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Flores E, Martínez-Racaj L, Torreblanca R, Blasco A, Lopez-Garrigós M, Gutiérrez I, Salinas M. Clinical Decision Support System in laboratory medicine. Clin Chem Lab Med 2024; 62:1277-1282. [PMID: 38044692 DOI: 10.1515/cclm-2023-1239] [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] [Received: 11/01/2023] [Accepted: 11/24/2023] [Indexed: 12/05/2023]
Abstract
Clinical Decision Support Systems (CDSS) have been implemented in almost all healthcare settings. Laboratory medicine (LM), is one of the most important structured health data stores, but efforts are still needed to clarify the use and scope of these tools, especially in the laboratory setting. The aim is to clarify CDSS concept in LM, in the last decade. There is no consensus on the definition of CDSS in LM. A theoretical definition of CDSS in LM should capture the aim of driving significant improvements in LM mission, prevention, diagnosis, monitoring, and disease treatment. We identified the types, workflow and data sources of CDSS. The main applications of CDSS in LM were diagnostic support and clinical management, patient safety, workflow improvements, and cost containment. Laboratory professionals, with their expertise in quality improvement and quality assurance, have a chance to be leaders in CDSS.
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Affiliation(s)
- Emilio Flores
- Clinical Laboratory, University Hospital Sant Joan d'Alacant, San Juan de Alicante, Spain
- Clinical Medicine Department, Universidad Miguel Hernandez, San Juan de Alicante, Spain
| | - Laura Martínez-Racaj
- Clinical Laboratory, University Hospital Sant Joan d'Alacant, San Juan de Alicante, Spain
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Valencia, Spain
| | - Ruth Torreblanca
- Clinical Laboratory, University Hospital Sant Joan d'Alacant, San Juan de Alicante, Spain
| | - Alvaro Blasco
- Clinical Laboratory, University Hospital Sant Joan d'Alacant, San Juan de Alicante, Spain
| | - Maite Lopez-Garrigós
- Clinical Laboratory, University Hospital Sant Joan d'Alacant, San Juan de Alicante, Spain
- Department of Biochemistry and Molecular Pathology, Universidad Miguel Hernandez, Elche, Spain
| | - Irene Gutiérrez
- Clinical Laboratory, University Hospital Sant Joan d'Alacant, San Juan de Alicante, Spain
| | - Maria Salinas
- Clinical Laboratory, University Hospital Sant Joan d'Alacant, San Juan de Alicante, Spain
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Morris EJ, Vouri SM, Maraka S, Singh Ospina N. Trends and Components of Thyroid Status Evaluation in Commercially Insured Adults in the United States, 2006-2020. J Clin Endocrinol Metab 2024; 109:611-618. [PMID: 37889845 PMCID: PMC10876400 DOI: 10.1210/clinem/dgad632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/16/2023] [Accepted: 10/23/2023] [Indexed: 10/29/2023]
Abstract
CONTEXT Thyroid-stimulating hormone (TSH) is one of the most ordered laboratory tests. OBJECTIVE Determine trends of TSH testing rates and components of thyroid function testing. METHODS This was a retrospective analysis of adults 18-64 years old without evidence of thyroid disease with at least 365 days of continuous enrollment between 2006 and 2020 in the IBM MarketScan Claims Database. The main outcome measures were trends of TSH tests/1000 eligible patient-months stratified by age, sex, and region and composition of thyroid function testing. RESULTS Among 67 353 280 patients meeting eligibility criteria, we identified 25 606 518 TSH tests and 15 138 211 patients with ≥1 TSH test. Patients contributing an episode of TSH testing were most commonly 45-54 years old (29.8%) and female (63.6%). TSH testing rates remained consistent throughout the study period with 11.4 and 11.7 TSH tests/1000 person-months in the first and last study months, respectively (mean 12.2 TSH tests/1000 person-months). TSH testing rates dropped sharply in the spring of 2020 (4.2 TSH tests/1000 person-months). Females showed a nearly 2-fold higher rate of TSH testing than males (16.1 TSH tests/1000 person-months vs 8.6 TSH tests/1000 person-months). TSH testing rates increased with age (8.2 TSH tests/1000 person-months among individuals 18-34 years old vs 15.4 TSH tests/1000 person-months among individuals 55-64 years old). No difference in TSH testing rates was noted between regions. Thyroid function testing episodes included only TSH in most cases (70.8%). CONCLUSION TSH testing rates among commercially insured individuals without known thyroid disease appears stable over time, with higher frequency in females and with increasing age.
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Affiliation(s)
- Earl J Morris
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Scott M Vouri
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Spyridoula Maraka
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
- Endocrine Section, Medicine Service, Central Arkansas Veterans Healthcare System, Little Rock, AR 72205, USA
| | - Naykky Singh Ospina
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL 32608, USA
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Piessens V, Delvaux N, Heytens S, Aertgeerts B, De Sutter A. Downstream activities after laboratory testing in primary care: an exploratory outcome of the ELMO cluster randomised trial (Electronic Laboratory Medicine Ordering with evidence-based order sets in primary care). BMJ Open 2022; 12:e059261. [PMID: 35379642 PMCID: PMC8981323 DOI: 10.1136/bmjopen-2021-059261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE To estimate the rate and type of downstream activities (DAs) after laboratory testing in primary care, with a specific focus on check-up laboratory panels, and to explore the effect of a clinical decision support system (CDSS) for laboratory ordering on these DAs. DESIGN Cluster randomised clinical trial. SETTING 72 primary care practices in Belgium, with 272 general practitioners (GPs), randomly assigned to the intervention arm or the control arm. PARTICIPANTS The study included 10 270 lab panels from 9683 primary care patients (women 55.1%, mean age 56.5). All adult patients who consulted one of the participating GPs during the trial period and needed a laboratory exam were eligible for participation. INTERVENTIONS GPs in the intervention group used a CDSS integrated into their online laboratory ordering system, while GPs in the control arm used their lab ordering system as usual. The trial duration was 6 months, with another 6 months follow-up. MAIN OUTCOME MEASURES This publication reports on the exploratory outcome of DAs after an initial laboratory exam and the effect of the CDSS on these DAs. RESULTS 19.7% of all laboratory panels resulted in further diagnostic procedures (95% CI 18.9% to 20.5%) and 19% (95% CI 18.2% to 19.7%) in treatment changes. Check-up laboratory exams showed similar rates of DAs, with 17.5% (95% CI 13.8% to 21.2%) diagnostic DAs and 18.9% (95% CI 13.9% to 23.9%) treatment changes. Using the CDSS resulted in a significant reduction in downstream referrals (-2.4%; 95% CI -4.2% to -0.6%; p=0008), imaging and endoscopies (-0.9%; 95% CI -1.6% to -0.1%; p=0026) and treatment changes (-5.4%; 95% CI -9.5% to -1.2%; p=0.01). CONCLUSION This is the largest study so far to examine DAs after laboratory testing. It shows that almost one in three laboratory exams leads to further DAs, even in check-up panels. Using a CDSS for laboratory orders may reduce the rate of some DAs. TRIAL REGISTRATION NUMBER NCT02950142.
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Affiliation(s)
- Veerle Piessens
- Public Health and Primary Care, Ghent University Faculty of Medicine and Health Sciences, Gent, Belgium
| | | | - Stefan Heytens
- Public Health and Primary Care, Ghent University Faculty of Medicine and Health Sciences, Gent, Belgium
| | | | - An De Sutter
- Public Health and Primary Care, Ghent University Faculty of Medicine and Health Sciences, Gent, Belgium
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Nursing errors and Computerized Provider Order Entry (CPOE). INFORMATICS IN MEDICINE UNLOCKED 2021. [DOI: 10.1016/j.imu.2021.100648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Delvaux N, Piessens V, Burghgraeve TD, Mamouris P, Vaes B, Stichele RV, Cloetens H, Thomas J, Ramaekers D, Sutter AD, Aertgeerts B. Clinical decision support improves the appropriateness of laboratory test ordering in primary care without increasing diagnostic error: the ELMO cluster randomized trial. Implement Sci 2020; 15:100. [PMID: 33148311 PMCID: PMC7640389 DOI: 10.1186/s13012-020-01059-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/22/2020] [Indexed: 12/21/2022] Open
Abstract
Background Inappropriate laboratory test ordering poses an important burden for healthcare. Clinical decision support systems (CDSS) have been cited as promising tools to improve laboratory test ordering behavior. The objectives of this study were to evaluate the effects of an intervention that integrated a clinical decision support service into a computerized physician order entry (CPOE) on the appropriateness and volume of laboratory test ordering, and on diagnostic error in primary care. Methods This study was a pragmatic, cluster randomized, open-label, controlled clinical trial. Setting Two hundred eighty general practitioners (GPs) from 72 primary care practices in Belgium. Patients Patients aged ≥ 18 years with a laboratory test order for at least one of 17 indications: cardiovascular disease management, hypertension, check-up, chronic kidney disease (CKD), thyroid disease, type 2 diabetes mellitus, fatigue, anemia, liver disease, gout, suspicion of acute coronary syndrome (ACS), suspicion of lung embolism, rheumatoid arthritis, sexually transmitted infections (STI), acute diarrhea, chronic diarrhea, and follow-up of medication. Interventions The CDSS was integrated into a computerized physician order entry (CPOE) in the form of evidence-based order sets that suggested appropriate tests based on the indication provided by the general physician. Measurements The primary outcome of the ELMO study was the proportion of appropriate tests over the total number of ordered tests and inappropriately not-requested tests. Secondary outcomes of the ELMO study included diagnostic error, test volume, and cascade activities. Results CDSS increased the proportion of appropriate tests by 0.21 (95% CI 0.16–0.26, p < 0.0001) for all tests included in the study. GPs in the CDSS arm ordered 7 (7.15 (95% CI 3.37–10.93, p = 0.0002)) tests fewer per panel. CDSS did not increase diagnostic error. The absolute difference in proportions was a decrease of 0.66% (95% CI 1.4% decrease–0.05% increase) in possible diagnostic error. Conclusions A CDSS in the form of order sets, integrated within the CPOE improved appropriateness and decreased volume of laboratory test ordering without increasing diagnostic error. Trial registration ClinicalTrials.gov Identifier: NCT02950142, registered on October 25, 2016 Supplementary Information The online version contains supplementary material available at 10.1186/s13012-020-01059-y.
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Affiliation(s)
- Nicolas Delvaux
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33 Blok J PB 7001, B-3000, Leuven, Belgium.
| | - Veerle Piessens
- Department of Public Health and Primary Care, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Tine De Burghgraeve
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33 Blok J PB 7001, B-3000, Leuven, Belgium
| | - Pavlos Mamouris
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33 Blok J PB 7001, B-3000, Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33 Blok J PB 7001, B-3000, Leuven, Belgium
| | - Robert Vander Stichele
- Department of Basic and Applied Medical Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Hanne Cloetens
- Center for General Practice, University of Antwerp, Gouverneur Kinsbergen Centrum, Doornstraat 331, 2610, Wilrijk, Belgium
| | | | - Dirk Ramaekers
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33 Blok J PB 7001, B-3000, Leuven, Belgium
| | - An De Sutter
- Department of Public Health and Primary Care, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33 Blok J PB 7001, B-3000, Leuven, Belgium
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Delvaux N, Aertgeerts B, van Bussel JC, Goderis G, Vaes B, Vermandere M. Health Data for Research Through a Nationwide Privacy-Proof System in Belgium: Design and Implementation. JMIR Med Inform 2018; 6:e11428. [PMID: 30455164 PMCID: PMC6300317 DOI: 10.2196/11428] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/03/2018] [Accepted: 09/04/2018] [Indexed: 01/19/2023] Open
Abstract
Background Health data collected during routine care have important potential for reuse for other purposes, especially as part of a learning health system to advance the quality of care. Many sources of bias have been identified through the lifecycle of health data that could compromise the scientific integrity of these data. New data protection legislation requires research facilities to improve safety measures and, thus, ensure privacy. Objective This study aims to address the question on how health data can be transferred from various sources and using multiple systems to a centralized platform, called Healthdata.be, while ensuring the accuracy, validity, safety, and privacy. In addition, the study demonstrates how these processes can be used in various research designs relevant for learning health systems. Methods The Healthdata.be platform urges uniformity of the data registration at the primary source through the use of detailed clinical models. Data retrieval and transfer are organized through end-to-end encrypted electronic health channels, and data are encoded using token keys. In addition, patient identifiers are pseudonymized so that health data from the same patient collected across various sources can still be linked without compromising the deidentification. Results The Healthdata.be platform currently collects data for >150 clinical registries in Belgium. We demonstrated how the data collection for the Belgian primary care morbidity register INTEGO is organized and how the Healthdata.be platform can be used for a cluster randomized trial. Conclusions Collecting health data in various sources and linking these data to a single patient is a promising feature that can potentially address important concerns on the validity and quality of health data. Safe methods of data transfer without compromising privacy are capable of transporting these data from the primary data provider or clinician to a research facility. More research is required to demonstrate that these methods improve the quality of data collection, allowing researchers to rely on electronic health records as a valid source for scientific data.
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Affiliation(s)
- Nicolas Delvaux
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | | | - Geert Goderis
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Mieke Vermandere
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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Van de Velde S, Kunnamo I, Roshanov P, Kortteisto T, Aertgeerts B, Vandvik PO, Flottorp S. The GUIDES checklist: development of a tool to improve the successful use of guideline-based computerised clinical decision support. Implement Sci 2018; 13:86. [PMID: 29941007 PMCID: PMC6019508 DOI: 10.1186/s13012-018-0772-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/30/2018] [Indexed: 02/08/2023] Open
Abstract
Background Computerised decision support (CDS) based on trustworthy clinical guidelines is a key component of a learning healthcare system. Research shows that the effectiveness of CDS is mixed. Multifaceted context, system, recommendation and implementation factors may potentially affect the success of CDS interventions. This paper describes the development of a checklist that is intended to support professionals to implement CDS successfully. Methods We developed the checklist through an iterative process that involved a systematic review of evidence and frameworks, a synthesis of the success factors identified in the review, feedback from an international expert panel that evaluated the checklist in relation to a list of desirable framework attributes, consultations with patients and healthcare consumers and pilot testing of the checklist. Results We screened 5347 papers and selected 71 papers with relevant information on success factors for guideline-based CDS. From the selected papers, we developed a 16-factor checklist that is divided in four domains, i.e. the CDS context, content, system and implementation domains. The panel of experts evaluated the checklist positively as an instrument that could support people implementing guideline-based CDS across a wide range of settings globally. Patients and healthcare consumers identified guideline-based CDS as an important quality improvement intervention and perceived the GUIDES checklist as a suitable and useful strategy. Conclusions The GUIDES checklist can support professionals in considering the factors that affect the success of CDS interventions. It may facilitate a deeper and more accurate understanding of the factors shaping CDS effectiveness. Relying on a structured approach may prevent that important factors are missed. Electronic supplementary material The online version of this article (10.1186/s13012-018-0772-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stijn Van de Velde
- Centre for Informed Health Choices, Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway.
| | - Ilkka Kunnamo
- Duodecim, Scientific Society of Finnish Physicians, Helsinki, Finland
| | - Pavel Roshanov
- Department of Medicine, McMaster University, Hamilton, Canada
| | | | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Per Olav Vandvik
- MAGIC Non-Profit Research and Innovation Programme, Oslo, Norway.,Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Signe Flottorp
- Centre for Informed Health Choices, Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway.,Institute of Health and Society, University of Oslo, Oslo, Norway
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