pharmacy, Novi Sad, Serbia
| | - Joao Tiago Guimaraes
- Department of Clinical Pathology, Sao Joao Hospital Center, University of Porto, Porto, Portugal.,Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal.,EPIUnit, Institute of Public Health, University of Porto, Porto, Portugal
| | - Svetlana Kovalevskaya
- Clinical Laboratory Diagnostic Department with Course of Molecular Medicine, 1st Pavlov State Medical University, St-Petersburg, Russia
| | - Mads Nybo
- Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Michael P Cornes
- Department of Clinical Biochemistry, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Pieter Vermeersch
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Ana-Maria Simundic
- Department of Medical Laboratory Diagnostics, Clinical Hospital "Sveti Duh", Zagreb, Croatia
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| |
Collapse
|
11
|
Monteiro L, Maricoto T, Solha I, Ribeiro-Vaz I, Martins C, Monteiro-Soares M. Reducing Potentially Inappropriate Prescriptions for Older Patients Using Computerized Decision Support Tools: Systematic Review. J Med Internet Res 2019; 21:e15385. [PMID: 31724956 PMCID: PMC6883366 DOI: 10.2196/15385] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/12/2019] [Accepted: 09/23/2019] [Indexed: 11/28/2022] Open
Abstract
Background Older adults are more vulnerable to polypharmacy and prescriptions of potentially inappropriate medications. There are several ways to address polypharmacy to prevent its occurrence. We focused on computerized decision support tools. Objective The available literature was reviewed to understand whether computerized decision support tools reduce potentially inappropriate prescriptions or potentially inappropriate medications in older adult patients and affect health outcomes. Methods Our systematic review was conducted by searching the literature in the MEDLINE, CENTRAL, EMBASE, and Web of Science databases for interventional studies published through February 2018 to assess the impact of computerized decision support tools on potentially inappropriate medications and potentially inappropriate prescriptions in people aged 65 years and older. Results A total of 3756 articles were identified, and 16 were included. More than half (n=10) of the studies were randomized controlled trials, one was a crossover study, and five were pre-post intervention studies. A total of 266,562 participants were included; of those, 233,144 participants were included and assessed in randomized controlled trials. Intervention designs had several different features. Computerized decision support tools consistently reduced the number of potentially inappropriate prescriptions started and mean number of potentially inappropriate prescriptions per patient. Computerized decision support tools also increased potentially inappropriate prescriptions discontinuation and drug appropriateness. However, in several studies, statistical significance was not achieved. A meta-analysis was not possible due to the significant heterogeneity among the systems used and the definitions of outcomes. Conclusions Computerized decision support tools may reduce potentially inappropriate prescriptions and potentially inappropriate medications. More randomized controlled trials assessing the impact of computerized decision support tools that could be used both in primary and secondary health care are needed to evaluate the use of medication targets defined by the Beers or STOPP (Screening Tool of Older People’s Prescriptions) criteria, adverse drug reactions, quality of life measurements, patient satisfaction, and professional satisfaction with a reasonable follow-up, which could clarify the clinical usefulness of these tools. Trial Registration International Prospective Register of Systematic Reviews (PROSPERO) CRD42017067021; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42017067021
Collapse
Affiliation(s)
- Luís Monteiro
- Esgueira+ Family Health Unit, Aveiro Healthcare Centre, Aveiro, Portugal.,Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Tiago Maricoto
- Aveiro-Aradas Family Health Unit, Aveiro Healthcare Centre, Aveiro, Portugal.,Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - Isabel Solha
- Terras de Souza Family Health Unit, Paredes, Portugal
| | - Inês Ribeiro-Vaz
- Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal.,Porto Pharmacovigilance Centre, Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Community Medicine, Information and Decision in Health, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Carlos Martins
- Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Community Medicine, Information and Decision in Health, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Matilde Monteiro-Soares
- Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Community Medicine, Information and Decision in Health, Faculty of Medicine, University of Porto, Porto, Portugal
| |
Collapse
|
12
|
Bucholc M, O'Kane M, Mullan C, Ashe S, Maguire L. Primary care use of laboratory tests in Northern Ireland's Western Health and Social Care Trust: a cross-sectional study. BMJ Open 2019; 9:e026647. [PMID: 31230008 PMCID: PMC6596952 DOI: 10.1136/bmjopen-2018-026647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES To describe the laboratory test ordering patterns by general practitioners (GPs) in Northern Ireland Western Health and Social Care Trust (WHSCT) and explore demographic and socioeconomic associations with test requesting. DESIGN Cross-sectional study. SETTING WHSCT, Northern Ireland. : Particip ANTS: 55 WHSCT primary care medical practices that remained open throughout the study period 1 April 2011-31 March 2016. OUTCOMES To identify the temporal patterns of laboratory test ordering behaviour for eight commonly requested clinical biochemistry tests/test groups in WHSCT. To analyse the extent of variations in laboratory test requests by GPs and to explore whether these variations can be accounted for by clinical outcomes or geographical, demographic and socioeconomic characteristics. RESULTS The median number of adjusted test request rates over 5 consecutive years of the study period decreased by 45.7% for urine albumin/creatinine ratio (p<0.000001) and 19.4% for lipid profiles (p<0.000001) while a 60.6%, 36.6% and 29.5% increase was observed for HbA1c (p<0.000001), immunoglobulins (p=0.000007) and prostate-specific antigen (PSA) (p=0.0003), respectively. The between-practice variation in test ordering rates increased by 272% for immunoglobulins (p=0.008) and 500% for HbA1c (p=0.0001). No statistically significant relationship between ordering activity and either demographic (age and gender) and socioeconomic factors (deprivation) or Quality and Outcome Framework scores was observed. We found the rural-urban differences in between-practice variability in ordering rates for lipid profiles, thyroid profiles, PSA and immunoglobulins to be statistically significant at the Bonferroni-adjusted significance level p<0.01. CONCLUSIONS We explored potential factors of the interpractice variability in the use of laboratory tests and found that differences in requesting activity appear unrelated to either demographic and socioeconomic characteristics of GP practices or clinical outcome indicators.
Collapse
Affiliation(s)
- Magda Bucholc
- School of Computing, Engineering and Intelligent Systems, University of Ulster - Magee Campus, Londonderry, UK
| | - Maurice O'Kane
- Clinical Chemistry, Altnagelvin Area Hospital, Londonderry, UK
| | - Ciaran Mullan
- Western Local Commissioning Group, Health and Social Care Board, Londonderry, UK
| | - Siobhan Ashe
- Clinical Chemistry, Altnagelvin Area Hospital, Londonderry, UK
| | - Liam Maguire
- School of Computing, Engineering and Intelligent Systems, University of Ulster - Magee Campus, Londonderry, UK
| |
Collapse
|
13
|
Abstract
Laboratory tests are an integral part of the electronic health record (EHR). Providing clinical decision support (CDS) for the ordering, collection, reporting, viewing, and interpretation of laboratory testing is a fundamental function of the EHR. The implementation of a sustainable, effective laboratory CDS program requires a commitment to standardization and harmonization of the laboratory dictionaries that are the foundation of laboratory-based CDS. In this review, the authors provide an overview of the tools available within the EHR to improve decision making throughout the entire laboratory testing process, from test order to clinical action.
Collapse
Affiliation(s)
- Joseph W Rudolf
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, 420 Delaware Street Southeast, MMC 609 Mayo, Minneapolis, MN 55455, USA
| | - Anand S Dighe
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114-2696, USA.
| |
Collapse
|
14
|
Abstract
IMPORTANCE Overuse of medical care is a well-recognized problem in health care, associated with patient harm and costs. We sought to identify and highlight original research articles published in 2017 that are most relevant to understanding medical overuse. OBSERVATIONS A structured review of English-language articles published in 2017 was performed, coupled with examination of tables of contents of high-impact journals to identify articles related to medical overuse in adult care. Manuscripts were appraised for their quality, clinical relevance, and impact. A total of 1446 articles were identified, 910 of which addressed medical overuse. Of these, 111 articles were deemed to be the most relevant based on originality, methodologic quality, and scope. The 10 most influential articles were selected by author consensus. Findings included that unnecessary electrocardiograms are common (performed in 22% of patients at low risk) and can lead to a cascade of services, lipid monitoring rarely affects care, patients who were overdiagnosed with cancer experienced anxiety and criticism about not seeking treatment, calcium and vitamin D supplementation does not reduce hip fracture (relative risk, 1.09; 95% CI, 0.85-1.39), and pregabalin does not improve symptoms of sciatica but frequently has adverse effects (40% of patients experienced dizziness). Antipsychotic medications increased the severity of delirium in patients receiving hospice care and were associated with an increased risk of death (hazard ratio, 1.7; P = .003), and robotic-assisted radical nephrectomy was without benefits by being slower and more costly than laparoscopic surgery. High-sensitivity troponin testing often yielded false-positive results, as 16% of patients with positive troponin results in a US hospital had a myocardial infarction. One-third of patients who received a diagnosis of asthma had no evidence of asthma. Restructuring the electronic health record was able to reduce unnecessary testing (from 31.3 to 13.9 low-value tests performed per 100 patient visits). CONCLUSIONS AND RELEVANCE Many current practices were found to represent overuse, with no benefit and potential harms. Other services were used inappropriately. Reviewing these findings and extrapolating to their patients will enable health care professionals to improve the care they provide.
Collapse
Affiliation(s)
- Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore.,Department of Hospital Epidemiology, Veterans Affairs Maryland Health Care System, Baltimore
| | - Sanket S Dhruva
- Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut.,Department of Veterans Affairs West Haven, West Haven, Connecticut
| | - Eric R Coon
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Scott M Wright
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah Korenstein
- Department of Medicine and Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
15
|
Duddy C, Wong G. Explaining variations in test ordering in primary care: protocol for a realist review. BMJ Open 2018; 8:e023117. [PMID: 30209159 PMCID: PMC6144329 DOI: 10.1136/bmjopen-2018-023117] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/29/2018] [Accepted: 08/10/2018] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Studies have demonstrated the existence of significant variation in test-ordering patterns in both primary and secondary care, for a wide variety of tests and across many health systems. Inconsistent practice could be explained by differing degrees of underuse and overuse of tests for diagnosis or monitoring. Underuse of appropriate tests may result in delayed or missed diagnoses; overuse may be an early step that can trigger a cascade of unnecessary intervention, as well as being a source of harm in itself. METHODS AND ANALYSIS This realist review will seek to improve our understanding of how and why variation in laboratory test ordering comes about. A realist review is a theory-driven systematic review informed by a realist philosophy of science, seeking to produce useful theory that explains observed outcomes, in terms of relationships between important contexts and generative mechanisms.An initial explanatory theory will be developed in consultation with a stakeholder group and this 'programme theory' will be tested and refined against available secondary evidence, gathered via an iterative and purposive search process. This data will be analysed and synthesised according to realist principles, to produce a refined 'programme theory', explaining the contexts in which primary care doctors fail to order 'necessary' tests and/or order 'unnecessary' tests, and the mechanisms underlying these decisions. ETHICS AND DISSEMINATION Ethical approval is not required for this review. A complete and transparent report will be produced in line with the RAMESES standards. The theory developed will be used to inform recommendations for the development of interventions designed to minimise 'inappropriate' testing. Our dissemination strategy will be informed by our stakeholders. A variety of outputs will be tailored to ensure relevance to policy-makers, primary care and pathology practitioners, and patients. PROSPERO REGISTRATION NUMBER CRD42018091986.
Collapse
Affiliation(s)
- Claire Duddy
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
| |
Collapse
|
16
|
Monteiro L, Maricoto T, Solha IS, Monteiro-Soares M, Martins C. Computerised decision to reduce inappropriate medication in the elderly: a systematic review with meta-analysis protocol. BMJ Open 2018; 8:e018988. [PMID: 29382677 PMCID: PMC5829874 DOI: 10.1136/bmjopen-2017-018988] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Life expectancy continues to increase in developed countries. Elderly people are more likely to consume more medications and become vulnerable to age-related changes in drugs' pharmacokinetics and pharmacodynamics. Recent studies have identified opportunities and barriers for deprescribing potentially inappropriate medications. It has already been demonstrated that computerised decision support systems can reduce physician orders for unnecessary tests. We will systematically review the available literature to understand if computerised decision support is effective in reducing the use of potentially inappropriate medications, thus having an impact on health outcomes. METHODS AND ANALYSIS A systematic review will be conducted using MEDLINE, CENTRAL, EMBASE and Web of Science databases, as well as the grey literature assessing the effectiveness of computer decision support interventions in deprescribing inappropriate medication, with an impact on health outcomes in the elderly. The search will be performed during January and February 2018. Two reviewers will conduct articles' screening, selection and data extraction, independently and blind to each other. Eligible sources will be selected after discussing non-conformities. All extracted data from the included articles will be assessed based on studies' participants, design and setting, methodological quality, bias and any other potential sources of heterogeneity. This review will be conducted and reported in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement of quality for reporting systematic reviews and meta-analyses. ETHICS AND DISSEMINATION As a systematic review, this research is exempt from ethical approval. We intend to publish the full article in a related peer-reviewed journal and present it at international conferences. PROSPEROREGISTRATION NUMBER CRD42017067021.
Collapse
Affiliation(s)
- Luís Monteiro
- Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal
- USF Esgueira +, Aveiro, Portugal
| | - Tiago Maricoto
- Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal
- USF Aveiro/Aradas, Aveiro, Portugal
| | | | - Matilde Monteiro-Soares
- Departamento de Medicina da Comunidade, Informação e Decisão em Saúde, Oporto University Faculty of Medicine, Oporto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Oporto University Faculty of Medicine, Oporto, Portugal
| | - Carlos Martins
- Departamento de Medicina da Comunidade, Informação e Decisão em Saúde, Oporto University Faculty of Medicine, Oporto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Oporto University Faculty of Medicine, Oporto, Portugal
| |
Collapse
|
17
|
Sá L, Teixeira ASC, Tavares F, Costa-Santos C, Couto L, Costa-Pereira A, Hespanhol AP, Santos P, Martins C. Diagnostic and laboratory test ordering in Northern Portuguese Primary Health Care: a cross-sectional study. BMJ Open 2017; 7:e018509. [PMID: 29146654 PMCID: PMC5695440 DOI: 10.1136/bmjopen-2017-018509] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To characterise the test ordering pattern in Northern Portugal and to investigate the influence of context-related factors, analysing the test ordered at the level of geographical groups of family physicians and at the level of different healthcare organisations. DESIGN Cross-sectional study. SETTING Northern Primary Health Care, Portugal. PARTICIPANTS Records about diagnostic and laboratory tests ordered from 2035 family physicians working at the Northern Regional Health Administration, who served approximately 3.5 million Portuguese patients, in 2014. OUTCOMES To determine the 20 most ordered diagnostic and laboratory tests in the Northern Regional Health Administration; to identify the presence and extent of variations in the 20 most ordered diagnostic and laboratory tests between the Groups of Primary Care Centres and between health units; and to study factors that may explain these variations. RESULTS The 20 most ordered diagnostic and laboratory tests almost entirely comprise laboratory tests and account for 70.9% of the total tests requested. We can trace a major pattern of test ordering for haemogram, glucose, lipid profile, creatinine and urinalysis. There was a significant difference (P<0.001) in test orders for all tests between Groups of Primary Care Centres and for all tests, except glycated haemoglobin (P=0.06), between health units. Generally, the Personalised Healthcare Units ordered more than Family Health Units. CONCLUSIONS The results from this study show that the most commonly ordered tests in Portugal are laboratory tests, that there is a tendency for overtesting and that there is a large variability in diagnostic and laboratory test ordering in different geographical and organisational Portuguese primary care practices, suggesting that there may be considerable potential for the rationalisation of test ordering. The existence of Family Health Units seems to be a strong determinant in decreasing test ordering by Portuguese family physicians. Approaches to ensuring more rational testing are needed.
Collapse
Affiliation(s)
- Luísa Sá
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Family Health Unit Nova Via, Porto, Portugal
| | - Andreia Sofia Costa Teixeira
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Fernando Tavares
- Department of Studies and Planning, Northern Regional Health Administration, Porto, Portugal
| | - Cristina Costa-Santos
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Luciana Couto
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Altamiro Costa-Pereira
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Alberto Pinto Hespanhol
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Paulo Santos
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Carlos Martins
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| |
Collapse
|
18
|
Shojania KG, Jennings A, Mayhew A, Ramsay CR, Eccles MP, Grimshaw J. The effects of on-screen, point of care computer reminders on processes and outcomes of care. Cochrane Database Syst Rev 2009; 2009:CD001096. [PMID: 19588323 PMCID: PMC4171964 DOI: 10.1002/14651858.cd001096.pub2] [Citation(s) in RCA: 271] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering 'computer reminders'. OBJECTIVES To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care. SEARCH STRATEGY We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles. SELECTION CRITERIA Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care. DATA COLLECTION AND ANALYSIS Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome. MAIN RESULTS Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering. In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase). AUTHORS' CONCLUSIONS Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.
Collapse
Affiliation(s)
- Kaveh G Shojania
- Director, University of Toronto Centre for Patient Safety, Sunnybrook Health Sciences Centre, Room D474, 2075 Bayview Avenue, Toronto, Ontario, Canada, M4N 3M5
| | | | | | | | | | | |
Collapse
|