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Cox J, Hamilton L, Thabane L, Foster G, MacKillop J, Xie F, Ciaccia A, Choudhri S, Nemis-White J, Parkash R. Computerized clinical decision support to improve stroke prevention therapy in primary care management of atrial fibrillation: a cluster randomized trial. Am Heart J 2024; 273:102-110. [PMID: 38685464 DOI: 10.1016/j.ahj.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 04/24/2024] [Accepted: 04/24/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Despite guidelines supporting antithrombotic therapy use in atrial fibrillation (AF), under-prescribing persists. We assessed whether computerized clinical decision support (CDS) would enable guideline-based antithrombotic therapy for AF patients in primary care. METHODS This cluster randomized trial of CDS versus usual care (UC) recruited participants from primary care practices across Nova Scotia, following them for 12 months. The CDS tool calculated bleeding and stroke risk scores and provided recommendations for using oral anticoagulants (OAC) per Canadian guidelines. RESULTS From June 14, 2014 to December 15, 2016, 203 primary care providers (99 UC, 104 CDS) with access to high-speed Internet were recruited, enrolling 1,145 eligible patients (543 UC, 590 CDS) assigned to the same treatment arm as their provider. Patient mean age was 72.3 years; most were male (350, 64.5% UC, 351, 59.5% CDS) and from a rural area (298, 54.9% UC, 315, 53.4% CDS). At baseline, a higher than anticipated proportion of patients were receiving guideline-based OAC therapy (373, 68.7% UC, 442, 74.9% CDS; relative risk [RR] 0.97 (95% confidence interval [CI], 0.87-1.07; P = .511)). At 12 months, prescription data were available for 538 usual care and 570 CDS patients, and significantly more CDS patients were managed according to guidelines (415, 77.1% UC, 479, 84.0% CDS; RR 1.08 (95% CI, 1.01-1.15; P = .024)). CONCLUSION Notwithstanding high baseline rates, primary care provider access to the CDS over 12 months further optimized the prescribing of OAC therapy per national guidelines to AF patients potentially eligible to receive it. This suggests that CDS can be effective in improving clinical process of care. TRIAL REGISTRATION Clinical Trials NCT01927367. https://clinicaltrials.gov/ct2/show/NCT01927367?term=NCT01927367&draw=2&rank=1.
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Affiliation(s)
- Jafna Cox
- Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Laura Hamilton
- QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario Canada; Departments of Anesthesia/Pediatrics, McMaster University, Hamilton, Ontario Canada; Biostatistics Unit, Centre for Evaluation of Medicine, McMaster University, Hamilton, Ontario Canada; Population Health Research Institute (PHRI), Hamilton Health Sciences, McMaster University, Hamilton, Ontario Canada; Department of Health Research Methods, Evidence, and Impact; McMaster University, Hamilton, Ontario Canada
| | - Gary Foster
- Department of Health Research Methods, Evidence, and Impact; McMaster University, Hamilton, Ontario Canada; Biostatistics Unit, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | | | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario Canada; Centre for Health Economics and Policy Analysis, McMaster University
| | - Antonio Ciaccia
- Medical Affairs - Cardiovascular Medicine, Bayer Inc, Mississauga, Ontario, Canada
| | - Shurjeel Choudhri
- Medical and Scientific Affairs, Bayer Inc, Mississauga, Ontario, Canada
| | | | - Ratika Parkash
- Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Amin AM, Ghaly R, Abuelazm MT, Ibrahim AA, Tanashat M, Arnaout M, Altobaishat O, Elshahat A, Abdelazeem B, Balla S. Clinical decision support systems to optimize adherence to anticoagulant guidelines in patients with atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials. Thromb J 2024; 22:45. [PMID: 38807186 PMCID: PMC11134712 DOI: 10.1186/s12959-024-00614-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 05/11/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Clinical decision support systems (CDSS) have been utilized as a low-cost intervention to improve healthcare process measures. Thus, we aim to estimate CDSS efficacy to optimize adherence to oral anticoagulant guidelines in eligible patients with atrial fibrillation (AF). METHODS A systematic review and meta-analysis of randomized controlled trials (RCTs) retrieved from PubMed, WOS, SCOPUS, EMBASE, and CENTRAL through August 2023. We used RevMan V. 5.4 to pool dichotomous data using risk ratio (RR) with a 95% confidence interval (CI). PROSPERO ID CRD42023471806. RESULTS We included nine RCTs with a total of 25,573 patients. There was no significant difference, with the use of CDSS compared to routine care, in the number of patients prescribed anticoagulants (RR: 1.06, 95% CI [0.98, 1.14], P = 0.16), the number of patients prescribed antiplatelets (RR: 1.01 with 95% CI [0.97, 1.06], P = 0.59), all-cause mortality (RR: 1.19, 95% CI [0.31, 4.50], P = 0.80), major bleeding (RR: 0.84, 95% CI [0.21, 3.45], P = 0.81), and clinically relevant non-major bleeding (RR: 1.05, 95% CI [0.52, 2.16], P = 0.88). However, CDSS was significantly associated with reduced incidence of myocardial infarction (RR: 0.18, 95% CI [0.06, 0.54], P = 0.002) and cerebral or systemic embolic event (RR: 0.11, 95% CI [0.01, 0.83], P = 0.03). CONCLUSION We report no significant difference with the use of CDSS compared to routine care in anticoagulant or antiplatelet prescription in eligible patients with AF. CDSS was associated with a reduced incidence of myocardial infarction and cerebral or systemic embolic events.
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Affiliation(s)
| | - Ramy Ghaly
- Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | | | | | | | | | - Obieda Altobaishat
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | | | - Basel Abdelazeem
- Department of Cardiology, West Virginia University, Morgantown, WV, USA
| | - Sudarshan Balla
- Department of Cardiology, West Virginia University, Morgantown, WV, USA
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 286] [Impact Index Per Article: 286.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 95] [Impact Index Per Article: 95.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Fletcher E, Burns A, Wiering B, Lavu D, Shephard E, Hamilton W, Campbell JL, Abel G. Workload and workflow implications associated with the use of electronic clinical decision support tools used by health professionals in general practice: a scoping review. BMC PRIMARY CARE 2023; 24:23. [PMID: 36670354 PMCID: PMC9857918 DOI: 10.1186/s12875-023-01973-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 01/05/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Electronic clinical decision support tools (eCDS) are increasingly available to assist General Practitioners (GP) with the diagnosis and management of a range of health conditions. It is unclear whether the use of eCDS tools has an impact on GP workload. This scoping review aimed to identify the available evidence on the use of eCDS tools by health professionals in general practice in relation to their impact on workload and workflow. METHODS A scoping review was carried out using the Arksey and O'Malley methodological framework. The search strategy was developed iteratively, with three main aspects: general practice/primary care contexts, risk assessment/decision support tools, and workload-related factors. Three databases were searched in 2019, and updated in 2021, covering articles published since 2009: Medline (Ovid), HMIC (Ovid) and Web of Science (TR). Double screening was completed by two reviewers, and data extracted from included articles were analysed. RESULTS The search resulted in 5,594 references, leading to 95 full articles, referring to 87 studies, after screening. Of these, 36 studies were based in the USA, 21 in the UK and 11 in Australia. A further 18 originated from Canada or Europe, with the remaining studies conducted in New Zealand, South Africa and Malaysia. Studies examined the use of eCDS tools and reported some findings related to their impact on workload, including on consultation duration. Most studies were qualitative and exploratory in nature, reporting health professionals' subjective perceptions of consultation duration as opposed to objectively-measured time spent using tools or consultation durations. Other workload-related findings included impacts on cognitive workload, "workflow" and dialogue with patients, and clinicians' experience of "alert fatigue". CONCLUSIONS The published literature on the impact of eCDS tools in general practice showed that limited efforts have focused on investigating the impact of such tools on workload and workflow. To gain an understanding of this area, further research, including quantitative measurement of consultation durations, would be useful to inform the future design and implementation of eCDS tools.
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Affiliation(s)
- Emily Fletcher
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Alex Burns
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Bianca Wiering
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Deepthi Lavu
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Elizabeth Shephard
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Willie Hamilton
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - John L. Campbell
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Gary Abel
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
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Jones JL, Simons K, Manski-Nankervis JA, Lumsden NG, Fernando S, de Courten MP, Cox N, Hamblin PS, Janus ED, Nelson CL. Chronic disease IMPACT (chronic disease early detection and improved management in primary care project): An Australian stepped wedge cluster randomised trial. Digit Health 2023; 9:20552076231194948. [PMID: 37588155 PMCID: PMC10426307 DOI: 10.1177/20552076231194948] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 07/28/2023] [Indexed: 08/18/2023] Open
Abstract
Background Interrelated chronic vascular diseases (chronic kidney disease (CKD), type 2 diabetes (T2D) and cardiovascular disease (CVD)) are common with high morbidity and mortality. This study aimed to assess if an electronic-technology-based quality improvement intervention in primary care could improve detection and management of people with and at risk of these diseases. Methods Stepped-wedge trial with practices randomised to commence intervention in one of five 16-week periods. Intervention included (1) electronic-technology tool extracting data from general practice electronic medical records and generating graphs and lists for audit; (2) education regarding chronic disease and the electronic-technology tool; (3) assistance with quality improvement audit plan development, benchmarking, monitoring and support. De-identified data analysis using R 3.5.1 conducted using Bayesian generalised linear mixed model with practice and time-specific random intercepts. Results At baseline, eight included practices had 37,946 active patients (attending practice ≥3 times within 2 years) aged ≥18 years. Intervention was associated with increased OR (95% CI) for: kidney health checks (estimated glomerular filtration rate, urine albumin:creatinine ratio (uACR) and blood pressure) in those at risk 1.34 (1.26-1.42); coded diagnosis of CKD 1.18 (1.09-1.27); T2D diagnostic testing (fasting glucose or HbA1c) in those at risk 1.15 (1.08-1.23); uACR in patients with T2D 1.78 (1.56-2.05). Documented eye checks within recommended frequency in patients with T2D decreased 0.85 (0.77-0.96). There were no significant changes in other assessed variables. Conclusions This electronic-technology-based intervention in primary care has potential to help translate guidelines into practice but requires further refining to achieve widespread improvements across the interrelated chronic vascular diseases.
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Affiliation(s)
- Julia L Jones
- Nephrology, Western Health, Melbourne, Australia
- Western Health Chronic Disease Alliance, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Koen Simons
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
- Office for Research, Western Health, Melbourne, Australia
| | | | - Natalie G Lumsden
- Nephrology, Western Health, Melbourne, Australia
- Western Health Chronic Disease Alliance, Melbourne, Australia
- Department of General Practice, The University of Melbourne, Melbourne, Australia
| | | | - Maximilian P de Courten
- Mitchell Institute for Education and Health Policy, Melbourne, Australia
- Centre for Chronic Disease, Victoria University, Melbourne, Australia
| | - Nicholas Cox
- Western Health Chronic Disease Alliance, Melbourne, Australia
- Centre for Chronic Disease, Victoria University, Melbourne, Australia
- Cardiology, Western Health, Melbourne, Australia
| | - Peter Shane Hamblin
- Western Health Chronic Disease Alliance, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Endocrinology and Diabetes, Western Health, Melbourne, Australia
| | - Edward D Janus
- Western Health Chronic Disease Alliance, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Medicine, Western Health, Melbourne, Australia
| | - Craig L Nelson
- Nephrology, Western Health, Melbourne, Australia
- Western Health Chronic Disease Alliance, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
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Ru X, Wang T, Zhu L, Ma Y, Qian L, Sun H, Pan Z. Using a Clinical Decision Support System to Improve Anticoagulation in Patients with Nonvalve Atrial Fibrillation in China's Primary Care Settings: A Feasibility Study. Int J Clin Pract 2023; 2023:2136922. [PMID: 36713952 PMCID: PMC9876694 DOI: 10.1155/2023/2136922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/25/2022] [Accepted: 01/04/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND To primarily investigate the effect of using a clinical decision support system (CDSS) in community health centers in Shanghai, China, on the proportion of patients prescribed guideline-directed antithrombotic therapy. This study also gauged the general practitioner (GP)'s acceptance of the CDSS who worked in the atrial fibrillation (AF) special consulting room of the CDSS group. METHODS This was a prospective cohort study that included a semistructured interview and a feasibility study for a cluster-randomized controlled trial. Eligible patients who sought medical care in the AF special consulting rooms in two community health centers in Shanghai, China, between April 1, 2020, and October 1, 2020, were enrolled, and their medical records from the enrollment date, up to October 1, 2021, were extracted. Based on whether the GPs in the AF special consulting rooms of the two sites used the CDSS or not, we classified the two sites as a software group and a control group. The CDSS could automatically assess the risks of stroke and bleeding and provide suggestions on treatment, follow-up, adjustment of anticoagulants or dosage, and other items. The primary outcome was the proportion of patients prescribed guideline-directed antithrombotic therapy. We also conducted a semistructured interview with the GP in the AF special consulting rooms of the software group regarding the acceptance of the CDSS and suggestions on the optimization of the CDSS and the study protocol of the cluster-randomized controlled trial in the future. RESULTS Eighty-four patients completed the follow-up. The mean age of these subjects was 75.71 years, the median time of clinical visits was six times per person, and the follow-up duration was 15 months. The basic demographics were similar between the two groups, except for age (t = 2.109, p = 0.038) and the HAS-BLED score (χ 2 = 4.363, p = 0.037). The primary outcome in the software group was 8.071 times higher than that in the control group (adjusted odds ratio (OR) = 8.071, 95% confidence interval (2.570-25.344), p < 0.001). The frequency of consultation between groups was not significantly different (p = 0.981). It seemed that the incidence of adverse clinical events in the software group was lower than that in the control group. The main reason for dropouts in both groups was "following up in other hospitals." The GP in the AF special consulting rooms of the software group accepted the CDSS well. CONCLUSIONS The findings indicated that it was feasible to further promote the CDSS in the study among community health centers in China. The use of the CDSS might improve the proportion of patients prescribed guideline-directed antithrombotic therapy. The GP in the AF special consulting room of the software group showed a positive attitude toward the CDSS.
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Affiliation(s)
- Xueying Ru
- Department of General Practice, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Tianhao Wang
- Department of General Practice, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Lan Zhu
- Department of General Practice, Zhongshan Hospital, Fudan University, Shanghai 200032, China
- Xuhui District Xietu Community Health Service Center, Shanghai 200023, China
| | - Yunhui Ma
- Department of General Practice, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Liqun Qian
- Xuhui District Fenglin Community Health Service Center, Shanghai 200032, China
| | - Huan Sun
- Pudong New Area Beicai Community Health Service Center, Shanghai 201204, China
| | - Zhigang Pan
- Department of General Practice, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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Garabedian PM, Gannon MP, Aaron S, Wu E, Burns Z, Samal L. Human-centered design of clinical decision support for management of hypertension with chronic kidney disease. BMC Med Inform Decis Mak 2022; 22:217. [PMID: 35964083 PMCID: PMC9375189 DOI: 10.1186/s12911-022-01962-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/02/2022] [Indexed: 11/16/2022] Open
Abstract
Background Primary care providers face challenges in recognizing and controlling hypertension in patients with chronic kidney disease (CKD). Clinical decision support (CDS) has the potential to aid clinicians in identifying patients who could benefit from medication changes. This study designed an alert to control hypertension in CKD patients using an iterative human-centered design process. Methods In this study, we present a human-centered design process employing multiple methods for gathering user requirements and feedback on design and usability. Initially, we conducted contextual inquiry sessions to gather user requirements for the CDS. This was followed by group design sessions and one-on-one formative think-aloud sessions to validate requirements, obtain feedback on the design and layout, uncover usability issues, and validate changes. Results This study included 20 participants. The contextual inquiry produced 10 user requirements which influenced the initial alert design. The group design sessions revealed issues related to several themes, including recommendations and clinical content that did not match providers' expectations and extraneous information on the alerts that did not provide value. Findings from the individual think-aloud sessions revealed that participants disagreed with some recommended clinical actions, requested additional information, and had concerns about the placement in their workflow. Following each step, iterative changes were made to the alert content and design. Discussion This study showed that participation from users throughout the design process can lead to a better understanding of user requirements and optimal design, even within the constraints of an EHR alerting system. While raising awareness of design needs, it also revealed concerns related to workflow, understandability, and relevance. Conclusion The human-centered design framework using multiple methods for CDS development informed the creation of an alert to assist in the treatment and recognition of hypertension in patients with CKD. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-022-01962-y.
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Affiliation(s)
- Pamela M Garabedian
- Mass General Brigham, 399 Revolution Drive, Somerville, MA, 857-282-4091, USA.
| | - Michael P Gannon
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Skye Aaron
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Edward Wu
- Alabama College of Osteopathic Medicine, Dothan, AL, USA
| | - Zoe Burns
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Lipika Samal
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Li M, Ji YG, Yang ZQ, Xie HZ. Development of humanistic nursing practice guidelines for stroke patients. Front Public Health 2022; 10:915472. [PMID: 36016905 PMCID: PMC9395746 DOI: 10.3389/fpubh.2022.915472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/15/2022] [Indexed: 01/22/2023] Open
Abstract
Purpose To construct humanistic nursing practice guidelines suitable for stroke patients. Design This study was a development and validation study of guidelines using multiple methods, including literature review, qualitative research, questionnaire survey, thematic discussion, and Delphi expert consultation. Methods Twenty-five experts from seven provinces and municipalities in China were interviewed over two rounds from December 2020 to February 2021. The first-level index was scored for importance and rationality, while the second-level index was scored for importance and feasibility using a five-point Likert scale. Delphi data was collected via a paper version of the questionnaire. The coefficients of variation and coordination were used to represent the degree of dispersion of expert opinions. Findings In the two rounds of letter consultation, the questionnaire's recovery and effective rates were both 100%, while the opinion submission rates of the two rounds were 84 and 52%, respectively. Moreover, the expert authority coefficient was 0.91, and the coordination coefficients of expert opinions in the first round were as follows: importance of 0.03 and rationality of 0.07 for the first-level index; importance of 0.09 and feasibility of 0.11 for the secondary index. In round two, the coordination coefficients of expert opinions were as follows: importance of 0.04 and rationality of 0.05 for the first-level indicators; importance of 0.12 and feasibility of 0.10 for the secondary index. The results for the secondary index were P < 0.001 for the two rounds. The humanistic nursing practice guidelines for stroke patients that were ultimately formed included five first-level indicators (physiological care, safety care, emotional care, dignity care, and rehabilitation needs) and 46 s-level indicators. Conclusion Our results show that the "Practice Guidelines for Humanistic Nursing for Stroke" established by experts adopts Maslow's hierarchy of needs as its structural framework. It meets people's basic needs and can provide a reference for the construction of a humanistic nursing specialty practice for stroke patients. Clinical relevance Humanistic nursing guidelines for stroke could provide a reference for the construction of humanistic nursing practice in the stroke specialty. Clinical resources Copeptin and long-term risk of recurrent vascular events after transient ischemic attack and ischemic stroke: population-based study https://pubmed.ncbi.nlm.nih.gov/26451023/. Effectiveness and usage of a decision support system to improve stroke prevention in general practice: a cluster randomized controlled trial https://pubmed.ncbi.nlm.nih.gov/28245247/. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association https://pubmed.ncbi.nlm.nih.gov/27145936/.
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Affiliation(s)
- Min Li
- Department of Trauma Surgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China
| | - Yu-gui Ji
- Department of Neurosurgery, General Hospital of Southern Theatre Command, Guangzhou, China
| | - Zi-qing Yang
- Department of Health Medicine, General Hospital of Southern Theatre Command, Guangzhou, China
| | - Hong-zhen Xie
- Department of Health Medicine, General Hospital of Southern Theatre Command, Guangzhou, China,*Correspondence: Hong-zhen Xie
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10
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Chen W, Howard K, Gorham G, O'Bryan CM, Coffey P, Balasubramanya B, Abeyaratne A, Cass A. Design, effectiveness, and economic outcomes of contemporary chronic disease clinical decision support systems: a systematic review and meta-analysis. J Am Med Inform Assoc 2022; 29:1757-1772. [PMID: 35818299 PMCID: PMC9471723 DOI: 10.1093/jamia/ocac110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/21/2022] [Accepted: 06/25/2022] [Indexed: 01/10/2023] Open
Abstract
Objectives Electronic health record-based clinical decision support (CDS) has the potential to improve health outcomes. This systematic review investigates the design, effectiveness, and economic outcomes of CDS targeting several common chronic diseases. Material and Methods We conducted a search in PubMed (Medline), EBSCOHOST (CINAHL, APA PsychInfo, EconLit), and Web of Science. We limited the search to studies from 2011 to 2021. Studies were included if the CDS was electronic health record-based and targeted one or more of the following chronic diseases: cardiovascular disease, diabetes, chronic kidney disease, hypertension, and hypercholesterolemia. Studies with effectiveness or economic outcomes were considered for inclusion, and a meta-analysis was conducted. Results The review included 76 studies with effectiveness outcomes and 9 with economic outcomes. Of the effectiveness studies, 63% described a positive outcome that favored the CDS intervention group. However, meta-analysis demonstrated that effect sizes were heterogenous and small, with limited clinical and statistical significance. Of the economic studies, most full economic evaluations (n = 5) used a modeled analysis approach. Cost-effectiveness of CDS varied widely between studies, with an estimated incremental cost-effectiveness ratio ranging between USD$2192 to USD$151 955 per QALY. Conclusion We summarize contemporary chronic disease CDS designs and evaluation results. The effectiveness and cost-effectiveness results for CDS interventions are highly heterogeneous, likely due to differences in implementation context and evaluation methodology. Improved quality of reporting, particularly from modeled economic evaluations, would assist decision makers to better interpret and utilize results from these primary research studies. Registration PROSPERO (CRD42020203716)
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Affiliation(s)
- Winnie Chen
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Kirsten Howard
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Gillian Gorham
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Claire Maree O'Bryan
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Patrick Coffey
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Bhavya Balasubramanya
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Asanga Abeyaratne
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
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11
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Gebreyohannes EA, Salter SM, Chalmers L, Radford J, Lee K. Use of thromboprophylaxis guidelines and risk stratification tools in atrial fibrillation: A survey of general practitioners in Australia. J Eval Clin Pract 2022; 28:483-492. [PMID: 35385183 PMCID: PMC9324914 DOI: 10.1111/jep.13685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/16/2022] [Accepted: 03/23/2022] [Indexed: 11/28/2022]
Abstract
RATIONALE AND OBJECTIVES Clinical guidelines produced by cardiology societies (henceforth referred to simply as 'clinical guidelines') recommend thromboprophylaxis with oral anticoagulants (OACs) in patients with atrial fibrillation (AF) who have moderate-to-high stroke risk. However, deviations from these recommendations are observed, especially in the primary healthcare setting. The primary aims of this study were to evaluate the self-reported use of AF clinical guidelines and risk stratification tools among Australian general practitioners (GPs), and their perceptions regarding the available resources. METHOD We conducted an online survey of Australian GPs. Descriptive statistics were used to summarise the findings. RESULTS Responses from 115 GPs were included for analysis. Respondents reported various ways of accessing thromboprophylaxis-related information (n = 113), including clinical guidelines (13.3%), 'Therapeutic Guidelines© ' (37.2%) and Royal Australian College of General Practitioners websites (16.8%). Of those who reported reasons against accessing information from clinical guidelines (n = 97), the most frequent issues were: too many AF guidelines to choose from (34.0%; 33/97), different guidelines for different diseases (32.0%; 31/97), time-consuming to read guidelines (21.6%; 21/97), disagreements between different guideline recommendations (20.0%; 19/97), conflict with criteria for government subsidy (17.5%; 17/97) and GPs' busy schedules (15.5%; 15/97). When assessing patients' risk of stroke (n = 112) and bleeding (n = 111), the majority of the respondents reported primarily relying on a formal stroke risk (67.0%) and bleeding risk (55.0%) assessment tools, respectively. Respondents reported using formal stroke and bleeding risk assessment tools mainly when newly initiating patients on therapy (72.4%; 76/105 and 65.3%; 65/101, respectively). CONCLUSION Among our small sample of Australian GPs, most did not access thromboprophylaxis-related information directly from AF-specific clinical guidelines developed by cardiology societies. Although the majority reported using formal stroke and bleeding assessment tools, these were typically used on OAC initiation only. More focus is needed on formal risk reassessment as clinically indicated and at regular review.
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Affiliation(s)
- Eyob Alemayehu Gebreyohannes
- Division of Pharmacy, School of Allied Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Sandra M Salter
- Division of Pharmacy, School of Allied Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Leanne Chalmers
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
| | - Jan Radford
- Launceston Clinical School, Tasmanian School of Medicine, University of Tasmania, Launceston, Tasmania, Australia
| | - Kenneth Lee
- Division of Pharmacy, School of Allied Health, The University of Western Australia, Perth, Western Australia, Australia
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12
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Abstract
Despite considerable progress in tackling cardiovascular disease over the past 50 years, many gaps in the quality of care for cardiovascular disease remain. Multiple missed opportunities have been identified at every step in the prevention and treatment of cardiovascular disease, such as failure to make risk factor modifications, failure to diagnose cardiovascular disease, and failure to use proper evidence based treatments. With the digital transformation of medicine and advances in health information technology, clinical decision support (CDS) tools offer promise to enhance the efficiency and effectiveness of delivery of cardiovascular care. However, to date, the promise of CDS delivering scalable and sustained value for patient care in clinical practice has not been realized. This article reviews the evidence on key emerging questions around the development, implementation, and regulation of CDS with a focus on cardiovascular disease. It first reviews evidence on the effectiveness of CDS on healthcare process and clinical outcomes related to cardiovascular disease and design features associated with CDS effectiveness. It then reviews the barriers encountered during implementation of CDS in cardiovascular care, with a focus on unintended consequences and strategies to promote successful implementation. Finally, it reviews the legal and regulatory environment of CDS with specific examples for cardiovascular disease.
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Affiliation(s)
- Yuan Lu
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Edward R Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Biostatistics (Health Informatics), Yale School of Public Health, New Haven, CT, USA
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
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13
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Eckman MH, Wise R, Knochelmann C, Mardis R, Wright S, Gummadi A, Dixon E, Becker R, Schauer DP, Flaherty ML, Costea A, Kleindorfer D, Ireton R, Baker P, Harnett BM, Adejare A, Leonard AC, Sucharew H, Costanzo A, Arduser L, Kues J. Electronic health record-embedded decision support to reduce stroke risk in patients with atrial fibrillation - Study protocol. Am Heart J 2022; 247:42-54. [PMID: 35081360 DOI: 10.1016/j.ahj.2022.01.012] [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] [Received: 07/16/2021] [Revised: 01/19/2022] [Accepted: 01/20/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common significant cardiac rhythm disorder and is a powerful common risk factor for stroke. Randomized trials have demonstrated that anticoagulation can reduce the risk of stroke in patients with AF. Yet, there continues to be widespread underutilization of this therapy. To address this practice gap locally and improve efforts to reduce the risk of stroke for patients with AF in our health system, we have designed a study to implement and evaluate the effectiveness of an Atrial Fibrillation Decision Support Tool (AFDST) embedded within our electronic health record. METHODS Our intervention is provider-facing and focused on decision support. The clinical setting is ambulatory patients being seen by primary care physicians. Patients include those with both incident and prevalent AF. This randomized, prospective trial will enroll 800 patients in our University of Cincinnati Health System who are currently receiving less than optimal anticoagulation therapy as determined by the AFDST. Patients will be randomized to one of two arms - 1) usual care, in which the AFDST is available for use; 2) addition of a best practice advisory (BPA) to the AFDST notifying the clinician that their patient stands to gain a significant benefit from a change in their current thromboprophylactic therapy. RESULTS The primary outcome is effectiveness of the BPA measured by change to "appropriate thromboprophylaxis" based on the AFDST recommendation at 3 months post randomization. Secondary endpoints include Reach and Adoption, from the RE-AIM framework for implementation studies. Sample size is based upon an improvement from inappropriate to appropriate anticoagulation therapy estimated at 4% in the usual care arm and ≥10% in the experimental arm. CONCLUSION Our goal is to examine whether addition of a BPA to an AFDST focused on primary care physicians in an ambulatory care setting will improve "appropriate thromboprophylaxis" compared with usual care. Results will be examined at 3 months post randomization and at the end of the study to evaluate durability of changes. We expect to complete patient enrollment by the end of June 2022. TRIAL REGISTRATION Clinicaltrials.gov NCT04099485.
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14
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Ru X, Zhu L, Ma Y, Wang T, Pan Z. Effect of an artificial intelligence-assisted tool on non-valvular atrial fibrillation anticoagulation management in primary care: protocol for a cluster randomized controlled trial. Trials 2022; 23:316. [PMID: 35428315 PMCID: PMC9013112 DOI: 10.1186/s13063-022-06250-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background Atrial fibrillation (AF) is one of the most common cardiac arrhythmia diseases. Thromboembolic prophylaxis plays an essential role in AF therapy, but at present, general practitioners (GPs) are presumed to lack the knowledge and enthusiasm for AF management. Clinical decision support systems (CDSS), assisted by artificial intelligence, help primary care providers (PCPs) make quick, individualized, and correct clinical decisions. This primary aim of the study is to identify whether the promotion of the CDSS would improve the primary care provided to patients with AF. The secondary objectives are mainly to assess the health-economic and clinical benefits from using the CDSS, and the improvement of GPs’ AF management capability. Methods This study will be a prospective cluster randomized controlled trial, conducted among 14 community health centers in Shanghai which were randomized as the intervention group and control group in a ratio of 1:1. The intervention group will use the CDSS in the consultation of patients with AF and the control group will maintain their usual care. The trial will include 498 patients with AF and the follow-up period will be 12 months. The primary outcome is set as the proportion of antithrombotic treatment prescriptions in agreement with recommendations in the latest China’s AF-related guidelines. The secondary outcomes are the frequency of consultation, the compliance rate of international normalized ratio (INR) in patients with warfarin, stroke morbidity, treatment compliance, medication satisfaction, and the cost-benefit analysis. Per-protocol (PP) analysis and the intention-to-treat (ITT) analysis will be conducted. Discussion This study aims to identify whether the application of CDSS to manage patients with AF in China’s community health centers would bring benefits for patients, physicians, and health economics. Trial registration Registry name: 非瓣膜性房颤社区AI辅助管理工具研发及推广效果研究 (Development and promotion of an AI-assisted tool for NVAF management in primary care); registry number: ChiCTR2100052307; registration date: Nov. 22nd, 2021; http://www.chictr.org.cn/showproj.aspx?proj=133849. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06250-8.
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15
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Quintens C, Verhamme P, Vanassche T, Vandenbriele C, Van den Bosch B, Peetermans WE, Van der Linden L, Spriet I. Improving appropriate use of anticoagulants in hospitalised patients: a pharmacist-led Check of Medication Appropriateness intervention. Br J Clin Pharmacol 2021; 88:2959-2968. [PMID: 34913184 DOI: 10.1111/bcp.15184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 11/13/2021] [Accepted: 12/05/2021] [Indexed: 11/29/2022] Open
Abstract
AIM Inappropriate anticoagulant use increases the risk of bleeding and thrombotic events. We implemented clinical decision rules to promote judicious medication use, as part of the 'Check of Medication Appropriateness' (CMA). The CMA concerns a pharmacist-led review service, targeting potentially inappropriate prescriptions (PIPs). In this analysis, we aimed to evaluate the impact of the CMA on anticoagulant prescribing. METHODS The number of anticoagulant-related PIPs was evaluated before and after implementation of the intervention in a quasi-experimental interrupted time series analysis. The pre-implementation cohort received usual care. The anticoagulant-focused CMA, comprising 13 clinical rules pertaining to anticoagulation therapies, was implemented in the post-implementation cohort. Segmented regression analysis was used to assess the impact of the intervention on the number of residual PIPs. A residual PIP was defined as a PIP which persisted up to 48h after the CMA intervention. Total number of recommendations and acceptance rate were documented for the 2-year post-implementation period. RESULTS Pre-implementation, we observed 501 PIPs in 466 inpatients on 36 days, with a median proportion of 78.5% (range: 46.2%-100%) residual PIPs per day. Post-implementation, 538 PIPs were detected in 485 patients over the same number of days. The CMA intervention reduced the median proportion to 18.2% (range: 0-100%) per day. The effect coincided with an immediate relative reduction of 70% (95%CI 0.19-0.46) in anticoagulant-related residual PIPs. Post-implementation, 2778 recommendations were provided and 75.1% were accepted. CONCLUSION Our CMA approach significantly reduced anticoagulant-related PIPs. Implementing a pharmacist-led intervention, based on clinical rules, may support safer prescribing of anticoagulants.
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Affiliation(s)
- Charlotte Quintens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Bart Van den Bosch
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Department of Information Technology, University Hospitals Leuven, Leuven, Belgium
| | - Willy E Peetermans
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Lorenz Van der Linden
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
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16
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Essien UR, Kornej J, Johnson AE, Schulson LB, Benjamin EJ, Magnani JW. Social determinants of atrial fibrillation. Nat Rev Cardiol 2021; 18:763-773. [PMID: 34079095 PMCID: PMC8516747 DOI: 10.1038/s41569-021-00561-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 02/05/2023]
Abstract
Atrial fibrillation affects almost 60 million adults worldwide. Atrial fibrillation is associated with a high risk of cardiovascular morbidity and death as well as with social, psychological and economic burdens on patients and their families. Social determinants - such as race and ethnicity, financial resources, social support, access to health care, rurality and residential environment, local language proficiency and health literacy - have prominent roles in the evaluation, treatment and management of atrial fibrillation. Addressing the social determinants of health provides a crucial opportunity to reduce the substantial clinical and non-clinical complications associated with atrial fibrillation. In this Review, we summarize the contributions of social determinants to the patient experience and outcomes associated with this common condition. We emphasize the relevance of social determinants and their important intersection with atrial fibrillation treatment and outcomes. In closing, we identify gaps in the literature and propose future directions for the investigation of social determinants and atrial fibrillation.
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Affiliation(s)
- Utibe R. Essien
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,
| | - Jelena Kornej
- Sections of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Amber E. Johnson
- Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lucy B. Schulson
- Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Emelia J. Benjamin
- Sections of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Jared W. Magnani
- Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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17
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Song D, Zhou J, Fan T, Chang J, Qiu Y, Zhuang Z, Ma J, Zeng L. Decision aids for shared decision-making and appropriate anticoagulation therapy in patients with atrial fibrillation: a systematic review and meta-analysis. Eur J Cardiovasc Nurs 2021; 21:97-106. [PMID: 34550376 DOI: 10.1093/eurjcn/zvab085] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/23/2021] [Accepted: 09/03/2021] [Indexed: 11/12/2022]
Abstract
AIMS Underuse of oral anticoagulants (OACs) is commonly observed among patients with atrial fibrillation (AF), which hinders stroke prevention in AF. Shared decision-making (SDM) can help enhance adherence by minimizing patients' misunderstanding of treatment and aligning care with their preferences. Decision aids (DAs) have been developed to facilitate the SDM process. This study aimed to: (i) evaluate the effects of DAs on AF patients' knowledge, decisional conflict, OAC uptake, and adherence and on the incidence of stroke and bleeding; and (ii) explore characterizing factors associated with enhanced DA effectiveness. METHODS AND RESULTS Five databases were searched. Meta-analysis was conducted using RevMan 5.3 when data were available. Comparative analysis between effective and ineffective DAs was conducted to determine the DA designs associated with better effects. Ten studies were included. Pooling results indicated that DAs reduce decisional conflict related to warfarin use [mean difference = -0.10; 95% confidence interval (CI): -0.18 to -0.02; P = 0.01] and enhance OAC uptake [risk ratio: 1.03; 95% CI: 1.01-1.05; P = 0.004]. The effects of DAs on adherence and incidence of stroke and bleeding were unclear. Comparative analysis revealed that DAs with key elements of SDM (situation diagnosis, choice awareness, option clarification, benefits and disadvantages, and patient's preference) and pre-consultation delivery are more likely to be effective in promoting SDM and OAC uptake. CONCLUSIONS DAs are promising in promoting SDM and OAC uptake in patients with AF. The evidence on adherence and incidence of stroke and bleeding remains uncertain. More trials with rigorous study design and longer follow-up are necessary to obtain evidence.
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Affiliation(s)
- Dan Song
- Shenzhen Qianhai and Shekou Free Trade Zone Hospital, No. 36, 7th Industrial Road, Nanshan District, Shenzhen City, Guangdong Province 518067, P.R. China
| | - Jie Zhou
- Shenzhen Qianhai and Shekou Free Trade Zone Hospital, No. 36, 7th Industrial Road, Nanshan District, Shenzhen City, Guangdong Province 518067, P.R. China
| | - Tianli Fan
- Shenzhen Qianhai and Shekou Free Trade Zone Hospital, No. 36, 7th Industrial Road, Nanshan District, Shenzhen City, Guangdong Province 518067, P.R. China
| | - Jing Chang
- Shenzhen Qianhai and Shekou Free Trade Zone Hospital, No. 36, 7th Industrial Road, Nanshan District, Shenzhen City, Guangdong Province 518067, P.R. China
| | - Yuzhen Qiu
- Shenzhen Qianhai and Shekou Free Trade Zone Hospital, No. 36, 7th Industrial Road, Nanshan District, Shenzhen City, Guangdong Province 518067, P.R. China
| | - Zexiang Zhuang
- Shenzhen Qianhai and Shekou Free Trade Zone Hospital, No. 36, 7th Industrial Road, Nanshan District, Shenzhen City, Guangdong Province 518067, P.R. China
| | - Juanjuan Ma
- Shenzhen Qianhai and Shekou Free Trade Zone Hospital, No. 36, 7th Industrial Road, Nanshan District, Shenzhen City, Guangdong Province 518067, P.R. China
| | - Li Zeng
- Shenzhen Qianhai and Shekou Free Trade Zone Hospital, No. 36, 7th Industrial Road, Nanshan District, Shenzhen City, Guangdong Province 518067, P.R. China
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18
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Quintens C, Van der Linden L, Meeusen K, Nijns E, Willems R, Spriet I. Development and validation of a Screening Tool to Evaluate and Warrant Anticoagulation Treatment prior to Discharge in inpatients with Atrial Fibrillation (STEWAR xD-AF). Int J Med Inform 2021; 154:104555. [PMID: 34438318 DOI: 10.1016/j.ijmedinf.2021.104555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 08/10/2021] [Accepted: 08/15/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Anticoagulation is highly effective for stroke prevention in atrial fibrillation (AF), reducing the risk by about 64%. Despite overwhelming evidence in support of anticoagulation, up to 40% of AF patients remain untreated. We aimed to develop and validate STEWARxD-AF: a Screening Tool to Evaluate and Warrant Anticoagulation Treatment prior to Discharge in Atrial Fibrillation. MATERIALS AND METHODS STEWARxD-AF was developed by integrating information extracted from the electronic health record (EHR). A stepwise decision process was applied, based on AF diagnosis, estimated CHA2DS2-VASc-score and anticoagulant use. A priority score was assigned accordingly, ranging from 0 (no risk) to 5 (highest risk of undertreatment). A cross-sectional study was performed to assess the accuracy of STEWARxD-AF. Criterion and tool validity were ascertained by determining sensitivity and specificity, compared to a manual check of the EHR in an inpatient sample (n = 800). Consistency regarding the priority score was determined by estimating Cohen's kappa. RESULTS A tool to screen for un(der)treated AF was developed and embedded into the EHR. Sensitivity and specificity for AF diagnosis were 98.4% and 87.6%, respectively. Overall sensitivity and specificity for identification of a CHA2DS2-VASc-score ≥ 2 was 97.7% and 72.7%. Sensitivity and specificity to determine the presence of anticoagulant treatment was at least 87.8% and 97.1% There was good agreement for the priority score (κ 0.74 (unweighted); 0.66 (weighted)). CONCLUSIONS STEWARxD-AF was able to identify untreated AF inpatients reliably and with a high sensitivity. Nearly no patients were missed. We will now implement this AF-screening tool in clinical practice to improve the use of anticoagulation and reduce the risk of stroke.
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Affiliation(s)
- Charlotte Quintens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium; Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.
| | - Lorenz Van der Linden
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium; Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.
| | - Kaat Meeusen
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium.
| | - Egon Nijns
- Department of Information Technology, University Hospitals Leuven, Leuven, Belgium.
| | - Rik Willems
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium; Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.
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19
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Nemis-White JM, Hamilton LM, Shaw S, MacKillop JH, Parkash R, Choudhri SH, Ciaccia A, Xie F, Thabane L, Cox JL. Lessons learned from Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF): a pragmatic clinical trial of computerized decision support in primary care. Trials 2021; 22:531. [PMID: 34380542 PMCID: PMC8359062 DOI: 10.1186/s13063-021-05488-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 07/26/2021] [Indexed: 12/04/2022] Open
Abstract
Background Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF) was a pragmatic, cluster randomized trial assessing the effectiveness of a clinical decision support (CDS) tool in primary care, Nova Scotia, Canada. We evaluated if CDS software versus Usual Care could help primary care providers (PCPs) deliver individualized guideline-based AF patient care. Methods Key study challenges including CDS development and implementation, recruitment, and data integration documented over the trial duration are presented as lessons learned. Results Adequate resources must be allocated for software development, updates and feasibility testing. Development took longer than projected. End-user feedback suggested network access and broadband speeds impeded uptake; they felt further that the CDS was not sufficiently user-friendly or efficient in supporting AF care (i.e., repetitive alerts). Integration across e-platforms is crucial. Intellectual property and other issues prohibited CDS integration within electronic medical records and provincial e-health platforms. Double login and data entry were impediments to participation or reasons for provider withdrawal. Data integration challenges prevented easy and timely data access, analysis, and reporting. Primary care study recruitment is resource intensive. Altogether, 203 PCPs and 1145 of their patients participated, representing 25% of eligible providers and 12% of AF patients in Nova Scotia, respectively. The most effective provider recruitment strategy was in-office, small group lunch-and-learns. PCPs with past research experience or who led patient consent were top recruiters. The study office played a pivotal role in achieving patient recruitment targets. Conclusions A rapid growth in healthcare data is leading to widespread development of CDS. Our experience found practical issues to address for such applications to succeed. Feasibility testing to assess the utility of any healthcare CDS prior to implementation is recommended. Adequate resources are necessary to support successful recruitment for future pragmatic trials. CDS tools that integrate multiple co-morbid guidelines across eHealth platforms should be pursued. Trial registration ClinicalTrials.gov NCT01927367. Registered on August 22, 2013
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Affiliation(s)
- Joanna M Nemis-White
- Principal, Strive Health Management Consulting Ltd., Halifax, Nova Scotia, Canada
| | - Laura M Hamilton
- Research Manager, QEII Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Sarah Shaw
- Healthy Communities Program Officer, Public Health, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - James H MacKillop
- Family Physician, Sydney Primary Care Medical Clinic, Sydney, Nova Scotia, Canada
| | - Ratika Parkash
- Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Shurjeel H Choudhri
- Senior Vice President and Head, Medical & Scientific Affairs, Bayer Inc, Mississauga, Ontario, Canada
| | - Antonio Ciaccia
- Director & Head, Medical Affairs - Cardiovascular Medicine, Bayer Inc, Mississauga, Ontario, Canada
| | - Feng Xie
- Professor, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Professor, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Vice President, Research, St. Joseph's Healthcare, Hamilton, Ontario, Canada.,Professor, Departments of Anesthesia/Pediatrics, McMaster University, Hamilton, Ontario, Canada.,Director, Biostatistics Unit, Centre for Evaluation of Medicine, McMaster University, Hamilton, Ontario, Canada.,Senior Scientist, Population Health Research Institute (PHRI), Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jafna L Cox
- Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. .,Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada. .,Heart and Stroke Foundation of Nova Scotia Endowed Chair in Cardiovascular Outcomes Research, Halifax, Nova Scotia, Canada.
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20
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Su PY, Wei YC, Luo H, Liu CH, Huang WY, Chen KF, Lin CP, Wei HY, Lee TH. Explanation of Machine Learning Models Revealed Influential Factors of Early Outcomes in Acute Ischemic Stroke: A registry database study (Preprint). JMIR Med Inform 2021; 10:e32508. [PMID: 35072631 PMCID: PMC8994144 DOI: 10.2196/32508] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 01/23/2022] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Po-Yuan Su
- Department of Electrical Engineering, National Taiwan University, Taipei, Taiwan
| | - Yi-Chia Wei
- Department of Neurology, Chang Gung Memorial Hospital, Keelung, Taiwan
- Institute of Neuroscience, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Hao Luo
- Department of Electrical Engineering, National Taiwan University, Taipei, Taiwan
| | - Chi-Hung Liu
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Yi Huang
- Department of Neurology, Chang Gung Memorial Hospital, Keelung, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuan-Fu Chen
- Clinical Informatics and Medical Statistics Research Center, Chung Gung University, Taoyuan, Taiwan
- Department of Emergency, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Ching-Po Lin
- Institute of Neuroscience, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hung-Yu Wei
- Department of Electrical Engineering, National Taiwan University, Taipei, Taiwan
| | - Tsong-Hai Lee
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
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21
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Agarwal S, Glenton C, Tamrat T, Henschke N, Maayan N, Fønhus MS, Mehl GL, Lewin S. Decision-support tools via mobile devices to improve quality of care in primary healthcare settings. Cochrane Database Syst Rev 2021; 7:CD012944. [PMID: 34314020 PMCID: PMC8406991 DOI: 10.1002/14651858.cd012944.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The ubiquity of mobile devices has made it possible for clinical decision-support systems (CDSS) to become available to healthcare providers on handheld devices at the point-of-care, including in low- and middle-income countries. The use of CDSS by providers can potentially improve adherence to treatment protocols and patient outcomes. However, the evidence on the effect of the use of CDSS on mobile devices needs to be synthesized. This review was carried out to support a World Health Organization (WHO) guideline that aimed to inform investments on the use of decision-support tools on digital devices to strengthen primary healthcare. OBJECTIVES To assess the effects of digital clinical decision-support systems (CDSS) accessible via mobile devices by primary healthcare providers in the context of primary care settings. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Global Index Medicus, POPLINE, and two trial registries from 1 January 2000 to 9 October 2020. We conducted a grey literature search using mHealthevidence.org and issued a call for papers through popular digital health communities of practice. Finally, we conducted citation searches of included studies. SELECTION CRITERIA Study design: we included randomized trials, including full-text studies, conference abstracts, and unpublished data irrespective of publication status or language of publication. Types of participants: we included studies of all cadres of healthcare providers, including lay health workers and other individuals (administrative, managerial, and supervisory staff) involved in the delivery of primary healthcare services using clinical decision-support tools; and studies of clients or patients receiving care from primary healthcare providers using digital decision-support tools. Types of interventions: we included studies comparing digital CDSS accessible via mobile devices with non-digital CDSS or no intervention, in the context of primary care. CDSS could include clinical protocols, checklists, and other job-aids which supported risk prioritization of patients. Mobile devices included mobile phones of any type (but not analogue landline telephones), as well as tablets, personal digital assistants, and smartphones. We excluded studies where digital CDSS were used on laptops or integrated with electronic medical records or other types of longitudinal tracking of clients. DATA COLLECTION AND ANALYSIS A machine learning classifier that gave each record a probability score of being a randomized trial screened all search results. Two review authors screened titles and abstracts of studies with more than 10% probability of being a randomized trial, and one review author screened those with less than 10% probability of being a randomized trial. We followed standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care group. We used the GRADE approach to assess the certainty of the evidence for the most important outcomes. MAIN RESULTS Eight randomized trials across varying healthcare contexts in the USA,. India, China, Guatemala, Ghana, and Kenya, met our inclusion criteria. A range of healthcare providers (facility and community-based, formally trained, and lay workers) used digital CDSS. Care was provided for the management of specific conditions such as cardiovascular disease, gastrointestinal risk assessment, and maternal and child health. The certainty of evidence ranged from very low to moderate, and we often downgraded evidence for risk of bias and imprecision. We are uncertain of the effect of this intervention on providers' adherence to recommended practice due to the very low certainty evidence (2 studies, 185 participants). The effect of the intervention on patients' and clients' health behaviours such as smoking and treatment adherence is mixed, with substantial variation across outcomes for similar types of behaviour (2 studies, 2262 participants). The intervention probably makes little or no difference to smoking rates among people at risk of cardiovascular disease but probably increases other types of desired behaviour among patients, such as adherence to treatment. The effect of the intervention on patients'/clients' health status and well-being is also mixed (5 studies, 69,767 participants). It probably makes little or no difference to some types of health outcomes, but we are uncertain about other health outcomes, including maternal and neonatal deaths, due to very low-certainty evidence. The intervention may slightly improve patient or client acceptability and satisfaction (1 study, 187 participants). We found no studies that reported the time between the presentation of an illness and appropriate management, provider acceptability or satisfaction, resource use, or unintended consequences. AUTHORS' CONCLUSIONS We are uncertain about the effectiveness of mobile phone-based decision-support tools on several outcomes, including adherence to recommended practice. None of the studies had a quality of care framework and focused only on specific health areas. We need well-designed research that takes a systems lens to assess these issues.
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Affiliation(s)
- Smisha Agarwal
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, Maryland (MD), USA
| | | | - Tigest Tamrat
- Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland
| | | | | | | | - Garrett L Mehl
- Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland
| | - Simon Lewin
- Norwegian Institute of Public Health, Oslo, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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22
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Gebreyohannes EA, Mill D, Salter S, Chalmers L, Bereznicki L, Lee K. Strategies for improving guideline adherence of anticoagulants for patients with atrial fibrillation in primary healthcare: A systematic review. Thromb Res 2021; 205:128-136. [PMID: 34333301 DOI: 10.1016/j.thromres.2021.07.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/06/2021] [Accepted: 07/22/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Clinical guidelines on atrial fibrillation management help optimize the use of oral anticoagulants. However, guideline non-adherence is common, particularly in the primary care setting. The primary aim of this systematic review was to identify effective strategies for improving adherence to guideline-directed thromboprophylaxis to patients with atrial fibrillation in the primary care setting. METHODS A search was conducted on 6 electronic databases (Medline, Embase, ScienceDirect, Scopus, the Cumulative Indexing of Nursing and Allied Health Literature, and Web of Science) supplemented by a Google advanced search. Studies aimed at improving oral thromboprophylaxis guideline adherence in patients with atrial fibrillation, in the primary care setting, were included in the study. RESULTS A total of 33 studies were included in this review. Nine studies employed electronic decision support (EDS), of which 4 reported modest improvements in guideline adherence. Five of 6 studies that utilized local guidelines as quality improvement measures reported improvement in guideline adherence. All 5 studies that employed coordinated care and the use of specialist support and 4 of the 5 studies that involved pharmacist-led interventions reported improvements in guideline adherence. Interventions based mainly on feedback from audits were less effective. CONCLUSIONS Multifaceted interventions, especially those incorporating coordinated care and specialist support, pharmacists, or local adaptations to and implementation of national and/or international guidelines appear to be more consistently effective in improving guideline adherence in the primary care setting than interventions based mainly on EDS and feedback from audits.
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Affiliation(s)
| | - Deanna Mill
- Division of Pharmacy, School of Allied Health, University of Western Australia, WA, Australia
| | - Sandra Salter
- Division of Pharmacy, School of Allied Health, University of Western Australia, WA, Australia
| | | | - Luke Bereznicki
- School of Pharmacy and Pharmacology, University of Tasmania, TAS, Australia
| | - Kenneth Lee
- Division of Pharmacy, School of Allied Health, University of Western Australia, WA, Australia
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23
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Muhindo M, Bress J, Kalanda R, Armas J, Danziger E, Kamya MR, Butler LM, Ruel T. Implementation of a Newborn Clinical Decision Support Software (NoviGuide) in a Rural District Hospital in Eastern Uganda: Feasibility and Acceptability Study. JMIR Mhealth Uhealth 2021; 9:e23737. [PMID: 33605886 PMCID: PMC7935651 DOI: 10.2196/23737] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/22/2020] [Accepted: 01/04/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Lack of trained health care workers and nonadherence to national guidelines are key barriers to achieving high-quality newborn care in health care facilities in low- and middle-income countries. Traditional didactic approaches addressing these barriers fail to account for high staff turnover rates and result in temporary behavior change. NoviGuide, a clinical decision support software designed to standardize neonatal care through point-of-care assessments, has the potential to align bedside practice to national guidelines in settings lacking subspecialty neonatal providers. OBJECTIVE This study aims to determine the adaptation, adoption, feasibility, acceptability, and sustainability of NoviGuide and its impact on nurse-midwives' knowledge in a rural hospital in eastern Uganda. METHODS This mixed methods observational study was guided by the Proctor framework. Experts reviewed the clinical content of NoviGuide to ensure fidelity to Uganda guidelines. We enrolled nurses and midwives providing newborn care at Tororo District Hospital, trained them on NoviGuide use, and followed them for 12 months. We assessed adoption, feasibility, acceptability, and sustainability by analyzing NoviGuide use data, comparing it with maternity registry data and administering the System Usability Scale (SUS) and the Center for Health Care Evaluation Provider Satisfaction Questionnaire. We compared the mean knowledge assessment score at baseline, 6 months, and 12 months using a two-tailed t test. RESULTS Five Ugandan experts suggested two minor changes to NoviGuide: the inclusion of an unsterile birth environment as an indication for empiric antibiotics and the addition of a reminder to follow-up with newborns with temperatures between 37.7°C and 37.9°C. Of the 19 nurse-midwives enrolled in February 2017, 74% (n=14) completed the follow-up in March 2018. The participants entered a total of 1705 assessments of varying newborn characteristics into NoviGuide throughout the day, evening, and night nursing shifts. The SUS score at the end of the study was very high (93.5, above the average of 68). Participants had a positive perception about NoviGuide, reporting that NoviGuide saved time (mean 5, SD 0) and prevented mistakes (mean 5, SD 0), and that they felt more confident in taking care of newborns when they used NoviGuide (mean 5, SD 0). Participants were highly satisfied with NoviGuide (mean 4.86, SD 0.36), although they lacked medical supplies and materials needed to follow NoviGuide recommendations (mean 3.3, SD 1.22). The participants' knowledge scores improved by a mean change of 3.7 (95% CI 2.6-4.8) at 6 months and 6.7 (95% CI 4.6-8.2) at 12 months (P<.001). CONCLUSIONS NoviGuide was easily adapted to the Uganda guidelines. Nurse-midwives used NoviGuide frequently and reported high levels of satisfaction despite challenges with medical supplies and high staff turnover. NoviGuide improved knowledge and confidence in newborn care without in-person didactic training. NoviGuide use has the potential to scale up quality newborn care by facilitating adherence to national guidelines.
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Affiliation(s)
- Mary Muhindo
- UCSF Preterm Birth Initiative, University of California San Francisco School of Medicine, San Francisco, CA, United States.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Rogers Kalanda
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Jean Armas
- Global Strategies, Albany, CA, United States
| | | | - Moses R Kamya
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Lisa M Butler
- Institute for Collaboration on Health, Intervention and Policy, University of Connecticut, Storrs, CT, United States
| | - Theodore Ruel
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
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24
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Dowding D, Russell D, McDonald MV, Trifilio M, Song J, Brickner C, Shang J. "A catalyst for action": Factors for implementing clinical risk prediction models of infection in home care settings. J Am Med Inform Assoc 2021; 28:334-341. [PMID: 33260204 PMCID: PMC7883974 DOI: 10.1093/jamia/ocaa267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/05/2020] [Accepted: 10/19/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE The study sought to outline how a clinical risk prediction model for identifying patients at risk of infection is perceived by home care nurses, and to inform how the output of the model could be integrated into a clinical workflow. MATERIALS AND METHODS This was a qualitative study using semi-structured interviews with 50 home care nurses. Interviews explored nurses' perceptions of clinical risk prediction models, their experiences using them in practice, and what elements are important for the implementation of a clinical risk prediction model focusing on infection. Interviews were audio-taped and transcribed, with data evaluated using thematic analysis. RESULTS Two themes were derived from the data: (1) informing nursing practice, which outlined how a clinical risk prediction model could inform nurse clinical judgment and be used to modify their care plan interventions, and (2) operationalizing the score, which summarized how the clinical risk prediction model could be incorporated in home care settings. DISCUSSION The findings indicate that home care nurses would find a clinical risk prediction model for infection useful, as long as it provided both context around the reasons why a patient was deemed to be at high risk and provided some guidance for action. CONCLUSIONS It is important to evaluate the potential feasibility and acceptability of a clinical risk prediction model, to inform the intervention design and implementation strategy. The results of this study can provide guidance for the development of the clinical risk prediction tool as an intervention for integration in home care settings.
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Affiliation(s)
- Dawn Dowding
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - David Russell
- Department of Sociology, Appalachian State University, Boone, North Carolina, USA
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, New York, USA
| | - Margaret V McDonald
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, New York, USA
| | - Marygrace Trifilio
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, New York, USA
| | - Jiyoun Song
- Columbia University School of Nursing, New York, New York, USA
| | - Carlin Brickner
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, New York, USA
- Business Intelligence and Analytics, Visiting Nurse Service of New York, New York, New York, USA
| | - Jingjing Shang
- Columbia University School of Nursing, New York, New York, USA
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25
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Pedersen RA, Petursson H, Hetlevik I, Thune H. Stroke follow-up in primary care: a discourse study on the discharge summary as a tool for knowledge transfer and collaboration. BMC Health Serv Res 2021; 21:41. [PMID: 33413305 PMCID: PMC7792345 DOI: 10.1186/s12913-020-06021-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 12/16/2020] [Indexed: 12/02/2022] Open
Abstract
Background The acute treatment for stroke takes place in hospitals and in Norway follow-up of stroke survivors residing in the communities largely takes place in general practice. In order to provide continuous post stroke care, these two levels of care must collaborate, and information and knowledge must be transferred between them. The discharge summary, a written report from the hospital, is central to this communication. Norwegian national guidelines for treatment of stroke, issued in 2010, therefore give recommendations on the content of the discharge summaries. One ambition is to achieve collaboration and knowledge transfer, contributing to integration of the health care services. However, studies suggest that adherence to guidelines in general practice is weak, that collaboration within the health care services does not work the way the authorities intend, and that health care services are fragmented. This study aims to assess to what degree the discharge summaries adhere to the guideline recommendations on content and to what degree they are used as tools for knowledge transfer and collaboration between secondary and primary care. Methods The study was an analysis of 54 discharge summaries for home-dwelling stroke patients. The patients had been discharged from two Norwegian local hospitals in 2011 and 2012 and followed up in primary care. We examined whether content was according to guidelines’ recommendations and performed a descriptive and interpretative discourse analysis, using tools adapted from an established integrated approach to discourse analysis. Results We found a varying degree of adherence to the different advice for the contents of the discharge summaries. One tendency was clear: topics relevant here and now, i.e. at the hospital, were included, while topics most relevant for the later follow-up in primary care were to a larger degree omitted. In most discharge summaries, we did not find anything indicating that the doctors at the hospital made themselves available for collaboration with primary care after dischargeof the patient. Conclusions The discharge summaries did not fulfill their potential to serve as tools for collaboration, knowledge transfer, and guideline implementation. Instead, they may contribute to sustain the gap between hospital medicine and general practice.
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Affiliation(s)
- Rune Aakvik Pedersen
- Department of Public Health and Nursing, General Practice Research Unit, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Halfdan Petursson
- Department of Public Health and Nursing, General Practice Research Unit, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Irene Hetlevik
- Department of Public Health and Nursing, General Practice Research Unit, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Henriette Thune
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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Hagen B, Griebenow R. Prescription Rates for Antiplatelet Therapy (APT) in Coronary Artery Disease (CAD) - What Benchmark are We Aiming at in Continuing Medical Education (CME)? J Eur CME 2020; 9:1836866. [PMID: 33224627 PMCID: PMC7655043 DOI: 10.1080/21614083.2020.1836866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 11/09/2022] Open
Abstract
Physicians always aim to improve their patients' health. CME should be designed not only to provide knowledge transfer, but also to influence clinical decision-making and to close performance gaps. In aretrospective study we analysed prescription rates for APT in 254,932 CAD patients (male: 64.4%), treated in atotal of 3,405 practices in 2019 in aDMP in the region of North Rhine, Germany. Analyses were run for the whole study population stratified by sex as well as for subgroups of patients suffering from myocardial infarction/acute coronary syndrome, or who have been treated with percutaneous coronary intervention or bypass surgery. Patients mean age was 72.7 ± 11.2 years (mean ± 1SD), mean duration of DMP participation was 7.2 ± 4.7 years, and mean cumulative number of DMP visits was 27 ± 17. APT prescription rates were 85.0% in male and 78.8% in female CAD patients. In subgroups of male CAD patients APT prescription rates were between 89.7% and 92.8%, in the same subgroups of female CAD patients the corresponding rates were between 87.8% and 92.0%. Rates for amissing APT prescription per practice were between .0044% and .0062% for male and female CAD patients, respectively. Rates for amissing APT prescription per practice and DMP visit were .0002% for both sexes. These results suggest that a DMP can achieve high attainment rates for APT in CAD. To further improve attainment rates, consideration of absolute numbers of eligible patients per practice or physician is probably more appropriate than expression of performance as percentage values. This is especially true if attainment rates show substantial variations between subgroups, if subgroups show substantial variation in size, if attainment rates are already in the magnitude of 80% or higher, and if there are disparities in the evidence base underlying treatment recommendations related to subgroups.
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Affiliation(s)
- Bernd Hagen
- Department of Evaluation and Quality Assurance, Central Institute for Statutory Health Care in Germany, Cologne/Berlin, Germany
| | - Reinhard Griebenow
- Praxis Rheingalerie, Cologne, Academic Teaching Practice, University of Cologne, Cologne, Germany
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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: 173] [Impact Index Per Article: 43.3] [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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28
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Lee TC, Shah NU, Haack A, Baxter SL. Clinical Implementation of Predictive Models Embedded within Electronic Health Record Systems: A Systematic Review. INFORMATICS-BASEL 2020; 7. [PMID: 33274178 PMCID: PMC7710328 DOI: 10.3390/informatics7030025] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Predictive analytics using electronic health record (EHR) data have rapidly advanced over the last decade. While model performance metrics have improved considerably, best practices for implementing predictive models into clinical settings for point-of-care risk stratification are still evolving. Here, we conducted a systematic review of articles describing predictive models integrated into EHR systems and implemented in clinical practice. We conducted an exhaustive database search and extracted data encompassing multiple facets of implementation. We assessed study quality and level of evidence. We obtained an initial 3393 articles for screening, from which a final set of 44 articles was included for data extraction and analysis. The most common clinical domains of implemented predictive models were related to thrombotic disorders/anticoagulation (25%) and sepsis (16%). The majority of studies were conducted in inpatient academic settings. Implementation challenges included alert fatigue, lack of training, and increased work burden on the care team. Of 32 studies that reported effects on clinical outcomes, 22 (69%) demonstrated improvement after model implementation. Overall, EHR-based predictive models offer promising results for improving clinical outcomes, although several gaps in the literature remain, and most study designs were observational. Future studies using randomized controlled trials may help improve the generalizability of findings.
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Affiliation(s)
- Terrence C. Lee
- Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, La Jolla, CA 92093, USA
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
| | - Neil U. Shah
- Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, La Jolla, CA 92093, USA
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
| | - Alyssa Haack
- Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, La Jolla, CA 92093, USA
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
| | - Sally L. Baxter
- Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, La Jolla, CA 92093, USA
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
- Correspondence: ; Tel.: +1-858-534-8858
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29
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Torab-Miandoab A, Samad-Soltani T, Shams-Vahdati S, Rezaei-Hachesu P. An intelligent system for improving adherence to guidelines on acute stroke. Turk J Emerg Med 2020; 20:118-134. [PMID: 32832731 PMCID: PMC7416851 DOI: 10.4103/2452-2473.290062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 04/23/2020] [Accepted: 06/07/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES: A timely, accurate assessment and decision-making process is essential for the diagnosis and treatment of the acute stroke, which is the world's third leading cause of death. This process is often performed using the traditional method that increases the complexity, duration, and medical errors. The present study aimed to design and evaluate an intelligent system for improving adherence to the guidelines on the assessment and treatment of acute stroke patients. METHODS: Decision-making rules and data elements were used to predict the severity and to treat patients according to the specialists' opinions and guidelines. A system was then developed based on the intelligent decision-making algorithms. The system was finally evaluated by measuring the accuracy, sensitivity, specificity, applicability, performance, esthetics, information quality, and completeness and rates of medical errors. The segmented regression model was used to evaluate the effect of systems on the level and the trend of guideline adherence for the assessment and treatment of acute stroke. RESULTS: Fifty-three data elements were identified and used in the data collection and comprehensive decision-making rules. The rules were organized in a decision tree. In our analysis, 150 patients were included. The system accuracy was 98.30%. Evaluation results indicated an error rate of 1.69% by traditional methods. Documentation quality (completeness) increased from 78.66% to 100%. The average score of system quality was 4.60 indicating an acceptable range. After the system intervention, the mean of the adherence to the guideline significantly increased from 65% to 99.5% (P < 0.0008). CONCLUSION: The designed system was accurate and can improve adherence to the guideline for the severity assessment and the determination of a therapeutic trend for acute stroke patients. It leads to physicians' empowerment, significantly reduces medical errors, and improves the documentation quality.
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Affiliation(s)
- Amir Torab-Miandoab
- Department of Health Information Technology, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Taha Samad-Soltani
- Department of Health Information Technology, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samad Shams-Vahdati
- Department of Emergency Medicine, Imam Reza Teaching Hospital, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Peyman Rezaei-Hachesu
- Department of Health Information Technology, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
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Manski-Nankervis JA, Biezen R, Thursky K, Boyle D, Clark M, Lo S, Buising K. Developing a Clinical Decision Support Tool for Appropriate Antibiotic Prescribing in Australian General Practice: A Simulation Study. Med Decis Making 2020; 40:428-437. [PMID: 32507028 DOI: 10.1177/0272989x20926136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Inappropriate antibiotic prescribing can lead to antimicrobial resistance and drug side effects. Tools that assist general practitioners (GPs) in prescribing decisions may help to optimize prescribing. The aim of this study was to explore the use, acceptability, and feasibility of a clinical decision support (CDS) tool that incorporates evidence-based guidelines and consumer information that integrates with the electronic medical record (EMR). Methods. Eight GPs completed an interview and brief survey after participating in 2 simulated consultations. The survey consisted of demographic questions, perception of realism and representativeness of consultations, Post-Study System Usability Questionnaire, and System Usability Scale. Qualitative data were analyzed using framework analysis. Video data were reviewed, with length of consultation and time spent using the CDS tool documented. Results. Survey responses indicated that all GPs thought the consultations were "real" and representative of real-life consultations; 7 of 8 GPs were satisfied with usability of the tool. Key qualitative findings included that the tool assisted with clinical decision making and informed appropriate antibiotic prescribing. Accessibility and ease of use, including content (guideline and patient education resources), layout, and format, were key factors that determined whether GPs said that they would access the tool in everyday practice. Integration of the tool at multiple sites within the EMR facilitated access to guidelines and assisted in ensuring that the tool fit the clinical workflow. Conclusion. Our CDS tool was acceptable to GPs. Key features required for the tool were easy navigation, clear and useful guideline content, ability to fit into the clinical workflow, and incorporation into the EMR. Piloting of the tool in general practices to assess the impact and feasibility of use in real-world consultations will now be undertaken.
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Affiliation(s)
| | - Ruby Biezen
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Karin Thursky
- The National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Douglas Boyle
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Malcolm Clark
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Sean Lo
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Kirsty Buising
- The National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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Gattellari M, Hayen A, Leung DYC, Zwar NA, Worthington JM. Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial. BMC FAMILY PRACTICE 2020; 21:102. [PMID: 32513116 PMCID: PMC7281948 DOI: 10.1186/s12875-020-01175-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/28/2020] [Indexed: 12/15/2022]
Abstract
Background Anticoagulation for preventing stroke in atrial fibrillation is under-utilised despite evidence supporting its use, resulting in avoidable death and disability. We aimed to evaluate an intervention to improve the uptake of anticoagulation. Methods We carried out a national, cluster randomised controlled trial in the Australian primary health care setting. General practitioners received an educational session, delivered via telephone by a medical peer and provided information about their patients selected either because they were not receiving anticoagulation or for whom anticoagulation was considered challenging. General practitioners were randomised to receive feedback from a medical specialist about the cases (expert decisional support) either before or after completing a post-test audit. The primary outcome was the proportion of patients reported as receiving oral anticoagulation. A secondary outcome assessed antithrombotic treatment as appropriate against guideline recommendations. Results One hundred and seventy-nine general practitioners participated in the trial, contributing information about 590 cases. At post-test, 152 general practitioners (84.9%) completed data collection on 497 cases (84.2%). A 4.6% (Adjusted Relative Risk = 1.11, 95% CI = 0.86–1.43) difference in the post-test utilization of anticoagulation between groups was not statistically significant (p = 0.42). Sixty-one percent of patients in both groups received appropriate antithrombotic management according to evidence-based guidelines at post-test (Adjusted Relative Risk = 1.0; 95% CI = 0.85 to 1.19) (p = 0.97). Conclusions Specialist feed-back in addition to an educational session did not increase the uptake of anticoagulation in patients with AF. Trial registration ANZCTRN12611000076976 Retrospectively registered.
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Affiliation(s)
- Melina Gattellari
- Department of Neurology, Institute for Clinical Neurosciences, Neuroscience Research, Royal Prince Alfred Hospital, Missenden Road, Sydney Local Health District, Camperdown (Sydney), New South Wales, 2050, Australia. .,Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, New South Wales, 2170, Australia.
| | - Andrew Hayen
- Faculty of Health, University of Technology Sydney, 15 Broadway, Ultimo, New South Wales, 2007, Australia
| | - Dominic Y C Leung
- South Western Sydney Clinical School UNSW, Liverpool, Australia.,Department of Cardiology, Liverpool Health Service, Sydney South West Local Health District, Clinical Services Building, Elizabeth Street, Liverpool (Sydney), New South Wales, 2170, Australia
| | - Nicholas A Zwar
- Faculty of Health, Sciences and Medicine, Bond University, 14 University Drive, Robina, Queensland, 4226, Australia
| | - John M Worthington
- Department of Neurology, Institute for Clinical Neurosciences, Neuroscience Research, Royal Prince Alfred Hospital, Missenden Road, Sydney Local Health District, Camperdown (Sydney), New South Wales, 2050, Australia.,South Western Sydney Clinical School UNSW, Liverpool, Australia
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Thibert MJ, Hawkins NM, Andrade JG. Clinical decision support for atrial fibrillation in primary care: Steps forward. Am Heart J 2020; 224:54-56. [PMID: 32304880 DOI: 10.1016/j.ahj.2020.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Michael J Thibert
- Heart Rhythm Services, Department of Medicine, University of British Columbia, Canada
| | - Nathaniel M Hawkins
- Heart Rhythm Services, Department of Medicine, University of British Columbia, Canada; Center for Cardiovascular Innovation, Vancouver, Canada
| | - Jason G Andrade
- Heart Rhythm Services, Department of Medicine, University of British Columbia, Canada; Center for Cardiovascular Innovation, Vancouver, Canada; Montreal Heart Institute, Department of Medicine, Université de Montréal, Canada.
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Robertson LA, McLean MA, Montgomery Sardar C, Bryson G, Kurdi A. Evaluation of the prescribing decision support system Synonyms in a primary care setting: a mixed-method study. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2020; 28:473-482. [PMID: 32390231 DOI: 10.1111/ijpp.12629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 04/05/2020] [Accepted: 04/07/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Primary care prescribers must cope with an increasing number and complexity of considerations. Prescribing decision support systems (DSS) have therefore been developed to assist prescribers. Previous studies have shown that although there is wide variance in the different DSS available within primary care, barriers and facilitators to uptake remain. The Drug Synonyms function ('Synonyms') is a DSS inherent in the commercial electronic medical record system EMIS. Synonyms functionality has been further developed by the NHS Greater Glasgow and Clyde (GG&C) Central Prescribing Team to promote safe and cost-effective prescribing; however, it does not support the collection of usage data. As there is no knowledge on the uptake nor on the perceived effect of using Synonyms on prescribing, quantitative and qualitative analyses of Synonyms usage are required to ascertain the impact Synonyms has on primary care prescribers, which will influence the continued maintenance and/or future development of this prescribing DSS. AIM To determine the uptake of Synonyms and explore users' perceptions of its usefulness and future development. DESIGN AND SETTING An exploratory sequential mixed-method observational study using quantitative questionnaires, followed by semi-structured interviews with primary care prescribers within NHS GG&C. METHOD An electronic questionnaire (Questionnaire 1) accessible across 218 EMIS-compliant NHS GG&C GP practices ascertained Synonyms uptake by determining whether prescribers were aware of the DSS, whether they were aware of it and whether they used it. Prescribers who were aware of and used Synonyms were asked to opt in to participating further. This involved answering a second electronic questionnaire (Questionnaire 2), with the option of taking part in an additional one-to-one interview, to investigate their use and perceptions of Synonyms. RESULTS Questionnaire 1 was completed by 201 respondents from 43.1% of eligible GP practices: 186 (92.5%) respondents were aware of Synonyms, of whom 163 (87.6%) had used it and 155 (83.3%) continued to use it. Questionnaire 2 was completed by 104 respondents: 90 (86.5%) indicated that Synonyms informed or influenced their choice of drug prescribed; 94 (90.4%) reported that Synonyms changed their prescribing choice towards medication on NHS GG&C formulary, and 104 (100%) reported that they trust Synonyms. Six interviews generated suggestions for improvements, mainly extending the clinical conditions listed. CONCLUSION Most respondents were aware of and continued to use Synonyms. Respondents perceived Synonyms to influence prescribing choices towards local formulary medicines and improve adherence to local prescribing guidelines. Respondents trusted the DSS, but there is potential to increase awareness and training amongst non-users to encourage usage. Potentially, the NHS GG&C Synonyms function could be utilised by other health boards with supportive clinical systems.
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Affiliation(s)
- Lindsay A Robertson
- Glasgow City HSCP Prescribing Team, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Mairi-Anne McLean
- Greater Glasgow and Clyde Central Prescribing Team, NHS Greater Glasgow and Clyde, Glasgow, UK
| | | | - Graeme Bryson
- Glasgow City HSCP Prescribing Team, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Amanj Kurdi
- Strathclyde Institute of Pharmacy and Biomedical Science, University of Strathclyde, Glasgow, UK.,Department of Pharmacology, College of Pharmacy, Hawler Medical University, Erbil, Iraq
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Kapoor A, Amroze A, Vakil F, Crawford S, Der J, Mathew J, Alper E, Yogaratnam D, Javed S, Elhag R, Lin A, Narayanan S, Bartlett D, Nagy A, Shagoury BK, Fischer MA, Mazor KM, Saczynski JS, Ashburner JM, Lopes R, McManus DD. SUPPORT-AF II: Supporting Use of Anticoagulants Through Provider Profiling of Oral Anticoagulant Therapy for Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2020; 13:e005871. [DOI: 10.1161/circoutcomes.119.005871] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Previous provider-directed electronic messaging interventions have not by themselves improved anticoagulation use in patients with atrial fibrillation. Direct engagement with providers using academic detailing coupled with electronic messaging may overcome the limitations of the prior interventions.
Methods and Results:
We randomized outpatient providers affiliated with our health system in a 2.5:1 ratio to our electronic profiling/messaging combined with academic detailing intervention. In the intervention, we emailed providers monthly reports of their anticoagulation percentage relative to peers for atrial fibrillation patients with elevated stroke risk (CHA
2
DS
2
-VASc ≥2). We also sent electronic medical record-based messages shortly before an appointment with an anticoagulation-eligible but untreated atrial fibrillation patient. Providers had the option to send responses with explanations for prescribing decisions. We also offered to meet with intervention providers using an academic detailing approach developed based on knowledge gaps discussed in provider focus groups. To assess feasibility, we tracked provider review of our messages. To assess effectiveness, we measured the change in anticoagulation for patients of intervention providers relative to controls. We identified 85 intervention and 34 control providers taking care of 3591 and 1908 patients, respectively; 33 intervention providers participated in academic detailing. More than 80% of intervention providers read our emails, and 98% of the time a provider reviewed our in-basket messages. Replies to messages identified patient refusal as the most common reason for patients not being on anticoagulation (11.2%). For the group of patients not on anticoagulation at baseline assigned to an intervention versus control provider, the adjusted percent increase in the use of anticoagulation over 6 months was 5.2% versus 7.4%, respectively (
P
=0.21).
Conclusions:
Our electronic messaging and academic detailing intervention was feasible but did not increase anticoagulation use. Patient-directed interventions or provider interventions targeting patients declining anticoagulation may be necessary to raise the rate of anticoagulation.
Clinical Trial Registration
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT03583008.
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Affiliation(s)
- Alok Kapoor
- University of Massachusetts Memorial Health Care, Worcester (A.K., A.A, E.A., R.E., D.D.M.)
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester (A.K., A.A., K.M.M., D.D.M.)
| | - Azraa Amroze
- University of Massachusetts Memorial Health Care, Worcester (A.K., A.A, E.A., R.E., D.D.M.)
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester (A.K., A.A., K.M.M., D.D.M.)
| | - Fatima Vakil
- Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH (F.V.)
| | - Sybil Crawford
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | | | - Jomol Mathew
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Eric Alper
- University of Massachusetts Memorial Health Care, Worcester (A.K., A.A, E.A., R.E., D.D.M.)
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Dinesh Yogaratnam
- Mass College of Pharmacy and Health Sciences, Worcester, MA (D.Y., D.B.)
| | - Saud Javed
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Rasha Elhag
- University of Massachusetts Memorial Health Care, Worcester (A.K., A.A, E.A., R.E., D.D.M.)
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Abraham Lin
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Siddhartha Narayanan
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Donna Bartlett
- Mass College of Pharmacy and Health Sciences, Worcester, MA (D.Y., D.B.)
| | - Ahmed Nagy
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Bevin Kathleen Shagoury
- The National Resource Center for Academic Detailing, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA (B.K.S., M.A.F.)
| | - Michael A. Fischer
- The National Resource Center for Academic Detailing, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA (B.K.S., M.A.F.)
| | - Kathleen M. Mazor
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester (A.K., A.A., K.M.M., D.D.M.)
| | - Jane S. Saczynski
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
- Northeastern University, Boston, MA (J.D., J.S.S.)
| | - Jeffrey M. Ashburner
- Division of General Internal Medicine, Massachusetts General Hospital, Boston (J.M.A.)
| | - Renato Lopes
- Duke Clinical Research Institute, Durham, NC (R.L.)
| | - David D. McManus
- University of Massachusetts Memorial Health Care, Worcester (A.K., A.A, E.A., R.E., D.D.M.)
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester (A.K., A.A., K.M.M., D.D.M.)
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Sennesael AL, Krug B, Sneyers B, Spinewine A. Do computerized clinical decision support systems improve the prescribing of oral anticoagulants? A systematic review. Thromb Res 2020; 187:79-87. [PMID: 31972381 DOI: 10.1016/j.thromres.2019.12.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/13/2019] [Accepted: 12/28/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Serious adverse drug reactions have been associated with the underuse or the misuse of oral anticoagulant therapy. We systematically reviewed the impact of computerized clinical decision support systems (CDSS) on the prescribing of oral anticoagulants and we described CDSS features associated with success or failure. METHODS We searched Medline, Embase, CENTRAL, CINHAL, and PsycINFO for studies that compared CDSS for the initiation or monitoring of oral anticoagulants with routine care. Two reviewers performed study selection, data collection, and risk-of-bias assessment. Disagreements were resolved with a third reviewer. Potentially important CDSS features, identified from previous literature, were evaluated. RESULTS Sixteen studies were included in our qualitative synthesis. Most trials were performed in primary care (n = 7) or hospitals (n = 6) and included atrial fibrillation (AF) patients (n = 9). Recommendations mainly focused on anticoagulation underuse (n = 11) and warfarin-drug interactions (n = 5). Most CDSS were integrated in electronic records or prescribing and provided support automatically at the time and location of decision-making. Significant improvements in practitioner performance were found in 9 out of 16 studies, while clinical outcomes were poorly reported. CDSS features seemed slightly more common in studies that demonstrated improvement. CONCLUSIONS CDSS might positively impact the use of oral anticoagulants in AF patients at high risk of stroke. The scope of CDSS should now evolve to assist prescribers in selecting the most appropriate and tailored medication. Efforts should nevertheless be made to improve the relevance of notifications and to address implementation outcomes.
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Affiliation(s)
- Anne-Laure Sennesael
- Université catholique de Louvain, Louvain Drug Research Institute, Clinical Pharmacy Research Group, Brussels, Belgium; Université catholique de Louvain, CHU UCL Namur, Department of Pharmacy, Yvoir, Belgium.
| | - Bruno Krug
- Université catholique de Louvain, CHU UCL Namur, Department of Nuclear Medicine, Yvoir, Belgium; Université catholique de Louvain, Institute of Health and Society, Brussels, Belgium
| | - Barbara Sneyers
- Université catholique de Louvain, CHU UCL Namur, Department of Pharmacy, Yvoir, Belgium
| | - Anne Spinewine
- Université catholique de Louvain, Louvain Drug Research Institute, Clinical Pharmacy Research Group, Brussels, Belgium; Université catholique de Louvain, CHU UCL Namur, Department of Pharmacy, Yvoir, Belgium
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Pedersen RA, Petursson H, Hetlevik I. Stroke follow-up in primary care: a Norwegian modelling study on the implications of multimorbidity for guideline adherence. BMC FAMILY PRACTICE 2019; 20:138. [PMID: 31627726 PMCID: PMC6798338 DOI: 10.1186/s12875-019-1021-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 09/03/2019] [Indexed: 11/16/2022]
Abstract
Background Specialized acute treatment and high-quality follow-up is meant to reduce mortality and disability from stroke. While the acute treatment for stroke takes place in hospitals, the follow-up of stroke survivors largely takes place in general practice. National guidelines give recommendations for the follow-up. However, previous studies suggest that guidelines are not sufficiently adhered to. It has been suggested that this might be due to the complexity of general practice. A part of this complexity is constituted by patients’ multimorbidity; the presence of two or more chronic conditions in the same person. In this study we investigated the extent of multimorbidity among stroke survivors residing in the communities. The aim was to assess the implications of multimorbidity for the follow-up of stroke in general practice. Methods The study was a cross sectional analysis of the prevalence of multimorbidity among stroke survivors in Mid-Norway. We included 51 patients, listed with general practitioners in 18 different clinics. The material consists of the general practitioners’ medical records for these patients. The medical records for each patient were reviewed in a search for diagnoses corresponding to a predefined list of morbidities, resulting in a list of chronic conditions for each participant. These 51 lists were the basis for the subsequent analysis. In this analysis we modelled different hypothetical patients and assessed the implications of adhering to all clinical guidelines affecting their diseases. Result All 51 patients met the criteria for multimorbidity. On average the patients had 4.7 (SD: 1.9) chronic conditions corresponding to the predefined list of morbidities. By modelling implications of guideline adherence for a patient with an average number of co-morbidities, we found that 10–11 annual consultations with the general practitioner were needed for the follow-up of the stable state of the chronic conditions. More consultations were needed for patients with more complex multimorbidity. Conclusions Multimorbidity had a clear impact on the basis for the follow-up of patients with stroke in general practice. Adhering to the guidelines for each condition is challenging, even for patients with few co-morbidities. For patients with complex multimorbidity, adhering to the guidelines is obviously unmanageable.
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Affiliation(s)
- Rune Aakvik Pedersen
- General Practice Research Unit, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, PO Box 8905 MTFS, N-7491, Trondheim, Norway.
| | - Halfdan Petursson
- General Practice Research Unit, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, PO Box 8905 MTFS, N-7491, Trondheim, Norway.,Research and Development Primary Health Care, Research and Development Center Gothenburg and Södra Bohuslän, Region Västra Götaland, Sweden
| | - Irene Hetlevik
- General Practice Research Unit, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, PO Box 8905 MTFS, N-7491, Trondheim, Norway
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GP incentives to design hypertension and atrial fibrillation local quality-improvement schemes: a controlled before-after study in UK primary care. Br J Gen Pract 2019; 69:e689-e696. [PMID: 31455643 DOI: 10.3399/bjgp19x705521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/28/2019] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Financial incentives in the UK such as the Quality and Outcomes Framework (QOF) reward GP surgeries for achievement of nationally defined targets. These have shown mixed results, with weak evidence for some measures, but also possible unintended negative effects. AIM To look at the effects of a local intervention for atrial fibrillation (AF) and hypertension, with surgeries rewarded financially for work, including appointing designated practice leads, attendance at peer review workshops, and producing their own protocols. DESIGN AND SETTING A controlled before-after study comparing surgery performance measures in UK primary care. METHOD This study used published QOF data to analyse changes from baseline in mean scores per surgery relating to AF and hypertension prevalence and management at T1 (12 months) and T2 (24 months) for the intervention group, which consisted of all 58 surgeries in East Lancashire Clinical Commissioning Group (CCG), compared to the control group, which consisted of all other surgeries in north-west England. RESULTS There was a small acceleration between T0 (baseline) and T2 in recorded prevalence of hypertension in the intervention group compared to the controls, difference 0.29% (95% confidence interval [CI] = 0.05 to 0.53), P = 0.017, but AF prevalence did not increase more in the intervention group. Improvement in quality of management of AF was significantly better in the intervention group, difference 3.24% (95% CI = 1.37 to 5.12), P = 0.001. CONCLUSION This intervention improved diagnosis rates of hypertension but not AF, though it did improve quality of AF management. It indicates that funded time to develop quality-improvement measures targeted at a local population and involving peer support can engage staff and have the potential to improve quality.
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Effectiveness of CHA 2DS 2-VASc based decision support on stroke prevention in atrial fibrillation: A cluster randomised trial in general practice. Int J Cardiol 2018; 273:123-129. [PMID: 30224261 DOI: 10.1016/j.ijcard.2018.08.096] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/23/2018] [Accepted: 08/30/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Guidelines on atrial fibrillation (AF) recommend the CHA2DS2-VASc rule for anticoagulant decision-making, but underuse exists. We studied the impact of an automated decision support on stroke prevention in patients with AF in a cluster randomised trial in general practice. METHODS Intervention practices were provided with a CHA2DS2-VASc based anticoagulant treatment recommendation. Reference practices provided care as usual. The primary outcome was incidence of ischaemic stroke, transient ischaemic attack (TIA) and/or thromboembolism (TE). Secondary outcomes were bleeding and the proportion of patients on guideline recommended anticoagulant treatment. RESULTS In total, 1129 AF patients were included in the 19 intervention practices and 1226 AF patients in the 19 reference practices. The median age was 77 (interquartile range (IQR) 68-75) years, the median CHA2DS2-VASc score was 3.0 (IQR 2.0-5.0). Underuse of anticoagulants in patients with CHA2DS2-VASc score ≥ 2 was 6.6%. After a median follow-up of 2.7 years (IQR 2.3-3.0), the incidence rate per 100 person-years of ischaemic stroke/TIA/TE was 1.96 in the intervention group and 1.42 in the reference group (hazard ratio (HR) 1.3, 95% C.I. 0.8-2.1). No difference was observed in the rate of bleeding (0.79 versus 0.82), or in the underuse (7.2% versus 8.2%) or overuse (8.0% versus 7.9%) of anticoagulation. CONCLUSIONS In this study in patients with AF in general practice, underuse of anticoagulants was relatively low. Providing practitioners with CHA2DS2-VASc based decision support did not result in a reduction in stroke incidence, affect bleeding risk or anticoagulant over- or underuse.
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Kapoor A, Amroze A, Golden J, Crawford S, O'Day K, Elhag R, Nagy A, Lubitz SA, Saczynski JS, Mathew J, McManus DD. SUPPORT-AF: Piloting a Multi-Faceted, Electronic Medical Record-Based Intervention to Improve Prescription of Anticoagulation. J Am Heart Assoc 2018; 7:e009946. [PMID: 30371161 PMCID: PMC6201433 DOI: 10.1161/jaha.118.009946] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 07/24/2018] [Indexed: 01/24/2023]
Abstract
Background Only 50% of eligible atrial fibrillation ( AF ) patients receive anticoagulation ( AC ). Feasibility and effectiveness of electronic medical record (EMR)-based interventions to profile and raise provider AC percentage is poorly understood. The SUPPORT-AF (Supporting Use of AC Through Provider Profiling of Oral AC Therapy for AF) study aims to improve rates of adherence to AC guidelines by developing and delivering supportive tools based on the EMR to providers treating patients with AF. Methods and Results We emailed cardiologists and community-based primary care providers affiliated with our institution reports of their AC percentage relative to peers. We also sent an electronic medical record-based message to these providers the day before an appointment with an atrial fibrillation patient who was eligible but not receiving AC . The electronic medical record message asked the provider to discuss AC with the patient if he or she deemed it appropriate. To assess feasibility, we tracked provider review of our correspondence. We also tracked the change in AC for intervention providers relative to alternate primary care providers not receiving our intervention. We identified 3786, 1054, and 566 patients cared for by 49 cardiology providers, 90 community-based primary care providers, and 88 control providers, respectively. At baseline, the percentage of AC was 71.3%, 63.5%, and 58.3% for these 3 respective groups. Intervention providers reviewed our e-mails and electronic medical record messages 45% and 96% of the time, respectively. For providers responding, patient refusal was the most common reason for patients not being on AC (21%) followed by high bleeding risk (19%). At follow-up 10 weeks later, change in AC was no different for either cardiology or community-based primary care providers relative to controls (0.2% lower and 0.01% higher, respectively). Conclusions Our intervention profiling AC was feasible, but not sufficient to increase AC in our population.
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Affiliation(s)
- Alok Kapoor
- University of Massachusetts Memorial Health CareWorcesterMA
- University of Massachusetts Medical SchoolWorcesterMA
- Meyers Primary Care Institutea joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthWorcesterMA
| | - Azraa Amroze
- Meyers Primary Care Institutea joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthWorcesterMA
| | | | | | - Kevin O'Day
- University of Massachusetts Memorial Health CareWorcesterMA
| | - Rasha Elhag
- University of Massachusetts Memorial Health CareWorcesterMA
| | - Ahmed Nagy
- University of Massachusetts Memorial Health CareWorcesterMA
| | - Steve A. Lubitz
- Massachusetts General HospitalBostonMA
- Harvard Medical SchoolBostonMA
| | - Jane S. Saczynski
- University of Massachusetts Medical SchoolWorcesterMA
- Meyers Primary Care Institutea joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthWorcesterMA
- Northeastern UniversityBostonMA
| | - Jomol Mathew
- University of Massachusetts Medical SchoolWorcesterMA
| | - David D. McManus
- University of Massachusetts Memorial Health CareWorcesterMA
- University of Massachusetts Medical SchoolWorcesterMA
- Meyers Primary Care Institutea joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthWorcesterMA
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Systematic Review and Meta-analysis of the Effectiveness of Implementation Strategies for Non-communicable Disease Guidelines in Primary Health Care. J Gen Intern Med 2018; 33:1142-1154. [PMID: 29728892 PMCID: PMC6025666 DOI: 10.1007/s11606-018-4435-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 08/10/2017] [Accepted: 03/23/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND As clinical practice guidelines represent the most important evidence-based decision support tool, several strategies have been applied to improve their implementation into the primary health care system. This study aimed to evaluate the effect of intervention methods on the guideline adherence of primary care providers (PCPs). METHODS The studies selected through a systematic search in Medline and Embase were categorised according to intervention schemes and outcome indicator categories. Harvest plots and forest plots were applied to integrate results. RESULTS The 36 studies covered six intervention schemes, with single interventions being the most effective and distribution of materials the least. The harvest plot displayed 27 groups having no effect, 14 a moderate and 21 a strong effect on the outcome indicators in the categories of knowledge transfer, diagnostic behaviour, prescription, counselling and patient-level results. The forest plot revealed a moderate overall effect size of 0.22 [0.15, 0.29] where single interventions were more effective (0.27 [0.17, 0.38]) than multifaceted interventions (0.13 [0.06, 0.19]). DISCUSSION Guideline implementation strategies are heterogeneous. Reducing the complexity of strategies and tailoring to the local conditions and PCPs' needs may improve implementation and clinical practice.
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A clinical decision support tool for improving adherence to guidelines on anticoagulant therapy in patients with atrial fibrillation at risk of stroke: A cluster-randomized trial in a Swedish primary care setting (the CDS-AF study). PLoS Med 2018; 15:e1002528. [PMID: 29534063 PMCID: PMC5849292 DOI: 10.1371/journal.pmed.1002528] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is associated with substantial morbidity, in particular stroke. Despite good evidence for the reduction of stroke risk with anticoagulant therapy, there remains significant undertreatment. The main aim of the current study was to investigate whether a clinical decision support tool (CDS) for stroke prevention integrated in the electronic health record could improve adherence to guidelines for stroke prevention in patients with AF. METHODS AND FINDINGS We conducted a cluster-randomized trial where all 43 primary care clinics in the county of Östergötland, Sweden (population 444,347), were randomized to be part of the CDS intervention or to serve as controls. The CDS produced an alert for physicians responsible for patients with AF and at increased risk for thromboembolism (according to the CHA2DS2-VASc algorithm) without anticoagulant therapy. The primary endpoint was adherence to guidelines after 1 year. After randomization, there were 22 and 21 primary care clinics in the CDS and control groups, respectively. There were no significant differences in baseline adherence to guidelines regarding anticoagulant therapy between the 2 groups (CDS group 70.3% [5,186/7,370; 95% CI 62.9%-77.7%], control group 70.0% [4,187/6,009; 95% CI 60.4%-79.6%], p = 0.83). After 12 months, analysis with linear regression with adjustment for primary care clinic size and adherence to guidelines at baseline revealed a significant increase in guideline adherence in the CDS (73.0%, 95% CI 64.6%-81.4%) versus the control group (71.2%, 95% CI 60.8%-81.6%, p = 0.013, with a treatment effect estimate of 0.016 [95% CI 0.003-0.028]; number of patients with AF included in the final analysis 8,292 and 6,508 in the CDS and control group, respectively). Over the study period, there was no difference in the incidence of stroke, transient ischemic attack, or systemic thromboembolism in the CDS group versus the control group (49 [95% CI 43-55] per 1,000 patients with AF in the CDS group compared to 47 [95% CI 39-55] per 1,000 patients with AF in the control group, p = 0.64). Regarding safety, the CDS group had a lower incidence of significant bleeding, with events in 12 (95% CI 9-15) per 1,000 patients with AF compared to 16 (95% CI 12-20) per 1,000 patients with AF in the control group (p = 0.04). Limitations of the study design include that the analysis was carried out in a catchment area with a high baseline adherence rate, and issues regarding reproducibility to other regions. CONCLUSIONS The present study demonstrates that a CDS can increase guideline adherence for anticoagulant therapy in patients with AF. Even though the observed difference was small, this is the first randomized study to our knowledge indicating beneficial effects with a CDS in patients with AF. TRIAL REGISTRATION ClinicalTrials.gov NCT02635685.
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Vinson DR, Warton EM, Mark DG, Ballard DW, Reed ME, Chettipally UK, Singh N, Bouvet SZ, Kea B, Ramos PC, Glaser DS, Go AS. Thromboprophylaxis for Patients with High-risk Atrial Fibrillation and Flutter Discharged from the Emergency Department. West J Emerg Med 2018; 19:346-360. [PMID: 29560065 PMCID: PMC5851510 DOI: 10.5811/westjem.2017.9.35671] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/23/2017] [Accepted: 09/05/2017] [Indexed: 12/18/2022] Open
Abstract
Introduction Many patients with atrial fibrillation or atrial flutter (AF/FL) who are high risk for ischemic stroke are not receiving evidence-based thromboprophylaxis. We examined anticoagulant prescribing within 30 days of receiving dysrhythmia care for non-valvular AF/FL in the emergency department (ED). Methods This prospective study included non-anticoagulated adults at high risk for ischemic stroke (ATRIA score ≥7) who received emergency AF/FL care and were discharged home from seven community EDs between May 2011 and August 2012. We characterized oral anticoagulant prescribing patterns and identified predictors of receiving anticoagulants within 30 days of the index ED visit. We also describe documented reasons for withholding anticoagulation. Results Of 312 eligible patients, 128 (41.0%) were prescribed anticoagulation at ED discharge or within 30 days. Independent predictors of anticoagulation included age (adjusted odds ratio [aOR] 0.89 per year, 95% confidence interval [CI] 0.82–0.96); ED cardiology consultation (aOR 1.89, 95% CI [1.10–3.23]); and failure of sinus restoration by time of ED discharge (aOR 2.65, 95% CI [1.35–5.21]). Reasons for withholding anticoagulation at ED discharge were documented in 139 of 227 cases (61.2%), the most common of which were deferring the shared decision-making process to the patient’s outpatient provider, perceived bleeding risk, patient refusal, and restoration of sinus rhythm. Conclusion Approximately 40% of non-anticoagulated AF/FL patients at high risk for stroke who presented for emergency dysrhythmia care were prescribed anticoagulation within 30 days. Physicians were less likely to anticoagulate older patients and those with ED sinus restoration. Opportunities exist to improve rates of thromboprophylaxis in this high-risk population.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente, Division of Research, Oakland, California.,Kaiser Permanente Sacramento Medical Center, Department of Emergency Medicine, Sacramento, California
| | | | - Dustin G Mark
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente, Division of Research, Oakland, California.,Kaiser Permanente Oakland Medical Center, Department of Emergency Medicine, Oakland, California
| | - Dustin W Ballard
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente, Division of Research, Oakland, California.,Kaiser Permanente San Rafael Medical Center, Department of Emergency Medicine, San Rafael, California
| | - Mary E Reed
- Kaiser Permanente, Division of Research, Oakland, California
| | - Uli K Chettipally
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente South San Francisco Medical Center, Department of Emergency Medicine, San Francisco, California
| | - Nimmie Singh
- Mercy Redding Family Practice Residency Program, Redding, California
| | - Sean Z Bouvet
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente Walnut Creek Medical Center, Department of Emergency Medicine, Walnut Creek, California
| | - Bory Kea
- Oregon Health and Science University, Department of Emergency Medicine, Portland, Oregon
| | - Patricia C Ramos
- Kaiser Permanente Sunnyside Medical Center, Northwest Permanente Physicians and Surgeons, Department of Emergency Medicine, Portland, Oregon
| | - David S Glaser
- Sisters of Charity of Leavenworth St. Joseph Hospital, Department of Emergency Medicine, Denver, Colorado
| | - Alan S Go
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente, Division of Research, Oakland, California.,University of California, San Francisco, Departments of Epidemiology, Biostatistics, and Medicine, San Francisco, California.,Stanford University School of Medicine, Department of Health Research and Policy, Palo Alto, California
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Sheibani R, Sheibani M, Heidari-Bakavoli A, Abu-Hanna A, Eslami S. The Effect of a Clinical Decision Support System on Improving Adherence to Guideline in the Treatment of Atrial Fibrillation: An Interrupted Time Series Study. J Med Syst 2017; 42:26. [PMID: 29273997 DOI: 10.1007/s10916-017-0881-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 12/13/2017] [Indexed: 11/26/2022]
Abstract
To evaluate the effect of a computerized Decision Support System (CDSS) on improving adherence to an anticoagulation guideline for the treatment of atrial fibrillation (AF). This study had an interrupted time series design. The adherence to the guideline was assessed at fortnightly (two weeks) intervals from January 2016 to January 2017, 6 months before and 6 months after intervention. Newly diagnosed patients with AF were included in the offices of ten cardiologists. Stroke and major bleeding risks were calculated by the CDSS which was implemented via a mobile application. Treatment recommendations based on the guideline were shown to cardiologists. The segmented regression model was used to evaluate the effect of CDSS on level and trend of guideline adherence for the treatment of AF. In our analysis, 373 patients were included. The trend of adherence to the anticoagulation guideline for the treatment of AF was stable in the pre-intervention phase. After the CDSS intervention, mean of the adherence to the guideline significantly increased from 48% to 65.5% (P-value < 0.0001). The trend of adherence to the guideline was stable in the post-intervention phase. Our results showed that the CDSS can improve adherence to the anticoagulation guideline for the treatment of AF. Registration ID: IRCT2016052528070N1.
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Affiliation(s)
- Reza Sheibani
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Computer Engineering, Mashhad Branch, Islamic Azad University, Mashhad, Iran
| | - Mehdi Sheibani
- Cardiovascular Research Center, Shahid Beheshti University of Medical Science, Tehran, Iran
| | | | - Ameen Abu-Hanna
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Saeid Eslami
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
- Pharmaceutical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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Danahey K, Borden BA, Furner B, Yukman P, Hussain S, Saner D, Volchenboum SL, Ratain MJ, O'Donnell PH. Simplifying the use of pharmacogenomics in clinical practice: Building the genomic prescribing system. J Biomed Inform 2017; 75:110-121. [PMID: 28963061 DOI: 10.1016/j.jbi.2017.09.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 09/21/2017] [Accepted: 09/25/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND A barrier to the use of genomic information during prescribing is the limited number of software solutions that combine a user-friendly interface with complex medical data. We built and designed an online, secure, electronic custom interface termed the Genomic Prescribing System (GPS). METHODS Actionable pharmacogenomic (PGx) information was reviewed, collected, and stored in the back-end of GPS to enable creation of customized drug- and variant-specific clinical decision support (CDS) summaries. The database architecture utilized the star schema to store information. Patient raw genomic data underwent transformation via custom-designed algorithms to enable gene and phenotype-level associations. Multiple external data sets (PubMed, The Systematized Nomenclature of Medicine (SNOMED), National Drug File - Reference Terminology (ND-FRT), and a publically-available PGx knowledgebase) were integrated to facilitate the delivery of patient, drug, disease, and genomic information. Institutional security infrastructure was leveraged to securely store patient genomic and clinical data on a HIPAA-compliant server farm. RESULTS As of May 17, 2016, the GPS back-end housed 257 CDS encompassing 112 genetic variants, 42 genes, and 46 PGx-actionable drugs. The GPS user interface presented patient-specific CDS alongside a recognizable traffic light symbol (green/yellow/red), denoting PGx risk for each genomic result. The number of traffic lights per visit increased with the corresponding increase in the number of available PGx-annotated drugs over time. An integrated drug and disease search functionality, links to primary literature sources, and potential alternative PGx drugs were indicated. The system, which was initially used as stand-alone CDS software within our clinical environment, was then integrated with the institutional electronic medical record for enhanced usability. There have been nearly 2000 logins in 43months since inception, with usage exceeding 56 logins per month and system up-times of 99.99%. For all patient-provider visits encompassing >3years of implementation, unique alert click-through rates corresponded to genomic risk: red lights clicked 100%, yellow lights 79%, green lights 43%. CONCLUSIONS Successful deployment of GPS by combining complex data and recognizable iconography led to a tool that enabled point-of-care genomic delivery with high usability. Continued scalability and incorporation of additional clinical elements to be considered alongside PGx information could expand future impact.
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Affiliation(s)
- Keith Danahey
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA; Center for Research Informatics, University of Chicago, Chicago, IL, USA
| | - Brittany A Borden
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA
| | - Brian Furner
- Center for Research Informatics, University of Chicago, Chicago, IL, USA
| | - Patrick Yukman
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA; Center for Research Informatics, University of Chicago, Chicago, IL, USA
| | - Sheena Hussain
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA
| | - Donald Saner
- Center for Research Informatics, University of Chicago, Chicago, IL, USA
| | - Samuel L Volchenboum
- Center for Research Informatics, University of Chicago, Chicago, IL, USA; Department of Pediatrics, University of Chicago, Chicago, IL, USA
| | - Mark J Ratain
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA; Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Peter H O'Donnell
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA; Department of Medicine, University of Chicago, Chicago, IL, USA.
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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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