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Blasiak A, Tan LWJ, Chong LM, Tadeo X, Truong ATL, Senthil Kumar K, Sapanel Y, Poon M, Sundar R, de Mel S, Ho D. Personalized dose selection for the first Waldenström macroglobulinemia patient on the PRECISE CURATE.AI trial. NPJ Digit Med 2024; 7:223. [PMID: 39191913 DOI: 10.1038/s41746-024-01195-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 07/12/2024] [Indexed: 08/29/2024] Open
Abstract
The digital revolution in healthcare, amplified by the COVID-19 pandemic and artificial intelligence (AI) advances, has led to a surge in the development of digital technologies. However, integrating digital health solutions, especially AI-based ones, in rare diseases like Waldenström macroglobulinemia (WM) remains challenging due to limited data, among other factors. CURATE.AI, a clinical decision support system, offers an alternative to big data approaches by calibrating individual treatment profiles based on that individual's data alone. We present a case study from the PRECISE CURATE.AI trial with a WM patient, where, over two years, CURATE.AI provided dynamic Ibrutinib dose recommendations to clinicians (users) aimed at achieving optimal IgM levels. An 80-year-old male with newly diagnosed WM requiring treatment due to anemia was recruited to the trial for CURATE.AI-based dosing of the Bruton tyrosine kinase inhibitor Ibrutinib. The primary and secondary outcome measures were focused on scientific and logistical feasibility. Preliminary results underscore the platform's potential in enhancing user and patient engagement, in addition to clinical efficacy. Based on a two-year-long patient enrollment into the CURATE.AI-augmented treatment, this study showcases how AI-enabled tools can support the management of rare diseases, emphasizing the integration of AI to enhance personalized therapy.
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Affiliation(s)
- Agata Blasiak
- The Institute for Digital Medicine (WisDM), National University of Singapore, Singapore, 117456, Singapore.
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore.
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore, 117583, Singapore.
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore.
- Roche Information Solutions, Santa Clara, California, USA.
| | - Lester W J Tan
- The Institute for Digital Medicine (WisDM), National University of Singapore, Singapore, 117456, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore, 117583, Singapore
| | - Li Ming Chong
- The Institute for Digital Medicine (WisDM), National University of Singapore, Singapore, 117456, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore, 117583, Singapore
| | - Xavier Tadeo
- The Institute for Digital Medicine (WisDM), National University of Singapore, Singapore, 117456, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore
| | - Anh T L Truong
- The Institute for Digital Medicine (WisDM), National University of Singapore, Singapore, 117456, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore, 117583, Singapore
| | - Kirthika Senthil Kumar
- The Institute for Digital Medicine (WisDM), National University of Singapore, Singapore, 117456, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore
| | - Yoann Sapanel
- The Institute for Digital Medicine (WisDM), National University of Singapore, Singapore, 117456, Singapore
| | - Michelle Poon
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119228, Singapore
- Department of Haematology-Oncology, National University Cancer Institute (NCIS), National University Hospital, Singapore, 119228, Singapore
| | - Raghav Sundar
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119228, Singapore
- Department of Haematology-Oncology, National University Cancer Institute (NCIS), National University Hospital, Singapore, 119228, Singapore
- Singapore Gastric Cancer Consortium, Department of Medicine, National University of Singapore, Singapore, 119228, Singapore
| | - Sanjay de Mel
- Department of Haematology-Oncology, National University Cancer Institute (NCIS), National University Hospital, Singapore, 119228, Singapore.
| | - Dean Ho
- The Institute for Digital Medicine (WisDM), National University of Singapore, Singapore, 117456, Singapore.
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore.
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore, 117583, Singapore.
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore.
- Singapore Gastric Cancer Consortium, Department of Medicine, National University of Singapore, Singapore, 119228, Singapore.
- The Bia-Echo Asia Centre for Reproductive Longevity and Equality (ACRLE), National University of Singapore, Singapore, 117456, Singapore.
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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.
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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
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Scott P, Kuziemsky C, Zhu X, Nøhr C, Ammenwerth E, Kukhareva P, Peute L, Marcilly R. One Health: Insights from Organizational & Social, Technology Assessment and Human Factors Perspectives. Yearb Med Inform 2023; 32:76-83. [PMID: 38147851 PMCID: PMC10751123 DOI: 10.1055/s-0043-1768729] [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] [Indexed: 12/28/2023] Open
Abstract
OBJECTIVES To offer diverse but complementary perspectives on how biomedical and health informatics can be informed by and help to achieve the vision of One Health. METHODS Overview of key considerations and critical discussion of common themes, barriers and opportunities, based on collaborative review by International Medical Informatics Association (IMIA) working group members active in related fields. RESULTS Health and care systems are complex sociotechnical systems that need explicit design and implementation strategies to align with the goals of One Health. The evidence-based health informatics paradigm and associated frameworks for evaluation of digital health technologies need to broaden their scope to take full account of the One Health approach. Informatics has specific contributions to make to One Health, for example by improved user experience reducing energy consumption and effective app design enhancing medication adherence. CONCLUSIONS One Health is inherently intertwined with ergonomic, sociotechnical and evaluation perspectives in biomedical and health informatics. Health is a planetary issue that requires interdisciplinary collaborative action. The theories and principles of biomedical and health informatics offer many opportunities to transform digital health technology to better serve the One Health agenda.
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Affiliation(s)
- Philip Scott
- Institute of Management & Health, University of Wales Trinity Saint David, Carmarthen, Wales, UK
| | | | | | - Christian Nøhr
- Department for Sustainability and Planning, Aalborg University, Aalborg, Denmark
| | - Elske Ammenwerth
- UMIT TIROL - Private University for Health Sciences and Health Informatics, Institute of Medical Informatics, Hall in Tirol, Austria
| | - Polina Kukhareva
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Linda Peute
- Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Romaric Marcilly
- Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, Lille, France
- Inserm, CIC-IT 1403 Lille, France
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Smith SN, Lanham M, Seagull FJ, Dorsch M, Errickson J, Barnes GD. Implementing pharmacist-prescriber collaboration to improve evidence-based anticoagulant use: a randomized trial. Implement Sci 2023; 18:16. [PMID: 37189171 PMCID: PMC10184412 DOI: 10.1186/s13012-023-01273-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/21/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Direct oral anticoagulant medications are commonly used to treat or prevent thrombotic conditions, such as pulmonary embolism, deep vein thrombosis, and atrial fibrillation. However, up to 10-15% of patients receiving these medications get unsafe doses based on a patient's kidney or liver function, potential interactions with other medications, and indication for taking the medication. Alert systems may be beneficial for improving evidence-based prescribing, but can be burdensome and are not currently able to provide monitoring after the initial prescription is written. METHODS/DESIGN This study will improve upon existing alert systems by testing novel medication alerts that encourage collaboration between prescribers (e.g., physicians, nurse practitioners, physician assistants) and expert pharmacists working in anticoagulation clinics. The study will also improve upon the existing alert system by incorporating dynamic long-term monitoring of patient needs and encouraging collaboration between prescribers and expert pharmacists working in anticoagulation clinics. Incorporating state-of-the-art user-centered design principles, prescribing healthcare providers will be randomized to different types of electronic health record medication alerts when a patient has an unsafe anticoagulant prescription. We will identify which alerts are most effective at encouraging evidence-based prescribing and will test moderators to tailor alert delivery to when it is most beneficial. The aims of the project are to (1) determine the effect of notifications targeting existing inappropriate DOAC prescriptions; (2) examine the effect of alerts on newly prescribed inappropriate DOACs; and (3) examine changes in the magnitude of effects over time for both the new prescription alerts and existing prescription notifications for inappropriate DOACs over the 18-month study period. DISCUSSION Findings from this project will establish a framework for implementing prescriber-pharmacist collaboration for high-risk medications, including anticoagulants. If effectively implemented at the more than 3000 anticoagulation clinics that exist nationally, hundreds of thousands of patients taking direct oral anticoagulants stand to benefit from safer, evidence-based healthcare. TRIALS REGISTRATION NCT05351749.
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Affiliation(s)
- Shawna N Smith
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Michael Lanham
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - F Jacob Seagull
- Center for Bioethics and Social Science in Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael Dorsch
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Josh Errickson
- Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, Institute for Healthcare Policy and Innovation, Frankel Cardiovascular Center, University of Michigan, 2800 Plymouth Rd, Ann Arbor, MI, B14 G21448108, USA.
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Olivares-Tirado P, Zanga R. Waste in health care spending: A scoping review. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2023. [DOI: 10.1080/20479700.2023.2185580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Affiliation(s)
- Pedro Olivares-Tirado
- Research and Development Department of the Superintendency of Health of Chile, Santiago, Chile
- Adjunct researcher at Health Service Development Research Center, University of Tsukuba, Tsukuba, Japan
| | - Rosendo Zanga
- Research and Development Department of the Superintendency of Health of Chile, Santiago, Chile
- School of Public Health, Faculty of Medicine, University of Chile, Santiago, Chile
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Kiessling KA, Iott BE, Pater JA, Toscos TR, Wagner SR, Gottlieb LM, Veinot TC. Health informatics interventions to minimize out-of-pocket medication costs for patients: what providers want. JAMIA Open 2022; 5:ooac007. [PMID: 35274083 PMCID: PMC8903137 DOI: 10.1093/jamiaopen/ooac007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 12/13/2021] [Accepted: 01/31/2022] [Indexed: 11/14/2022] Open
Abstract
Objective To explore diverse provider perspectives on: strategies for addressing patient medication cost barriers; patient medication cost information gaps; current medication cost-related informatics tools; and design features for future tool development. Materials and Methods We conducted 38 semistructured interviews with providers (physicians, nurses, pharmacists, social workers, and administrators) in a Midwestern health system in the United States. We used 3 rounds of qualitative coding to identify themes. Results Providers lacked access to information about: patients’ ability to pay for medications; true costs of full medication regimens; and cost impacts of patient insurance changes. Some providers said that while existing cost-related tools were helpful, they contained unclear insurance information and several questioned the information’s quality. Cost-related information was not available to everyone who needed it and was not always available when needed. Fragmentation of information across sources made cost-alleviation information difficult to access. Providers desired future tools to compare medication costs more directly; provide quick references on costs to facilitate clinical conversations; streamline medication resource referrals; and provide centrally accessible visual summaries of patient affordability challenges. Discussion These findings can inform the next generation of informatics tools for minimizing patients’ out-of-pocket costs. Future tools should support the work of a wider range of providers and situations and use cases than current tools do. Such tools would have the potential to improve prescribing decisions and better link patients to resources. Conclusion Results identified opportunities to fill multidisciplinary providers’ information gaps and ways in which new tools could better support medication affordability for patients. Almost a quarter of Americans taking prescription medications have difficulty affording them. We asked 38 healthcare providers what they do to help patients get affordable medications. They try to reduce the number of medications that patients take, choose more affordable medication options, and connect them to free medications or financial help. But it is hard for providers to do these things because they don’t always know which patients have financial challenges, and they may not know how much medications cost patients. Healthcare providers use digital tools like ordering systems to pick medications for patients, but they do not always have clear price information and they do not help outside of healthcare visits with prescribers. It is also hard for healthcare providers to get information about what patients have difficulty affording medications, and about resources to help them. Healthcare providers want new and improved digital tools to help them choose medications, and to be able to compare exact medication price differences. They also want a visual sign for patients with financial challenges, and centralized information about cost reduction resources. Finally, they desire tools to help them talk to patients about mediation prices, and medication price reports for patients themselves.
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Affiliation(s)
| | - Bradley E Iott
- School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
- School of Information, University of Michigan, Ann Arbor, Michigan, USA
| | - Jessica A Pater
- Parkview Mirro Center for Research & Innovation, Parkview Health, Fort Wayne, Indiana, USA
| | - Tammy R Toscos
- Parkview Mirro Center for Research & Innovation, Parkview Health, Fort Wayne, Indiana, USA
| | - Shauna R Wagner
- Parkview Mirro Center for Research & Innovation, Parkview Health, Fort Wayne, Indiana, USA
| | - Laura M Gottlieb
- Social Interventions Research and Evaluation Network, University of California San Francisco, San Francisco, California, USA
| | - Tiffany C Veinot
- School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
- School of Information, University of Michigan, Ann Arbor, Michigan, USA
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Proctor EK, Toker E, Tabak R, McKay VR, Hooley C, Evanoff B. Market viability: a neglected concept in implementation science. Implement Sci 2021; 16:98. [PMID: 34801036 PMCID: PMC8605560 DOI: 10.1186/s13012-021-01168-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 10/26/2021] [Indexed: 11/15/2022] Open
Abstract
This debate paper asserts that implementation science needs to incorporate a key concept from entrepreneurship—market demand—and demonstrates how assessing an innovation’s potential market viability might advance the pace and success of innovation adoption and sustainment. We describe key concepts, language distinctions, and questions that entrepreneurs pose to implementation scientists—many of which implementation scientists appear ill-equipped to answer. The paper concludes with recommendations about how concepts from entrepreneurship, notably market viability assessment, can enhance the translation of research discoveries into real-world adoption, sustained use, and population health benefits. The paper further proposes activities that can advance implementation science’s capacity to draw from the field of entrepreneurship, along with the data foundations required to assess and cultivate market demand.
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Affiliation(s)
- Enola K Proctor
- Brown School, Washington University in St. Louis, One Brookings Drive, Saint Louis, MO, 63130, USA.
| | - Emre Toker
- Washington University Medical School in St. Louis and the University of Arizona, 1110 E. Campus Drive, P.O. Box 210033, Tucson, AZ, USA, 85721-0033
| | - Rachel Tabak
- Brown School, Washington University in St. Louis, One Brookings Drive, Saint Louis, MO, 63130, USA
| | - Virginia R McKay
- Brown School, Washington University in St. Louis, One Brookings Drive, Saint Louis, MO, 63130, USA
| | - Cole Hooley
- School of Social Work, Brigham Young University, 2166 JFSB, Provo, UT, 84602, USA
| | - Bradley Evanoff
- Division of General Medical Sciences, School of Medicine, Washington University in St. Louis, 660 S. Euclid Drive, St. Louis, MO, 63110, USA
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Zhang ZY, Yu YL, Asayama K, Hansen TW, Maestre GE, Staessen JA. Starting Antihypertensive Drug Treatment With Combination Therapy: Controversies in Hypertension - Con Side of the Argument. Hypertension 2021; 77:788-798. [PMID: 33566687 PMCID: PMC7884241 DOI: 10.1161/hypertensionaha.120.12858] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text.
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Affiliation(s)
- Zhen-Yu Zhang
- From the Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (Z.-Y.Z., Y.-L.Y., K.A.)
| | - Yu-Ling Yu
- From the Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (Z.-Y.Z., Y.-L.Y., K.A.)
| | - Kei Asayama
- From the Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (Z.-Y.Z., Y.-L.Y., K.A.)
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan (K.A.)
- Tohoku Institute for Management of Blood Pressure, Sendai, Japan (K.A.)
- Research Institute Alliance for the Promotion of Preventive Medicine (APPREMED), Mechelen, Belgium (K.A., G.E.M., T.W.H., J.A.S)
| | - Tine W. Hansen
- Research Institute Alliance for the Promotion of Preventive Medicine (APPREMED), Mechelen, Belgium (K.A., G.E.M., T.W.H., J.A.S)
- Steno Diabetes Center Copenhagen, Capital Region of Denmark, Denmark (T.W.H.)
| | - Gladys E. Maestre
- Research Institute Alliance for the Promotion of Preventive Medicine (APPREMED), Mechelen, Belgium (K.A., G.E.M., T.W.H., J.A.S)
- Department of Neurosciences and Department of Human Genetics, University of Texas Rio Grande Valley School of Medicine, Brownsville, TX (G.E.M.)
- Alzheimer´s Disease Resource Center for Minority Aging Research, University of Texas Rio Grande Valley, Brownsville, TX (G.E.M.)
| | - Jan A. Staessen
- Research Institute Alliance for the Promotion of Preventive Medicine (APPREMED), Mechelen, Belgium (K.A., G.E.M., T.W.H., J.A.S)
- Biomedical Sciences Group, Faculty of Medicine, University of Leuven, Belgium (J.A.S.)
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Izeogu C, Kalinowski J, Schoenthaler A. Strategies to Improve Adherence to Anti-Hypertensive Medications: a Narrative Review. Curr Hypertens Rep 2020; 22:105. [PMID: 33165652 DOI: 10.1007/s11906-020-01115-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2020] [Indexed: 01/16/2023]
Abstract
PURPOSE OF REVIEW Medication adherence is critical for effective management of hypertension, yet half of patients with hypertension are non-adherent to medications. In this review, we describe and critically evaluate medication adherence interventions published in the past 3 years for patients with hypertension. RECENT FINDINGS We identified 1593 articles and 163 underwent full review, of which 42 studies met the inclusion criteria. Studies were classified into eight categories: simplification of medication regimen (e.g., fixed dose combination pills); electronic Health (eHealth) tools (e.g., text messaging reminders); behavioral counseling (e.g., motivational interviewing); healthcare system changes (e.g., patient-centered medical home); patient education; multicomponent chronic disease management program; home blood pressure monitoring; and financial incentives. Studies utilizing strategies to simplify medication regimens, eHealth tools, patient education, and behavioral counseling were most likely to report positive findings. Interventions targeting patient behavior were more likely to be associated with improvements in medication adherence compared to those targeting providers or the healthcare system. eHealth tools show promise for augmenting behavioral interventions. A major limitation of included trials was short study duration and use of self-report measures of medication adherence. Future research should explore how complex interventions that utilize a combination of evidence-based strategies and target multiple adherence behaviors (e.g., both day-to-day medication taking and long-term persistence) may be efficacious in improving medication adherence.
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Affiliation(s)
- Chigozirim Izeogu
- Department of Population Health, Center for Healthful Behavior Change, New York University Grossman School of Medicine, New York, NY, USA
| | - Jolaade Kalinowski
- Department of Human Development and Family Sciences, University of Connecticut, Storrs, CT, USA
| | - Antoinette Schoenthaler
- Department of Population Health, Center for Healthful Behavior Change, New York University Grossman School of Medicine, New York, NY, USA.
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Gorfinkel I, Brown A, Lexchin JR. Engaging physicians to prescribe more cost-effectively: Blueprint for change. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2020; 66:723-725. [PMID: 33077447 PMCID: PMC7571639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Iris Gorfinkel
- General practitioner and Principal Investigator and Founder of PrimeHealth Clinical Research in Toronto, Ont.
| | - Ahuva Brown
- Clinical Research Fellow at the Hospital For Sick Children in Toronto
| | - Joel R Lexchin
- Fellow of the Canadian Academy of Health Sciences, Professor Emeritus in the School of Health Policy and Management at York University in Toronto, and an emergency physician in the University Health Network
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11
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Gorfinkel I, Brown A, Lexchin JR. [Not Available]. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2020; 66:e251-e254. [PMID: 33077464 PMCID: PMC7571646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Iris Gorfinkel
- Omnipraticienne, chercheure principale et fondatrice de PrimeHealth Clinical Research à Toronto (Ontario).
| | - Ahuva Brown
- Boursière de recherche clinique au Hospital For Sick Children à Toronto
| | - Joel R Lexchin
- Membre de l'Académie canadienne des sciences de la santé, professeur émérite à l'École des politiques et de la gestion de la santé de l'Université York à Toronto et urgentologue à l'University Health Network
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Kwan JL, Lo L, Ferguson J, Goldberg H, Diaz-Martinez JP, Tomlinson G, Grimshaw JM, Shojania KG. Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials. BMJ 2020; 370:m3216. [PMID: 32943437 PMCID: PMC7495041 DOI: 10.1136/bmj.m3216] [Citation(s) in RCA: 166] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To report the improvements achieved with clinical decision support systems and examine the heterogeneity from pooling effects across diverse clinical settings and intervention targets. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline up to August 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES AND METHODS Randomised or quasi-randomised controlled trials reporting absolute improvements in the percentage of patients receiving care recommended by clinical decision support systems. Multilevel meta-analysis accounted for within study clustering. Meta-regression was used to assess the degree to which the features of clinical decision support systems and study characteristics reduced heterogeneity in effect sizes. Where reported, clinical endpoints were also captured. RESULTS In 108 studies (94 randomised, 14 quasi-randomised), reporting 122 trials that provided analysable data from 1 203 053 patients and 10 790 providers, clinical decision support systems increased the proportion of patients receiving desired care by 5.8% (95% confidence interval 4.0% to 7.6%). This pooled effect exhibited substantial heterogeneity (I2=76%), with the top quartile of reported improvements ranging from 10% to 62%. In 30 trials reporting clinical endpoints, clinical decision support systems increased the proportion of patients achieving guideline based targets (eg, blood pressure or lipid control) by a median of 0.3% (interquartile range -0.7% to 1.9%). Two study characteristics (low baseline adherence and paediatric settings) were associated with significantly larger effects. Inclusion of these covariates in the multivariable meta-regression, however, did not reduce heterogeneity. CONCLUSIONS Most interventions with clinical decision support systems appear to achieve small to moderate improvements in targeted processes of care, a finding confirmed by the small changes in clinical endpoints found in studies that reported them. A minority of studies achieved substantial increases in the delivery of recommended care, but predictors of these more meaningful improvements remain undefined.
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Affiliation(s)
- Janice L Kwan
- Sinai Health System, Department of Medicine, 600 University Avenue, Toronto, ON M5G 1X5, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lisha Lo
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, ON, Canada
| | - Jacob Ferguson
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Hanna Goldberg
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Juan Pablo Diaz-Martinez
- Biostatistics Research Unit, University Health Network and Sinai Health System, Toronto, ON, Canada
| | - George Tomlinson
- Biostatistics Research Unit, University Health Network and Sinai Health System, Toronto, ON, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kaveh G Shojania
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Lewkowicz D, Wohlbrandt A, Boettinger E. Economic impact of clinical decision support interventions based on electronic health records. BMC Health Serv Res 2020; 20:871. [PMID: 32933513 PMCID: PMC7491136 DOI: 10.1186/s12913-020-05688-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/25/2020] [Indexed: 12/28/2022] Open
Abstract
Background Unnecessary healthcare utilization, non-adherence to current clinical guidelines, or insufficient personalized care are perpetual challenges and remain potential major cost-drivers for healthcare systems around the world. Implementing decision support systems into clinical care is promised to improve quality of care and thereby yield substantial effects on reducing healthcare expenditure. In this article, we evaluate the economic impact of clinical decision support (CDS) interventions based on electronic health records (EHR). Methods We searched for studies published after 2014 using MEDLINE, CENTRAL, WEB OF SCIENCE, EBSCO, and TUFTS CEA registry databases that encompass an economic evaluation or consider cost outcome measures of EHR based CDS interventions. Thereupon, we identified best practice application areas and categorized the investigated interventions according to an existing taxonomy of front-end CDS tools. Results and discussion Twenty-seven studies are investigated in this review. Of those, twenty-two studies indicate a reduction of healthcare expenditure after implementing an EHR based CDS system, especially towards prevalent application areas, such as unnecessary laboratory testing, duplicate order entry, efficient transfusion practice, or reduction of antibiotic prescriptions. On the contrary, order facilitators and undiscovered malfunctions revealed to be threats and could lead to new cost drivers in healthcare. While high upfront and maintenance costs of CDS systems are a worldwide implementation barrier, most studies do not consider implementation cost. Finally, four included economic evaluation studies report mixed monetary outcome results and thus highlight the importance of further high-quality economic evaluations for these CDS systems. Conclusion Current research studies lack consideration of comparative cost-outcome metrics as well as detailed cost components in their analyses. Nonetheless, the positive economic impact of EHR based CDS interventions is highly promising, especially with regard to reducing waste in healthcare.
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Affiliation(s)
- Daniel Lewkowicz
- Digital Health Center, Hasso Plattner Institute, University of Potsdam, Prof.-Dr.-Helmert-Str. 2-3, 14482, Potsdam, Germany.
| | - Attila Wohlbrandt
- Digital Health Center, Hasso Plattner Institute, University of Potsdam, Prof.-Dr.-Helmert-Str. 2-3, 14482, Potsdam, Germany
| | - Erwin Boettinger
- Digital Health Center, Hasso Plattner Institute, University of Potsdam, Prof.-Dr.-Helmert-Str. 2-3, 14482, Potsdam, Germany.,Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
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Buckley K, Fairman KA. Beneficial Agents for Patients With Type 2 Diabetes and Cardiovascular Disease or Obesity: Utilization in an Era of Accumulating Evidence. Clin Diabetes 2020; 38:176-180. [PMID: 32327890 PMCID: PMC7164997 DOI: 10.2337/cd19-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study was an analysis of a national sample of U.S. medical office visits from 2014 to 2016, a period when evidence of effectiveness was emerging for a variety of beneficial type 2 diabetes agents with regard to potential reduction in diabetes comorbidities. Ideal therapy was defined as an American Diabetes Association-identified beneficial agent plus metformin. The associations between atherosclerotic cardiovascular disease or obesity and use of these agents were explored.
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Affiliation(s)
- Kelsey Buckley
- Midwestern University College of Pharmacy - Glendale, Glendale AZ
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Wierzejska E, Giernaś B, Lipiak A, Karasiewicz M, Cofta M, Staszewski R. A global perspective on the costs of hypertension: a systematic review. Arch Med Sci 2020; 16:1078-1091. [PMID: 32863997 PMCID: PMC7444692 DOI: 10.5114/aoms.2020.92689] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 12/09/2019] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Hypertension, particularly untreated, leads to serious complications and contributes to high costs incurred by the whole society. The aim of the review was to carry out a social and economic comparison of various categories of hypertension costs from different countries. MATERIAL AND METHODS The study was a systematic review. PubMed, Cochrane Library and Google Scholar databases were searched. Hypertension costs were analyzed in 8 cost categories. An attempt was made to determine whether selected economic and social factors (such as HDI or GDP) influenced hypertension costs. RESULTS The review included data from 15 countries: Brazil, Cambodia, Canada, China, Greece, Indonesia, Italy, Jamaica, Kyrgyzstan, Mexico, Poland, Spain, USA, Vietnam and Zimbabwe. The papers included in the review were heterogeneous with respect to cost categories, which made comparisons difficult. The average total costs of hypertension for all the studied countries, calculated per person, amounted to 630.14 Int$, direct costs - 1,497.36 Int$, and indirect costs - 282.34 Int$. The ranking of countries by costs and by selected economic and social indices points at the possible relationship between these indices and hypertension costs. CONCLUSIONS The costs of hypertension calculated per country reached the region of several dozen billion Int$. Other sources usually showed lower costs than those presented in this review. This indicates a growth in costs from year to year and the future increasing burden on society. Globally uniform cost terminology and cost calculation standards need to be developed. That would facilitate making more informed decisions regarding fund allocation in hypertension management schemes.
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Affiliation(s)
- Ewelina Wierzejska
- Department of Preventive Medicine, Laboratory of International Health, Poznan University of Medical Sciences, Poznan, Poland
| | - Bogusz Giernaś
- Department of Preventive Medicine, Laboratory of International Health, Poznan University of Medical Sciences, Poznan, Poland
| | - Agnieszka Lipiak
- Department of Preventive Medicine, Laboratory of International Health, Poznan University of Medical Sciences, Poznan, Poland
| | - Monika Karasiewicz
- Department of Preventive Medicine, Laboratory of International Health, Poznan University of Medical Sciences, Poznan, Poland
| | - Mateusz Cofta
- Department of Preventive Medicine, Laboratory of International Health, Poznan University of Medical Sciences, Poznan, Poland
| | - Rafał Staszewski
- Department of Hypertensiology, Angiology and Internal Medicine, Laboratory of Pharmacoeconomics in Hypertension, Poznan University of Medical Sciences, Poznan, Poland
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Abstract
PURPOSE OF REVIEW This article introduces the haemodynamic principles that underpin the pathophysiology of hypertension and introduces a rational physiological approach to appropriate pharmacologic treatment. RECENT FINDINGS Outdated understanding of haemodynamics based on previous measurement systems can no longer be applied to our understanding of the circulation. We question the current view of hypertension as defined by a predominantly systolic blood pressure and introduce the concept of vasogenic, cardiogenic and mixed-origin hypertension. We postulate that failure to identify the individual's haemodynamic pattern may lead to the use of inappropriate medication, which in turn may be a major factor in patient non-compliance with therapeutic strategies. A population-based approach to treatment of hypertension may lead to suboptimal functional dynamics in the individual patient. Finally, we question the validity of current guidelines and published evidence relating morbidity and mortality to the future treatment of hypertension. The importance of individual haemodynamic profiles may be pivotal in the understanding, diagnosis and treatment of hypertension if optimal control with minimal adverse effects is to be achieved. Research based on individual haemodynamic patterns is overdue.
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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.
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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
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