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Song J, Wang X, Wang B, Ge Y, Bi L, Jing F, Jin H, Li T, Gu B, Wang L, Hao J, Zhao Y, Liu J, Zhang H, Li X, Li J, Ma W, Wang J, Normand SLT, Herrin J, Armitage J, Krumholz HM, Zheng X. Learning implementation of a guideline based decision support system to improve hypertension treatment in primary care in China: pragmatic cluster randomised controlled trial. BMJ 2024; 386:e079143. [PMID: 39043397 PMCID: PMC11265211 DOI: 10.1136/bmj-2023-079143] [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] [Accepted: 06/10/2024] [Indexed: 07/25/2024]
Abstract
OBJECTIVE To evaluate the effectiveness of a clinical decision support system (CDSS) in improving the use of guideline accordant antihypertensive treatment in primary care settings in China. DESIGN Pragmatic, open label, cluster randomised trial. SETTING 94 primary care practices in four urban regions of China between August 2019 and July 2022: Luoyang (central China), Jining (east China), and Shenzhen (south China, including two regions). PARTICIPANTS 94 practices were randomised (46 to CDSS, 48 to usual care). 12 137 participants with hypertension who used up to two classes of antihypertensives and had a systolic blood pressure <180 mm Hg and diastolic blood pressure <110 mm Hg were included. INTERVENTIONS Primary care practices were randomised to use an electronic health record based CDSS, which recommended a specific guideline accordant regimen for initiation, titration, or switching of antihypertensive (the intervention), or to use the same electronic health record without CDSS and provide treatment as usual (control). MAIN OUTCOME MEASURES The primary outcome was the proportion of hypertension related visits during which an appropriate (guideline accordant) treatment was provided. Secondary outcomes were the average reduction in systolic blood pressure and proportion of participants with controlled blood pressure (<140/90 mm Hg) at the last scheduled follow-up. Safety outcomes were patient reported antihypertensive treatment related events, including syncope, injurious fall, symptomatic hypotension or systolic blood pressure <90 mm Hg, and bradycardia. RESULTS 5755 participants with 23 113 visits in the intervention group and 6382 participants with 27 868 visits in the control group were included. Mean age was 61 (standard deviation 13) years and 42.5% were women. During a median 11.6 months of follow-up, the proportion of visits at which appropriate treatment was given was higher in the intervention group than in the control group (77.8% (17 975/23 113) v 62.2% (17 328/27 868); absolute difference 15.2 percentage points (95% confidence interval (CI) 10.7 to 19.8); P<0.001; odds ratio 2.17 (95% CI 1.75 to 2.69); P<0.001). Compared with participants in the control group, those in the intervention group had a 1.6 mm Hg (95% CI -2.7 to -0.5) greater reduction in systolic blood pressure (-1.5 mm Hg v 0.3 mm Hg; P=0.006) and a 4.4 percentage point (95% CI -0.7 to 9.5) improvement in blood pressure control rate (69.0% (3415/4952) v 64.6% (3778/5845); P=0.07). Patient reported antihypertensive treatment related adverse effects were rare in both groups. CONCLUSIONS Use of a CDSS in primary care in China improved the provision of guideline accordant antihypertensive treatment and led to a modest reduction in blood pressure. The CDSS offers a promising approach to delivering better care for hypertension, both safely and efficiently. TRIAL REGISTRATION ClinicalTrials.gov NCT03636334.
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Affiliation(s)
- Jiali Song
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Xiuling Wang
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Bin Wang
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Yilan Ge
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Lei Bi
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Fuyu Jing
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Huijun Jin
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Teng Li
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Bo Gu
- National Clinical Research Centre for Cardiovascular Diseases, Shenzhen, Fuwai Shenzhen Hospital, Chinese Academy of Medical Sciences, Shenzhen, China
| | - Lili Wang
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Jun Hao
- Medical Research and Biometrics Centre, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanyan Zhao
- Medical Research and Biometrics Centre, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiamin Liu
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Haibo Zhang
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Xi Li
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
- National Clinical Research Centre for Cardiovascular Diseases, Shenzhen, Fuwai Shenzhen Hospital, Chinese Academy of Medical Sciences, Shenzhen, China
| | - Jing Li
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Wenjun Ma
- Hypertension Centre, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Jiguang Wang
- The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Sharon-Lise T Normand
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jane Armitage
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Centre for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Xin Zheng
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
- National Clinical Research Centre for Cardiovascular Diseases, Shenzhen, Fuwai Shenzhen Hospital, Chinese Academy of Medical Sciences, Shenzhen, China
- Coronary Artery Disease Ward 2, Fuwai Shenzhen Hospital, Chinese Academy of Medical Sciences, Shenzhen, China
- Clinical Trial Centre, Fuwai Shenzhen Hospital, Chinese Academy of Medical Sciences, Shenzhen, China
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Ashcraft LE, Goodrich DE, Hero J, Phares A, Bachrach RL, Quinn DA, Qureshi N, Ernecoff NC, Lederer LG, Scheunemann LP, Rogal SS, Chinman MJ. A systematic review of experimentally tested implementation strategies across health and human service settings: evidence from 2010-2022. Implement Sci 2024; 19:43. [PMID: 38915102 PMCID: PMC11194895 DOI: 10.1186/s13012-024-01369-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 05/27/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Studies of implementation strategies range in rigor, design, and evaluated outcomes, presenting interpretation challenges for practitioners and researchers. This systematic review aimed to describe the body of research evidence testing implementation strategies across diverse settings and domains, using the Expert Recommendations for Implementing Change (ERIC) taxonomy to classify strategies and the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) framework to classify outcomes. METHODS We conducted a systematic review of studies examining implementation strategies from 2010-2022 and registered with PROSPERO (CRD42021235592). We searched databases using terms "implementation strategy", "intervention", "bundle", "support", and their variants. We also solicited study recommendations from implementation science experts and mined existing systematic reviews. We included studies that quantitatively assessed the impact of at least one implementation strategy to improve health or health care using an outcome that could be mapped to the five evaluation dimensions of RE-AIM. Only studies meeting prespecified methodologic standards were included. We described the characteristics of studies and frequency of implementation strategy use across study arms. We also examined common strategy pairings and cooccurrence with significant outcomes. FINDINGS Our search resulted in 16,605 studies; 129 met inclusion criteria. Studies tested an average of 6.73 strategies (0-20 range). The most assessed outcomes were Effectiveness (n=82; 64%) and Implementation (n=73; 56%). The implementation strategies most frequently occurring in the experimental arm were Distribute Educational Materials (n=99), Conduct Educational Meetings (n=96), Audit and Provide Feedback (n=76), and External Facilitation (n=59). These strategies were often used in combination. Nineteen implementation strategies were frequently tested and associated with significantly improved outcomes. However, many strategies were not tested sufficiently to draw conclusions. CONCLUSION This review of 129 methodologically rigorous studies built upon prior implementation science data syntheses to identify implementation strategies that had been experimentally tested and summarized their impact on outcomes across diverse outcomes and clinical settings. We present recommendations for improving future similar efforts.
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Affiliation(s)
- Laura Ellen Ashcraft
- Center for Health Equity Research and Promotion, Corporal Michael Crescenz VA Medical Center, Philadelphia, PA, USA.
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - David E Goodrich
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Clinical & Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Angela Phares
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Rachel L Bachrach
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Deirdre A Quinn
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Lisa G Lederer
- Clinical & Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leslie Page Scheunemann
- Division of Geriatric Medicine, University of Pittsburgh, Department of Medicine, Pittsburgh, PA, USA
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Pittsburgh, Department of Medicine, Pittsburgh, PA, USA
| | - Shari S Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Departments of Medicine and Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew J Chinman
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- RAND Corporation, Pittsburgh, PA, USA
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3
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Beal EW, McNamara M, Owen M, McAlearney AS, Tsung A. Interventions to Improve Surveillance for Hepatocellular Carcinoma in High-Risk Patients: A Scoping Review. J Gastrointest Cancer 2024; 55:1-14. [PMID: 37328730 DOI: 10.1007/s12029-023-00944-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/18/2023]
Abstract
PURPOSE Hepatocellular carcinoma (HCC) is most often a sequela of chronic liver disease or chronic hepatitis B infection. Among high-risk patients, surveillance for HCC every 6 months is recommended by international guidelines. However, rates of HCC surveillance are suboptimal (11-64%). Barriers at the patient, provider, and healthcare delivery system levels have been identified. METHODS We performed a systemic scoping review to identify and characterize interventions to improve HCC surveillance that has previously been evaluated. Searches using key terms in PubMed and Embase were performed to identify studies examining interventions designed to improve the surveillance rate for HCC in patients with cirrhosis or chronic liver disease that were published in English between January 1990 and September 2021. RESULTS Included studies (14) had the following study designs: (1) randomized clinical trials (3, 21.4%), (2) quasi-experimental (2, 14.3%), (3) prospective cohort (6, 42.8%), and (4) retrospective cohort (3, 21.4%). Interventions included mailed outreach invitations, nursing outreach, patient education with or without printed materials, provider education, patient navigation, chronic disease management programs, nursing-led protocols for image ordering, automated reminders to physicians and nurses, web-based clinical management tools, HCC surveillance databases, provider compliance reports, radiology-led surveillance programs, subsidized HCC surveillance, and the use of oral medications. It was found that HCC surveillance rates increased after intervention implementation in all studies. CONCLUSION Despite improvements in HCC surveillance rates with intervention, compliance remained suboptimal. Further analysis of which interventions yield the greatest increases in HCC surveillance, design of multi-pronged strategies, and improved implementation are needed.
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Affiliation(s)
- Eliza W Beal
- Departments of Surgery and Oncology, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, 4100 John R, Mailcode: HW04HO, Detroit, MI, 48201, USA.
| | - Molly McNamara
- The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | - Mackenzie Owen
- The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | - Ann Scheck McAlearney
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), The Ohio State University College of Medicine, Columbus, OH, 43210, USA
- Department of Family and Community Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, University of Virginia, Charlottsville, VA, 22908, USA
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Cornell S, Doust J, Morgan M, Greaves K, Hawkes AL, de Wet C, O'Connor D, Bonner C. Implementing patient decision aids into general practice clinical decision support systems: Feasibility study in cardiovascular disease prevention. PEC INNOVATION 2023; 2:100140. [PMID: 37214489 PMCID: PMC10194094 DOI: 10.1016/j.pecinn.2023.100140] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 02/18/2023] [Accepted: 02/18/2023] [Indexed: 05/24/2023]
Abstract
Objective Patient decision aids (DA) facilitate shared decision making, but implementation remains a challenge. This study tested the feasibility of integrating a cardiovascular disease (CVD) prevention DA into general practice software. Methods We developed a desktop computer application (app) to auto-populate a CVD prevention DA from general practice medical records. 4 practices received monthly practice reports from July-Nov 2021, and 2 practices use the app with limited engagement. CVD risk assessment data and app use were monitored. Results The proportion of eligible patients with complete CVD risk assessment data ranged from 59 to 94%. Monthly app use ranged from 0 to 285 sessions by 13 individual practice staff including GPs and nurses, with staff using the app an average of 67 sessions during the study period. High users in the 5-month study period continued to use the app for 10 months. Low use was attributed to reduced staff capacity during COVID-19 and technical issues. Conclusion High users sustained interest in the app, but additional strategies are required for low users. The study will inform implementation plans for new guidelines. Innovation This study showed it is feasible to integrate patient decision aids with Australian general practice software, despite the challenges of COVID-19 at the time of the study.
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Affiliation(s)
- Samuel Cornell
- Faculty of Medicine and Health, School of Public Health, University of Sydney, New South Wales, Australia
| | - Jenny Doust
- Australian Women and Girls' Health Research (AWaGHR) Centre, School of Public Health, Faculty of Medicine, University of Queensland, Queensland, Australia
| | - Mark Morgan
- Faculty of Health Sciences & Medicine, Bond University, Queensland, Australia
| | - Kim Greaves
- Department of Cardiology, Sunshine Coast University Hospital, University of the Sunshine Coast, Queensland, Australia
| | | | - Carl de Wet
- Gold Coast Hospital and Health Service, Queensland, Australia
| | - Denise O'Connor
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Victoria, Australia
| | - Carissa Bonner
- Faculty of Medicine and Health, School of Public Health, University of Sydney, New South Wales, Australia
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Luu A, Bui NA, Adeola M, Bhakta S, Fuentes A, Agarwal K. Impact of a passive clinical decision support tool on potentially inappropriate medications (PIM) use in older adult patients. J Am Geriatr Soc 2023; 71:3584-3594. [PMID: 37706219 DOI: 10.1111/jgs.18586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/19/2023] [Accepted: 08/15/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Medication related clinical decision support (CDS) interventions may improve patient safety. In older patient populations, there has been effort placed in reducing exposure to potentially inappropriate medications (PIMs). After years of reducing exposure of older adults in our hospitals to PIMs through multi-component interventions, our system chose to expand the scope and attempt a new strategy to lessen alert burden for providers and pharmacists. Based on the American Geriatric Society Beers Criteria and internal data, a passive CDS approach, termed "geriatric context" was established to recommend appropriate medication selection including lower dosage amounts and frequency of administration in older adults. METHODS Retrospective descriptive study examining change in a pre and post implementation analysis of medication usage patterns between two 9-month time periods in 2019 and 2021 in patients age ≥65 years across an 8-hospital health system. The primary endpoint is the percentage of each medication intervened with an ordered dose and frequency outside of alignment with recommended context parameters. Secondary endpoints include total daily dose (TDD) and average dose (AD) per patient of the individual PIMs. Exploratory endpoints include frequency of active alerts fired by the CPOE and overridden by providers. RESULTS A total of 62,738 older adult hospital admissions are included in the overall study period, with 32,969 pre-implementation and 29,769 post-implementation. Haloperidol showed the greatest reduction in inappropriate doses from 41.5% to 21.4% (p < 0.001) of orders, followed by reduction in inappropriate frequencies in orders for diphenhydramine from 57.2% to 39.7% (p < 0.001). Secondary endpoints showed favorable reductions across 11 of the 16 medications in both TDD and AD administered. Exploratory analysis with select medications showed reductions in frequency of alerts fired and overridden. CONCLUSIONS Utilization of a passive CDS positively influences prescribing patterns for older adults and reduces the alert burden to ordering providers.
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Affiliation(s)
- Alan Luu
- Department of Pharmacy Services, Houston Methodist Hospital, Houston, Texas, USA
- Department of Pharmacy Practice, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Nghi Andy Bui
- Department of Pharmacy Services, Houston Methodist Hospital, Houston, Texas, USA
| | - Mobolaji Adeola
- Department of Pharmacy Services, Houston Methodist Hospital, Houston, Texas, USA
| | - Sunny Bhakta
- Department of Pharmacy Services, Houston Methodist Hospital, Houston, Texas, USA
| | - Amaris Fuentes
- System Quality and Patient Safety, Houston Methodist, Houston, Texas, USA
| | - Kathryn Agarwal
- System Quality and Patient Safety, Houston Methodist, Houston, Texas, USA
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Ngai D, Kotamraju S, Do P, Luffy R, Winser-Bean C, Rockwell J, Hollaway L, Wright V, Barlow S, Sathe M. Standardizing and optimizing nutrition evaluation frequency of enterally fed patients in an ambulatory pediatric gastroenterology practice: A single-center study. Nutr Clin Pract 2023; 38:863-870. [PMID: 36453522 DOI: 10.1002/ncp.10939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/01/2022] [Accepted: 11/05/2022] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Nutrition monitoring is essential in feeding tube-dependent patients receiving home enteral nutrition (HEN). We identified lack of consistency in dietitian evaluations for our pediatric patients receiving HEN. Consequently, after establishing an institutional standard for nutrition reassessment intervals, we underwent a quality improvement (QI) initiative to improve rates of adherence to standard frequency of dietitian consults and referrals among patients receiving HEN. METHODS A prospective QI initiative from April 2021 to December 2021 was performed using multiple plan-do-study-act (PDSA) cycles. Interventions included (1) a reminder placard, (2) the display of feeding tube status and date of the last dietitian note in the electronic health record (EHR) clinic schedule dashboard, and (3) an autotext smart element to the EHR default clinic note template. The goal was to enable clinicians to quickly identify the need for nutrition evaluation with either a same-day dietitian consult or a referral to nutrition clinic. RESULTS Among 111 HEN patients with >6 months since last nutrition encounter, the dietitian referral/consult rate prior to any interventions was 58%. The placard (PDSA 1) was abandoned before obtaining reportable data because of sampling bias and clinic workflow inefficiencies. The clinic schedule dashboard modification (PDSA 2) improved the dietitian referral/consult rate to 66%. Subsequently, the clinic note smart element (PDSA 3) increased the rate to 77%. An 8-week postintervention check revealed a compliance rate of 78%. CONCLUSION Implementation of minimally interruptive EHR enhancements showed a sustained increase in dietitian referrals and consults for patients receiving HEN, which may improve nutrition outcomes.
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Affiliation(s)
- Derek Ngai
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern, Dallas, Texas, USA
- Children's Medical Center, Dallas, Texas, USA
| | - Swetha Kotamraju
- Children's Medical Center, Dallas, Texas, USA
- Department of Pediatrics, University of Texas Southwestern, Dallas, Texas, USA
| | - Phinga Do
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern, Dallas, Texas, USA
- Children's Medical Center, Dallas, Texas, USA
| | - Robin Luffy
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern, Dallas, Texas, USA
- Children's Medical Center, Dallas, Texas, USA
| | - Christine Winser-Bean
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern, Dallas, Texas, USA
- Children's Medical Center, Dallas, Texas, USA
| | - Jill Rockwell
- Department of Pediatric Clinical Nutrition, Children's Medical Center, Dallas, Texas, USA
| | - Lauren Hollaway
- Department of Pediatric Clinical Nutrition, Children's Medical Center, Dallas, Texas, USA
| | - Victoria Wright
- Quality and Patient Safety, Clinical Quality Improvement Consultant, Children's Medical Center, Dallas, Texas, USA
| | - Sarah Barlow
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern, Dallas, Texas, USA
- Children's Medical Center, Dallas, Texas, USA
| | - Meghana Sathe
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern, Dallas, Texas, USA
- Children's Medical Center, Dallas, Texas, USA
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Rottman BM, Caddick ZA, Nokes-Malach TJ, Fraundorf SH. Cognitive perspectives on maintaining physicians' medical expertise: I. Reimagining Maintenance of Certification to promote lifelong learning. Cogn Res Princ Implic 2023; 8:46. [PMID: 37486508 PMCID: PMC10366070 DOI: 10.1186/s41235-023-00496-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/20/2023] [Indexed: 07/25/2023] Open
Abstract
Until recently, physicians in the USA who were board-certified in a specialty needed to take a summative test every 6-10 years. However, the 24 Member Boards of the American Board of Medical Specialties are in the process of switching toward much more frequent assessments, which we refer to as longitudinal assessment. The goal of longitudinal assessments is to provide formative feedback to physicians to help them learn content they do not know as well as serve an evaluation for board certification. We present five articles collectively covering the science behind this change, the likely outcomes, and some open questions. This initial article introduces the context behind this change. This article also discusses various forms of lifelong learning opportunities that can help physicians stay current, including longitudinal assessment, and the pros and cons of each.
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Affiliation(s)
- Benjamin M Rottman
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA
- Department of Psychology, University of Pittsburgh, Pittsburgh, USA
| | - Zachary A Caddick
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA
- Department of Psychology, University of Pittsburgh, Pittsburgh, USA
| | - Timothy J Nokes-Malach
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA
- Department of Psychology, University of Pittsburgh, Pittsburgh, USA
| | - Scott H Fraundorf
- Learning Research and Development Center, University of Pittsburgh, 3420 Forbes Ave., Pittsburgh, PA, 15260, USA.
- Department of Psychology, University of Pittsburgh, Pittsburgh, USA.
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Sepucha K, Han PKJ, Chang Y, Atlas SJ, Korsen N, Leavitt L, Lee V, Percac-Lima S, Mancini B, Richter J, Scharnetzki E, Siegel LC, Valentine KD, Fairfield KM, Simmons LH. Promoting Informed Decisions About Colorectal Cancer Screening in Older Adults (PRIMED Study): a Physician Cluster Randomized Trial. J Gen Intern Med 2023; 38:406-413. [PMID: 35931908 PMCID: PMC9362387 DOI: 10.1007/s11606-022-07738-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 07/01/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND For adults aged 76-85, guidelines recommend individualizing decision-making about whether to continue colorectal cancer (CRC) testing. These conversations can be challenging as they need to consider a patient's CRC risk, life expectancy, and preferences. OBJECTIVE To promote shared decision-making (SDM) for CRC testing decisions for older adults. DESIGN Two-arm, multi-site cluster randomized trial, assigning physicians to Intervention and Comparator arms. Patients were surveyed shortly after the visit to assess outcomes. Analyses were intention-to-treat. PARTICIPANTS AND SETTING Primary care physicians affiliated with 5 academic and community hospital networks and their patients aged 76-85 who were due for CRC testing and had a visit during the study period. INTERVENTIONS Intervention arm physicians completed a 2-h online course in SDM communication skills and received an electronic reminder of patients eligible for CRC testing shortly before the visit. Comparator arm received reminders only. MAIN MEASURES The primary outcome was patient-reported SDM Process score (range 0-4 with higher scores indicating more SDM); secondary outcomes included patient-reported discussion of CRC screening, knowledge, intention, and satisfaction with the visit. KEY RESULTS Sixty-seven physicians (Intervention n=34 and Comparator n=33) enrolled. Patient participants (n=466) were on average 79 years old, 50% with excellent or very good self-rated overall health, and 66% had one or more prior colonoscopies. Patients in the Intervention arm had higher SDM Process scores (adjusted mean difference 0.36 (95%CI (0.08, 0.64), p=0.01) than in the Comparator arm. More patients in the Intervention arm reported discussing CRC screening during the visit (72% vs. 60%, p=0.03) and had higher intention to follow through with their preferred approach (58.0% vs. 47.1, p=0.03). Knowledge scores and visit satisfaction did not differ significantly between arms. CONCLUSION Physician training plus reminders were effective in increasing SDM and frequency of CRC testing discussions in an age group where SDM is essential. TRIAL REGISTRATION The trial is registered on clinicaltrials.gov (NCT03959696).
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Affiliation(s)
- Karen Sepucha
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Paul K J Han
- Center for Interdisciplinary Population and Health Research, Maine Medical Center, Portland, ME, USA
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, USA
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Steven J Atlas
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Neil Korsen
- Center for Interdisciplinary Population and Health Research, Maine Medical Center, Portland, ME, USA
| | - Lauren Leavitt
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
| | - Vivian Lee
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
| | - Sanja Percac-Lima
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Brittney Mancini
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
| | - James Richter
- Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth Scharnetzki
- Center for Interdisciplinary Population and Health Research, Maine Medical Center, Portland, ME, USA
| | - Lydia C Siegel
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - K D Valentine
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kathleen M Fairfield
- Center for Interdisciplinary Population and Health Research, Maine Medical Center, Portland, ME, USA
| | - Leigh H Simmons
- Division of General Internal Medicine, Massachusetts General Hospital Health Decision Sciences Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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9
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Sustainability of a Multifaceted Intervention to Improve Surrogate Decision Maker Documentation for Hospitalized Adults. Am J Med Qual 2022; 37:495-503. [PMID: 36149834 DOI: 10.1097/jmq.0000000000000081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Documenting surrogate decision makers (SDMs) is an important step in advance care planning (ACP) for hospitalized adults. The authors performed a quality improvement study of clinical and electronic health record (EHR) workflows aiming to increase SDM documentation for hospitalized adults. The intervention included an ACP education module, audit and feedback, as well as workflow and EHR adaptations. The authors prospectively tracked SDM documentation using control charts and used chart review to assess secondary outcome, process, and balancing measures. SDM documentation significantly increased from 69.5% to 80.2% ( P < 0.001) for intervention patients, sustained over 3 years, and was unchanged for control patients (34.6% to 36.3%; P = 0.355). There were no significant differences in secondary ACP outcomes in intervention or control patients. Clinical and EHR adaptations increased SDM documentation for hospitalized adults with minimal risk, although did not affect other ACP metrics. Future studies are needed to determine the effects of such changes on goal-concordant care.
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10
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Bartels CM, Johnson L, Ramly E, Panyard DJ, Gilmore-Bykovskyi A, Johnson HM, McBride P, Li Z, Sampene E, Lauver DR, Lewicki K, Piper ME. Impact of a Rheumatology Clinic Protocol on Tobacco Cessation Quit Line Referrals. Arthritis Care Res (Hoboken) 2022; 74:1421-1429. [PMID: 33825349 PMCID: PMC8492788 DOI: 10.1002/acr.24589] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 12/23/2020] [Accepted: 03/02/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Smoking increases cardiopulmonary and rheumatic disease risk, yet tobacco cessation intervention is rare in rheumatology clinics. This study aimed to implement a rheumatology staff-driven protocol, Quit Connect, to increase the rate of electronic referrals (e-referrals) to free, state-run tobacco quit lines. METHODS We conducted a quasi-experimental cohort study of Quit Connect at 3 rheumatology clinics comparing tobacco quit line referrals from 4 baseline years to referrals during a 6-month intervention period. Nurses and medical assistants were trained to use 2 standardized electronic health record (EHR) prompts to check readiness to quit smoking within 30 days, advise cessation, and connect patients using tobacco quit line e-referral orders. Our objective was to use EHR data to examine the primary outcome of tobacco quit line referrals using pre/post design. RESULTS Across 54,090 pre- and post-protocol rheumatology clinic visits, 4,601 were with current smokers. We compared outcomes between 4,078 eligible pre-implementation visits and 523 intervention period visits. Post-implementation, the odds of tobacco quit line referral were 26-fold higher compared to our pre-implementation rate (unadjusted odds ratio [OR] 26 [95% confidence interval (95% CI) 6-106]). Adjusted odds of checking readiness to quit in the next 30 days increased over 100-fold compared to pre-implementation (adjusted OR 132 [95% CI 99-177]). Intervention led to e-referrals for 71% of quit-ready patients in <90 seconds; 24% of referred patients reported a quit attempt. CONCLUSION Implementing Quit Connect in rheumatology clinics was feasible and improved referrals to a state-run tobacco quit line. Given the importance of smoking cessation to reduce cardiopulmonary and rheumatic disease risk, future studies should investigate disseminating cessation protocols like Quit Connect that leverage tobacco quit lines.
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Affiliation(s)
| | - Lauren Johnson
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Edmond Ramly
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Daniel J Panyard
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Heather M Johnson
- Charles E. Schmidt College of Medicine, Florida Atlantic University and Boca Raton Regional Hospital/Baptist Health South Florida, Boca Raton
| | - Patrick McBride
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Zhanhai Li
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Emmanuel Sampene
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Kristin Lewicki
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Megan E Piper
- University of Wisconsin School of Medicine and Public Health, Madison
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11
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Molloy M, Hagedorn P, Dewan M. Why Does Current Clinical Decision Support Frequently Fail to Support Clinical Decisions? Pediatr Crit Care Med 2022; 23:670-672. [PMID: 36165945 PMCID: PMC9523478 DOI: 10.1097/pcc.0000000000003000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Matthew Molloy
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Philip Hagedorn
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Maya Dewan
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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12
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Abstract
OBJECTIVES To assess the current landscape of clinical decision support (CDS) tools in PICUs in order to identify priority areas of focus in this field. DESIGN International, quantitative, cross-sectional survey. SETTING Role-specific, web-based survey administered in November and December 2020. SUBJECTS Medical directors, bedside nurses, attending physicians, and residents/advanced practice providers at Pediatric Acute Lung Injury and Sepsis Network-affiliated PICUs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The survey was completed by 109 respondents from 45 institutions, primarily attending physicians from university-affiliated PICUs in the United States. The most commonly used CDS tools were people-based resources (93% used always or most of the time) and laboratory result highlighting (86%), with order sets, order-based alerts, and other electronic CDS tools also used frequently. The most important goal providers endorsed for CDS tools were a proven impact on patient safety and an evidence base for their use. Negative perceptions of CDS included concerns about diminished critical thinking and the burden of intrusive processes on providers. Routine assessment of existing CDS was rare, with infrequent reported use of observation to assess CDS impact on workflows or measures of individual alert burden. CONCLUSIONS Although providers share some consensus over CDS utility, we identified specific priority areas of research focus. Consensus across practitioners exists around the importance of evidence-based CDS tools having a proven impact on patient safety. Despite broad presence of CDS tools in PICUs, practitioners continue to view them as intrusive and with concern for diminished critical thinking. Deimplementing ineffective CDS may mitigate this burden, though postimplementation evaluation of CDS is rare.
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13
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Song J, Wang X, Wang B, Gao Y, Liu J, Zhang H, Li X, Li J, Wang JG, Cai J, Herrin J, Armitage J, Krumholz HM, Zheng X. Effectiveness of a clinical decision support system for hypertension management in primary care: study protocol for a pragmatic cluster-randomized controlled trial. Trials 2022; 23:412. [PMID: 35578345 PMCID: PMC9109449 DOI: 10.1186/s13063-022-06374-x] [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: 06/27/2021] [Accepted: 04/29/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Clinical decision support systems (CDSS) are low-cost, scalable tools with the potential to improve guideline-based antihypertensive treatment in primary care, but their effectiveness needs to be tested, especially in low- and middle-income countries such as China. METHODS The Learning Implementation of Guideline-based decision support system for Hypertension Treatment (LIGHT) trial is a pragmatic, four-stage, cluster-randomized trial conducted in 94 primary care sites in China. For each city-based stage, sites are randomly assigned to either implementation of the CDSS for hypertension management (which guides doctors' treatment recommendations based on measured blood pressure and patient characteristics), or usual care. Patients are enrolled during the first 3 months after site randomization and followed for 9 months. The primary outcome is the proportion of hypertension management visits at which guideline-based treatment is provided. In a nested trial conducted within the CDSS, with the patient as the unit of randomization, the LIGHT-ACD trial, patients are randomized to receive different initial mono- or dual-antihypertensive therapy. The primary outcome of the LIGHT-ACD trial is the changes in blood pressure. DISCUSSION The LIGHT trial will provide evidence on the effectiveness of a CDSS for improving guideline adherence for hypertension management in primary care in China. The nested trial, the LIGHT-ACD trial, will provide data on the effect of different initial antihypertensive regimens for blood pressure management in this setting. TRIAL REGISTRATION ClinicalTrials.gov, identifier: LIGHT (NCT03636334) and LIGHT-ACD (NCT03587103). Registered on 3 July 2018.
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Affiliation(s)
- Jiali Song
- grid.415105.40000 0004 9430 5605National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037 China
| | - Xiuling Wang
- grid.415105.40000 0004 9430 5605National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037 China
| | - Bin Wang
- grid.415105.40000 0004 9430 5605National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037 China
| | - Yan Gao
- grid.415105.40000 0004 9430 5605National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037 China
| | - Jiamin Liu
- grid.415105.40000 0004 9430 5605National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037 China
| | - Haibo Zhang
- grid.415105.40000 0004 9430 5605National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037 China
| | - Xi Li
- grid.415105.40000 0004 9430 5605National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037 China
| | - Jing Li
- grid.415105.40000 0004 9430 5605National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037 China
| | - Ji-Guang Wang
- grid.16821.3c0000 0004 0368 8293The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jun Cai
- grid.415105.40000 0004 9430 5605Hypertension Center, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Jeph Herrin
- grid.47100.320000000419368710Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut USA
| | - Jane Armitage
- grid.4991.50000 0004 1936 8948Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF UK ,grid.4991.50000 0004 1936 8948MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Harlan M. Krumholz
- grid.16821.3c0000 0004 0368 8293The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China ,grid.417307.6Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut USA ,grid.47100.320000000419368710Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut USA
| | - Xin Zheng
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037, China. .,National Clinical Research Center for Cardiovascular Diseases, Shenzhen, Coronary Artery Disease Center, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, China.
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14
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Cunningham EB, Wheeler A, Hajarizadeh B, French CE, Roche R, Marshall AD, Fontaine G, Conway A, Valencia BM, Bajis S, Presseau J, Ward JW, Degenhardt L, Dore GJ, Hickman M, Vickerman P, Grebely J. Interventions to enhance testing, linkage to care, and treatment initiation for hepatitis C virus infection: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol 2022; 7:426-445. [PMID: 35303490 DOI: 10.1016/s2468-1253(21)00471-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/08/2021] [Accepted: 12/08/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Despite the goal set by WHO to eliminate hepatitis C virus (HCV) as a public health threat, uptake of HCV testing and treatment remains low. To achieve this target, evidence-based interventions are needed to address the barriers to care for people with, or at risk of, HCV infection. We aimed to assess the efficacy of interventions to improve HCV antibody testing, HCV RNA testing, linkage to HCV care, and treatment initiation. METHODS In this systematic review and meta-analysis, we searched MEDLINE (PubMed), Scopus, Web of Science, the Cochrane Central Register of Controlled Trials, and PsycINFO without language restrictions for reports published between database inception and July 21, 2020, assessing the following primary outcomes: HCV antibody testing; HCV RNA testing; linkage to HCV care; and direct-acting antiviral treatment initiation. We also searched key conference abstracts. We included randomised and non-randomised studies assessing non-pharmaceutical interventions that included a comparator or control group. Studies were excluded if they enrolled only paediatric populations (aged <18 years) or if they conducted the intervention in a different health-care setting to that of the control or comparator. Authors were contacted to clarify study details and to obtain additional population-level data. Data were extracted from the records identified into a pre-piloted and standardised data extraction form and a random-effects meta-analysis was used to pool the effects of the interventions on study outcomes. This study is registered in PROSPERO, CRD42020178035. FINDINGS Of 15 342 unique records identified, 142 were included, which reported on 148 unique studies (47 randomised controlled trials and 101 non-randomised studies). Medical chart reminders, provider education, and point-of-care antibody testing significantly improved at least three study outcomes compared with a comparator or control. Interventions that simplified HCV testing, including dried blood spot testing, point-of-care antibody testing, reflex RNA testing, and opt-out screening, significantly improved testing outcomes compared with a comparator or control. Enhanced patient and provider support through patient education, provider care coordination, and provider education also significantly improved testing outcomes compared with a comparator or control. Integrated care and patient navigation or care coordination significantly improved linkage to care and the uptake of direct-acting antiviral treatment compared with a comparator or control. INTERPRETATION Several interventions to improve HCV care that address several key barriers to HCV care were identified. New models of HCV care must be designed and implemented to address the barriers faced by the population of interest. Further high-quality research, including rigorously designed randomised studies, is still needed in key populations. FUNDING None.
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Affiliation(s)
| | - Alice Wheeler
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | | | - Clare E French
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health Research Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Rachel Roche
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Division, National Infection Service, Public Health England Colindale, London, UK; National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at UCL, National Institute for Health Research, London, UK
| | - Alison D Marshall
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
| | - Guillaume Fontaine
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Anna Conway
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
| | | | - Sahar Bajis
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - John W Ward
- Coalition for Global Hepatitis Elimination, The Task Force for Global Health, Decatur, GA, USA
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - Gregory J Dore
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
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15
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Frisina PG, Munene EN, Finnie J, Oakley JE, Ganesan G. Analysis of end-user satisfaction with electronic health records in college/university healthcare. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2022; 70:717-723. [PMID: 32529959 DOI: 10.1080/07448481.2020.1762610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/21/2020] [Accepted: 04/26/2020] [Indexed: 06/11/2023]
Abstract
ObjectiveTo determine levels of Electronic Health Record (EHR) satisfaction in order to add to the body of knowledge and assist professionals in the college/university health field with system/vendor selection. Methods: Nine health centers, all within highly selective colleges and universities, participated in this benchmarking study. Multidisciplinary staff (n = 316) received an anonymous 32-item survey to assess levels of agreement/satisfaction on statements pertaining to their EHR's functionality. Results: The EHRs most commonly used were Point and Click, Medicat, Allscripts, and EPIC. There was considerable variation on levels of user satisfaction/agreement within features among the EHR systems, but differences were not statistically significant. Conclusion: No systems emerged as clear "winners" in terms of user satisfaction. Features were identified within systems that can be leveraged to meet specific care delivery and quality reporting needs among college/university health professionals, and could be considered in the use of EHRs by health services.
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Affiliation(s)
- Pasquale G Frisina
- University Health Services, Princeton University, Princeton, New Jersey, USA
| | - Esther N Munene
- University Health Services, Princeton University, Princeton, New Jersey, USA
| | - Janet Finnie
- University Health Services, Princeton University, Princeton, New Jersey, USA
| | - Judith E Oakley
- University Health Services, Princeton University, Princeton, New Jersey, USA
| | - Gayathri Ganesan
- University Health Services, Princeton University, Princeton, New Jersey, USA
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16
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Potthoff S, Kwasnicka D, Avery L, Finch T, Gardner B, Hankonen N, Johnston D, Johnston M, Kok G, Lally P, Maniatopoulos G, Marques MM, McCleary N, Presseau J, Rapley T, Sanders T, Ten Hoor G, Vale L, Verplanken B, Grimshaw JM. Changing healthcare professionals' non-reflective processes to improve the quality of care. Soc Sci Med 2022; 298:114840. [PMID: 35287065 DOI: 10.1016/j.socscimed.2022.114840] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/19/2022] [Accepted: 02/20/2022] [Indexed: 11/18/2022]
Abstract
RATIONALE Translating research evidence into clinical practice to improve care involves healthcare professionals adopting new behaviours and changing or stopping their existing behaviours. However, changing healthcare professional behaviour can be difficult, particularly when it involves changing repetitive, ingrained ways of providing care. There is an increasing focus on understanding healthcare professional behaviour in terms of non-reflective processes, such as habits and routines, in addition to the more often studied deliberative processes. Theories of habit and routine provide two complementary lenses for understanding healthcare professional behaviour, although to date, each perspective has only been applied in isolation. OBJECTIVES To combine theories of habit and routine to generate a broader understanding of healthcare professional behaviour and how it might be changed. METHODS Sixteen experts met for a two-day multidisciplinary workshop on how to advance implementation science by developing greater understanding of non-reflective processes. RESULTS From a psychological perspective 'habit' is understood as a process that maintains ingrained behaviour through a learned link between contextual cues and behaviours that have become associated with those cues. Theories of habit are useful for understanding the individual's role in developing and maintaining specific ways of working. Theories of routine add to this perspective by describing how clinical practices are formed, adapted, reinforced and discontinued in and through interactions with colleagues, systems and organisational procedures. We suggest a selection of theory-based strategies to advance understanding of healthcare professionals' habits and routines and how to change them. CONCLUSION Combining theories of habit and routines has the potential to advance implementation science by providing a fuller understanding of the range of factors, operating at multiple levels of analysis, which can impact on the behaviours of healthcare professionals, and so quality of care provision.
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Affiliation(s)
- Sebastian Potthoff
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle Upon Tyne, NE7 7XA, UK; Population and Health Science Institute, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK.
| | - Dominika Kwasnicka
- Faculty of Psychology, SWPS University of Social Sciences and Humanities, 53-238, Wroclaw, Poland; NHMRC CRE in Digital Technology to Transform Chronic Disease Outcomes, Melbourne School of Population and Global Health, University of Melbourne, 333 Exhibition Street, 3000, Melbourne, Australia.
| | - Leah Avery
- School of Health & Life Sciences, Teesside University, Tees Valley, TS1 3BA, UK; Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
| | - Tracy Finch
- Department of Nursing, Midwifery & Health, Northumbria University, Newcastle upon Tyne, NE7 7XA, UK.
| | | | - Nelli Hankonen
- Faculty of Social Sciences, Tampere University, Tampere, Finland; Faculty of Social Sciences, University of Helsinki, Unioninkatu 37, 00014, Finland.
| | - Derek Johnston
- Health Psychology Group, University of Aberdeen, Aberdeen, AB25 2ZD, Scotland, UK.
| | - Marie Johnston
- Health Psychology Group, University of Aberdeen, Aberdeen, AB25 2ZD, Scotland, UK.
| | - Gerjo Kok
- Department of Work and Social Psychology, Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands.
| | - Phillippa Lally
- Research Department of Behavioural Science and Health, University College London, London, WC1E 6BT, UK.
| | - Gregory Maniatopoulos
- Population and Health Science Institute, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK; Faculty of Business and Law, Northumbria University, Newcastle upon Tyne, UK.
| | - Marta M Marques
- Comprehensive Health Research Centre (CHRC), NOVA Medical School, Universidade Nova de Lisboa, Portugal.
| | - Nicola McCleary
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, K1H 8L6, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, K1G 5Z3, Canada.
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, K1H 8L6, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, K1G 5Z3, Canada; School of Psychology, University of Ottawa, Ottawa, K1N 6N5, Canada.
| | - Tim Rapley
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle Upon Tyne, NE7 7XA, UK.
| | - Tom Sanders
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle Upon Tyne, NE7 7XA, UK.
| | - Gill Ten Hoor
- Department of Work and Social Psychology, Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands.
| | - Luke Vale
- Population and Health Science Institute, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK.
| | - Bas Verplanken
- Department of Psychology, University of Bath, Bath, BA2 7AY, UK.
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, K1H 8L6, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, K1G 5Z3, Canada; Department of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada.
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17
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Arsenault-Lapierre G, Le Berre M, Rojas-Rozo L, McAiney C, Ingram J, Lee L, Vedel I. Improving dementia care: insights from audit and feedback in interdisciplinary primary care sites. BMC Health Serv Res 2022; 22:353. [PMID: 35300660 PMCID: PMC8931981 DOI: 10.1186/s12913-022-07672-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 02/23/2022] [Indexed: 11/25/2022] Open
Abstract
Background Many primary care sites have implemented models to improve detection, diagnosis, and management of dementia, as per Canadian guidelines. The aim of this study is to describe the responses of clinicians, managers, and staff of sites that have implemented these models when presented with audit results, their insights on the factors that explain their results, their proposed solutions for improvement and how these align to one another. Methods One audit and feedback cycle was carried out in eight purposefully sampled sites in Ontario, Canada, that had previously implemented dementia care models. Audit consisted of a) chart review to assess quality of dementia care indicators, b) questionnaire to assess the physicians’ knowledge, attitudes and practice toward dementia care, and c) semi-structured interviews to understand barriers and facilitators to implementing these models. Feedback was given to clinicians, managers, and staff in the form of graphic and oral presentations, followed by eight focus groups (one per site). Discussions revolved around: what audit results elicited more discussion from the participants, 2) their insights on the factors that explain their audit results, and 3) solutions they propose to improve dementia care. Deductive content and inductive thematic analyses, grounded in causal pathways models’ theory was performed. Findings The audit and feedback process allowed the 63 participants to discuss many audit results and share their insights on a) organizational factors (lack of human resources, the importance of organized links with community services, clear roles and support from external memory clinics) and b) clinician factors (perceived competency practice and attitudes on dementia care), that could explain their audit results. Participants also provided solutions to improve dementia care in primary care (financial incentives, having clear pathways, adding tools to improve chart documentation, establish training on dementia care, and the possibility of benchmarking with other institutions). Proposed solutions were well aligned with their insights and further nuanced according to contextual details. Conclusions This study provides valuable information on solutions proposed by primary care clinicians, managers, and staff to improve dementia care in primary care. The solutions are grounded in clinical experience and will inform ongoing and future dementia strategies. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07672-5.
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Affiliation(s)
- Geneviève Arsenault-Lapierre
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada. .,Lady Davis Institute for Medical Research, Jewish General Hospital, Quebec, Montreal, Canada.
| | - Mélanie Le Berre
- Lady Davis Institute for Medical Research, Jewish General Hospital, Quebec, Montreal, Canada
| | - Laura Rojas-Rozo
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Carrie McAiney
- School of Public Health and Health Systems, University of Waterloo and Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
| | - Jennifer Ingram
- Kawartha Centre - Redefining Healthy Aging, and Senior Care Network, Central East Ontario, Peterborough, Ontario, Canada
| | - Linda Lee
- Schlegel-UW Research Institute for Aging, Waterloo, ON, Canada.,Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Isabelle Vedel
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada.,Lady Davis Institute for Medical Research, Jewish General Hospital, Quebec, Montreal, Canada
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18
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Kouri A, Yamada J, Lam Shin Cheung J, Van de Velde S, Gupta S. Do providers use computerized clinical decision support systems? A systematic review and meta-regression of clinical decision support uptake. Implement Sci 2022; 17:21. [PMID: 35272667 PMCID: PMC8908582 DOI: 10.1186/s13012-022-01199-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/28/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Computerized clinical decision support systems (CDSSs) are a promising knowledge translation tool, but often fail to meaningfully influence the outcomes they target. Low CDSS provider uptake is a potential contributor to this problem but has not been systematically studied. The objective of this systematic review and meta-regression was to determine reported CDSS uptake and identify which CDSS features may influence uptake. METHODS Medline, Embase, CINAHL, and the Cochrane Database of Controlled Trials were searched from January 2000 to August 2020. Randomized, non-randomized, and quasi-experimental trials reporting CDSS uptake in any patient population or setting were included. The main outcome extracted was CDSS uptake, reported as a raw proportion, and representing the number of times the CDSS was used or accessed over the total number of times it could have been interacted with. We also extracted context, content, system, and implementation features that might influence uptake, for each CDSS. Overall weighted uptake was calculated using random-effects meta-analysis and determinants of uptake were investigated using multivariable meta-regression. RESULTS Among 7995 citations screened, 55 studies involving 373,608 patients and 3607 providers met full inclusion criteria. Meta-analysis revealed that overall CDSS uptake was 34.2% (95% CI 23.2 to 47.1%). Uptake was only reported in 12.4% of studies that otherwise met inclusion criteria. Multivariable meta-regression revealed the following factors significantly associated with uptake: (1) formally evaluating the availability and quality of the patient data needed to inform CDSS advice; and (2) identifying and addressing other barriers to the behaviour change targeted by the CDSS. CONCLUSIONS AND RELEVANCE System uptake was seldom reported in CDSS trials. When reported, uptake was low. This represents a major and potentially modifiable barrier to overall CDSS effectiveness. We found that features relating to CDSS context and implementation strategy best predicted uptake. Future studies should measure the impact of addressing these features as part of the CDSS implementation strategy. Uptake reporting must also become standard in future studies reporting CDSS intervention effects. REGISTRATION Pre-registered on PROSPERO, CRD42018092337.
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Affiliation(s)
- Andrew Kouri
- Division of Respirology, Department of Medicine, St. Michael's Hospital, Unity Health Toronto, 6 PGT, 30 Bond St, Toronto, ON, Canada
| | - Janet Yamada
- Daphne Cockwell School of Nursing, Faculty of Community Services, Ryerson University, Toronto, ON, Canada
| | - Jeffrey Lam Shin Cheung
- Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Stijn Van de Velde
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | - Samir Gupta
- Division of Respirology, Department of Medicine, St. Michael's Hospital, Unity Health Toronto, 6 PGT, 30 Bond St, Toronto, ON, Canada.
- Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
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19
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Rooholamini SN, Jennings B, Zhou C, Kaiser SV, Garber MD, Tchou MJ, Ralston SL. Effect of a Quality Improvement Bundle to Standardize the Use of Intravenous Fluids for Hospitalized Pediatric Patients: A Stepped-Wedge, Cluster Randomized Clinical Trial. JAMA Pediatr 2022; 176:26-33. [PMID: 34779837 PMCID: PMC8593833 DOI: 10.1001/jamapediatrics.2021.4267] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Given that hypotonic maintenance intravenous fluids (IVF) may cause hospital-acquired harm, in November 2018, the American Academy of Pediatrics released a clinical practice guideline recommending the use of isotonic IVF for patients aged 28 days to 18 years without contraindications. No recommendations were made regarding laboratory monitoring; however, unnecessary laboratory tests may contribute to health care waste and harm patients. OBJECTIVE To examine the effect of a quality improvement intervention bundle on (1) increasing the mean proportion of hours per hospital day with exclusive isotonic IVF use to at least 80% and (2) decreasing the mean proportion of hospital days with laboratory tests obtained. DESIGN, SETTING, AND PARTICIPANTS This stepped-wedge, cluster randomized clinical trial (Standardization of Fluids in Inpatient Settings [SOFI]) was sponsored by a national quality improvement collaborative and was conducted across 106 US pediatric hospitals. The SOFI intervention period was from September 2019 to March 2020. INTERVENTIONS Hospital sites were exposed to educational materials, a clinical algorithm and order set for IVF use, electronic medical record interventions to reduce laboratory testing, and "harms of overtesting" cards. MAIN OUTCOMES AND MEASURES Primary outcomes were mean proportion of hours per hospital day receiving exclusive isotonic IVF and mean proportion of hospital days with laboratory test values obtained. Secondary measures included total IVF duration per hospital day, daily patient weight measurement while receiving IVF, serum sodium testing, and adverse events. Baseline data were collected for 2 months; intervention period data, 7 months. Outcomes were analyzed using linear mixed-effects regression models. RESULTS A total of 106 hospitals were randomly assigned to 1 of 3 intervention start dates (wedges), and 100 hospitals (94%) completed the study. In total, 5215 hospitalizations were reviewed before the intervention, and 6724 hospitalizations were reviewed after the intervention. Prior to interventions, the mean (SD) proportion of hours per day with exclusive isotonic IVF use was 88.5% (31.7%). Interventions led to an absolute increase of 5.4% (95% CI, 3.9%-6.9%) above baseline in exclusive isotonic IVF use but did not change the proportion of hospital days during which a laboratory test value was obtained (estimated difference, 0.1%; 95% CI, -1.5% to 1.7%; P = .90), IVF use duration (estimated difference, -1.2%; 95% CI, -2.9% to 0.4%), serum sodium testing, or adverse events. There was an absolute increase of 4.4% (95% CI, 2.6%-6.2%) in the mean proportion of hospital days with a patient weight measurement while receiving IVF. CONCLUSIONS AND RELEVANCE In this stepped-wedge, cluster randomized clinical trial, an intervention bundle significantly improved the use of isotonic maintenance IVF without a concomitant increase in adverse events or electrolyte testing. Further work is required to deimplement laboratory testing. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03924674.
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Affiliation(s)
| | | | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle,Seattle Children’s Research Institute, Seattle, Washington
| | | | | | - Michael J. Tchou
- Department of Pediatrics, University of Colorado and Children’s Hospital Colorado, Aurora
| | - Shawn L. Ralston
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
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20
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Orenstein EW, Kandaswamy S, Muthu N, Chaparro JD, Hagedorn PA, Dziorny AC, Moses A, Hernandez S, Khan A, Huth HB, Beus JM, Kirkendall ES. Alert burden in pediatric hospitals: a cross-sectional analysis of six academic pediatric health systems using novel metrics. J Am Med Inform Assoc 2021; 28:2654-2660. [PMID: 34664664 DOI: 10.1093/jamia/ocab179] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/02/2021] [Accepted: 09/10/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Excessive electronic health record (EHR) alerts reduce the salience of actionable alerts. Little is known about the frequency of interruptive alerts across health systems and how the choice of metric affects which users appear to have the highest alert burden. OBJECTIVE (1) Analyze alert burden by alert type, care setting, provider type, and individual provider across 6 pediatric health systems. (2) Compare alert burden using different metrics. MATERIALS AND METHODS We analyzed interruptive alert firings logged in EHR databases at 6 pediatric health systems from 2016-2019 using 4 metrics: (1) alerts per patient encounter, (2) alerts per inpatient-day, (3) alerts per 100 orders, and (4) alerts per unique clinician days (calendar days with at least 1 EHR log in the system). We assessed intra- and interinstitutional variation and how alert burden rankings differed based on the chosen metric. RESULTS Alert burden varied widely across institutions, ranging from 0.06 to 0.76 firings per encounter, 0.22 to 1.06 firings per inpatient-day, 0.98 to 17.42 per 100 orders, and 0.08 to 3.34 firings per clinician day logged in the EHR. Custom alerts accounted for the greatest burden at all 6 sites. The rank order of institutions by alert burden was similar regardless of which alert burden metric was chosen. Within institutions, the alert burden metric choice substantially affected which provider types and care settings appeared to experience the highest alert burden. CONCLUSION Estimates of the clinical areas with highest alert burden varied substantially by institution and based on the metric used.
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Affiliation(s)
- Evan W Orenstein
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Division of Hospital Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | - Naveen Muthu
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Juan D Chaparro
- Division of Clinical Informatics, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Philip A Hagedorn
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA.,Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Adam C Dziorny
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, New York, USA.,Division of Critical Care Medicine, Golisano Children's Hospital at Strong, Rochester, New York, USA
| | - Adam Moses
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Sean Hernandez
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Department of General Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Amina Khan
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Hannah B Huth
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jonathan M Beus
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Eric S Kirkendall
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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21
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Shah S, Yeheskel A, Hossain A, Kerr J, Young K, Shakik S, Nichols J, Yu C. The Impact of Guideline Integration into Electronic Medical Records on Outcomes for Patients with Diabetes: A Systematic Review. Am J Med 2021; 134:952-962.e4. [PMID: 33775644 DOI: 10.1016/j.amjmed.2021.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 10/21/2020] [Accepted: 03/17/2021] [Indexed: 11/28/2022]
Abstract
Optimal strategies for integration of clinical practice guidelines into electronic medical records and its impact on processes of care and clinical outcomes in diabetic patients are not well understood. A systematic review of CINAHL, MEDLINE, PubMed, and Cochrane Library databases in August 2016, November 2017, and June 2020 was conducted. Studies investigating integration of diabetes guidelines into ambulatory care electronic medical records reporting quantitative results were included. After screening 15,783 records, 21 articles were included. Lipid and blood pressure control consistently improved with guideline integration, but A1c control remained equivocal. Electronic guideline integration improved microvascular complication screening, vaccination, and documentation of cardiovascular risk factors, while medication prescription and blood pressure, lipid, and A1c documentation did not improve. Studies employing a combination of electronic record intervention strategies were associated with improvement in monitoring and attainment of guideline and screening targets. Thus, strategies employing combinations of interventions to incorporate guidelines into electronic records may improve processes of care and some clinical outcomes.
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Affiliation(s)
- Sapna Shah
- Department of Medicine; Faculty of Medicine, University of Toronto, Ont, Canada
| | - Ariel Yeheskel
- Department of Medicine; Faculty of Medicine, University of Toronto, Ont, Canada
| | - Abrar Hossain
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Jenessa Kerr
- Department of Pediatrics, University of Calgary, Alb, Canada
| | | | | | - Jennica Nichols
- Faculty of Graduate and Postdoctoral Studies, University of British Columbia, Vancouver, Canada
| | - Catherine Yu
- Department of Medicine; Faculty of Medicine, University of Toronto, Ont, Canada; Dalla Lana School of Public Health; University of Toronto, Ont, Canada.
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22
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Okoli GN, Reddy VK, Lam OLT, Abdulwahid T, Askin N, Thommes E, Chit A, Abou-Setta AM, Mahmud SM. Interventions on health care providers to improve seasonal influenza vaccination rates among patients: a systematic review and meta-analysis of the evidence since 2000. Fam Pract 2021; 38:524-536. [PMID: 33517381 PMCID: PMC8317218 DOI: 10.1093/fampra/cmaa149] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Seasonal influenza vaccination (SIV) rates remain suboptimal in many populations, even in those with universal SIV. OBJECTIVE To summarize the evidence on interventions on health care providers (physicians/nurses/pharmacists) to increase SIV rates. METHODS We systematically searched/selected full-text English publications from January 2000 to July 2019 (PROSPERO-CRD42019147199). Our outcome was the difference in SIV rates between patients in intervention and non-intervention groups. We calculated pooled difference using an inverse variance, random-effects model. RESULTS We included 39 studies from 8370 retrieved citations. Compared with no intervention, team-based training/education of physicians significantly increased SIV rates in adult patients: 20.1% [7.5-32.7%; I2 = 0%; two randomized controlled trials (RCTs)] and 13.4% [8.6-18.1%; I2 = 0%; two non-randomized intervention studies (NRS)]. A smaller increase was observed in paediatric patients: 7% (0.1-14%; I2 = 0%; two NRS), and in adult patients with team-based training/education of physicians and nurses together: 0.9% (0.2-1.5%; I2 = 30.6%; four NRS). One-off provision of guidelines/information to physicians, and to both physicians and nurses, increased SIV rates in adult patients: 23.8% (15.7-31.8%; I2 = 45.8%; three NRS) and paediatric patients: 24% (8.1-39.9%; I2 = 0%; two NRS), respectively. Use of reminders (prompts) by physicians and nurses slightly increased SIV rates in paediatric patients: 2.3% (0.5-4.2%; I2 = 0%; two RCTs). A larger increase was observed in adult patients: 18.5% (14.8-22.1%; I2 = 0%; two NRS). Evidence from both RCTs and NRS showed significant increases in SIV rates with varied combinations of interventions. CONCLUSIONS Limited evidence suggests various forms of physicians' and nurses' education and use of reminders may be effective for increasing SIV rates among patients.
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Affiliation(s)
| | | | - Otto L T Lam
- George and Fay Yee Centre for Healthcare Innovation
| | | | - Nicole Askin
- Neil John Maclean Health Sciences Library, University of Manitoba, Winnipeg, Canada
| | | | | | - Ahmed M Abou-Setta
- George and Fay Yee Centre for Healthcare Innovation.,Community Health Sciences, Rady Faculty of Health Sciences
| | - Salaheddin M Mahmud
- Community Health Sciences, Rady Faculty of Health Sciences.,Vaccine and Drug Evaluation Centre, University of Manitoba, Winnipeg, Canada
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23
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Cecil E, Dewa LH, Ma R, Majeed A, Aylin P. General practitioner and nurse practitioner attitudes towards electronic reminders in primary care: a qualitative analysis. BMJ Open 2021; 11:e045050. [PMID: 34253661 PMCID: PMC8276294 DOI: 10.1136/bmjopen-2020-045050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Reminders in primary care administrative systems aim to help clinicians provide evidence-based care, prescribe safely and save money. However, increased use of reminders can lead to alert fatigue. Our study aimed to assess general practitioners' (GPs) and nurse practitioners' (NPs) views on electronic reminders in primary care. DESIGN A qualitative analysis using semistructured interviews. SETTING AND PARTICIPANTS Fifteen GPs and NP based in general practices located in North-West London and Yorkshire, England. METHODS We collected data on participants' views on: (1) perceptions of the value of information provided; (2) reminder-related behaviours and (3) how to improve reminders. We carried out a thematic analysis. RESULTS Participants were familiar with reminders in their clinical systems and felt many were important to support their clinical work. However, participants reported, on average, 70% of reminders were ignored. Four major themes emerged: (1) reaction to a reminder, which was mixed and varied by situation. (2) Factors influencing the decision to act on reminders, often related to experience, consultation styles and interests of participants. Time constraints, alert design, inappropriate presentation and litigation were also factors. (3) Negative consequences of using reminders were increased workload or costs and compromising GP and NPs behaviour. (4) Factors relating to improving users' engagement with reminders were prevention of unnecessary reminders through data linkage across healthcare administrative systems or the development of more intelligent algorithms. Participants felt training was vital to effectively manage reminders. CONCLUSIONS GPs and NPs believe reminders are useful in supporting the provision of good quality patient care. Improving GPs and NPs' engagement with reminders centres on further developing their relevance to their clinical practice, which is personalised, considers cognitive workflow and suppresses inappropriate presentation.
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Affiliation(s)
- Elizabeth Cecil
- Department of Primary Care and Public Health, Imperial College London, London, UK
- School of Life Course Sciences, King's College London, London, UK
| | - Lindsay Helen Dewa
- Patient Safety Translational Research Centre, Imperial College London, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Richard Ma
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Paul Aylin
- Department of Primary Care and Public Health, Imperial College London, London, UK
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24
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Increasing uptake of NHS Health Checks: a randomised controlled trial using GP computer prompts. Br J Gen Pract 2021; 71:e693-e700. [PMID: 34048362 PMCID: PMC8279658 DOI: 10.3399/bjgp.2020.0887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 04/13/2021] [Indexed: 11/24/2022] Open
Abstract
Background Public Health England wants to increase the uptake of the NHS Health Check (NHSHC), a cardiovascular disease prevention programme. Most invitations are sent by letter, but opportunistic invitations may be issued and verbal invitations have a higher rate of uptake. Prompting staff to issue opportunistic invitations might increase uptake. Aim To assess the effect on uptake of automated prompts to clinical staff to invite patients to NHSHC, delivered via primary care computer systems. Design and setting Pseudo-randomised controlled trial of patients eligible for the NHSHC attending GP practices in Southwark, London. Method Eligible patients were allocated into one of two conditions, (a) Prompt and (b) No Prompt, to clinical staff. The primary outcome was attendance at an NHSHC. Results Fifteen of 43 (34.88%) practices in Southwark were recruited; 7564 patients were eligible for an NHSHC, 3778 (49.95%) in the control and 3786 (50.05%) in the intervention. Attendance in the intervention arm was 454 (12.09%) compared with 280 (7.41%) in the control group, a total increase of 4.58% (OR = 2.28; 95% CI = 1.46 to 3.55; P<0.001). Regressions found an interaction between intervention and sex (OR = 0.65; 95% CI = 0.44 to 0.86, P = 0.004), with the intervention primarily effective on males. Comparing the probabilities of attendance for each age category across intervention and control suggests that the intervention was primarily effective for younger patients. Conclusion Prompts on computer systems in general practice were effective at improving the uptake of the NHSHC, especially for males and younger patients.
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25
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Christensen KD, Bell M, Zawatsky CLB, Galbraith LN, Green RC, Hutchinson AM, Jamal L, LeBlanc JL, Leonhard JR, Moore M, Mullineaux L, Petry N, Platt DM, Shaaban S, Schultz A, Tucker BD, Van Heukelom J, Wheeler E, Zoltick ES, Hajek C. Precision Population Medicine in Primary Care: The Sanford Chip Experience. Front Genet 2021; 12:626845. [PMID: 33777099 PMCID: PMC7994529 DOI: 10.3389/fgene.2021.626845] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 02/11/2021] [Indexed: 01/10/2023] Open
Abstract
Genetic testing has the potential to revolutionize primary care, but few health systems have developed the infrastructure to support precision population medicine applications or attempted to evaluate its impact on patient and provider outcomes. In 2018, Sanford Health, the nation's largest rural nonprofit health care system, began offering genetic testing to its primary care patients. To date, more than 11,000 patients have participated in the Sanford Chip Program, over 90% of whom have been identified with at least one informative pharmacogenomic variant, and about 1.5% of whom have been identified with a medically actionable predisposition for disease. This manuscript describes the rationale for offering the Sanford Chip, the programs and infrastructure implemented to support it, and evolving plans for research to evaluate its real-world impact.
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Affiliation(s)
- Kurt D Christensen
- Center for Healthcare Research in Pediatrics, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, United States.,Department of Population Medicine, Harvard Medical School, Boston, MA, United States.,Broad Institute of MIT and Harvard, Cambridge, MA, United States
| | - Megan Bell
- Sanford Health Imagenetics, Sioux Falls, SD, United States
| | - Carrie L B Zawatsky
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States.,Ariadne Labs, Boston, MA, United States
| | - Lauren N Galbraith
- Center for Healthcare Research in Pediatrics, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, United States
| | - Robert C Green
- Broad Institute of MIT and Harvard, Cambridge, MA, United States.,Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States.,Ariadne Labs, Boston, MA, United States.,Department of Medicine, Harvard Medical School, Boston, MA, United States
| | | | - Leila Jamal
- National Cancer Institute, Bethesda, MD, United States.,Department of Bioethics, National Institutes of Health, Bethesda, MD, United States
| | - Jessica L LeBlanc
- Center for Healthcare Research in Pediatrics, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, United States
| | | | - Michelle Moore
- Sanford Health Imagenetics, Sioux Falls, SD, United States
| | - Lisa Mullineaux
- Mayo Clinic Genomics Laboratory, Rochester, MN, United States
| | - Natasha Petry
- Sanford Health Imagenetics, Fargo, ND, United States.,Department of Pharmacy Practice, North Dakota State University, Fargo, ND, United States
| | - Dylan M Platt
- Sanford Health Imagenetics, Sioux Falls, SD, United States
| | - Sherin Shaaban
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, United States.,ARUP Laboratories, Salt Lake City, UT, United States
| | - April Schultz
- Sanford Health Imagenetics, Sioux Falls, SD, United States.,Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, United States
| | | | - Joel Van Heukelom
- Sanford Health Imagenetics, Sioux Falls, SD, United States.,Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, United States
| | | | - Emilie S Zoltick
- Center for Healthcare Research in Pediatrics, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, United States
| | - Catherine Hajek
- Sanford Health Imagenetics, Sioux Falls, SD, United States.,Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, United States
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26
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Beriault DR, Gilmour JA, Hicks LK. Overutilization in laboratory medicine: tackling the problem with quality improvement science. Crit Rev Clin Lab Sci 2021; 58:430-446. [PMID: 33691585 DOI: 10.1080/10408363.2021.1893642] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Overutilization of tests and treatments is a widespread problem in contemporary heath care, and laboratory medicine is no exception. It is estimated that 10-70% of laboratory tests may be unnecessary, with estimates in the literature varying depending on the situation and the laboratory test. Inappropriate use of laboratory tests can lead to further unnecessary testing, adverse events, inaccurate diagnoses, and inappropriate treatments. Altogether, this increases the risk of harm to a patient, which can be physical, psychological, or financial in nature. Overutilization in healthcare is driven by complex factors including care delivery models, litigious practice environments, and medical and patient culture. Quality improvement (QI) methods can help to tackle overutilization. In this review, we outline the global healthcare problem of laboratory overutilization, particularly in the developed world, and describe how an understanding of and application of quality improvement principles can help to address this challenge.
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Affiliation(s)
- Daniel R Beriault
- Department of Laboratory Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Julie A Gilmour
- Division of Endocrinology, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lisa K Hicks
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Hematology and Oncology, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
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Shahmoradi L, Safdari R, Ahmadi H, Zahmatkeshan M. Clinical decision support systems-based interventions to improve medication outcomes: A systematic literature review on features and effects. Med J Islam Repub Iran 2021; 35:27. [PMID: 34169039 PMCID: PMC8214039 DOI: 10.47176/mjiri.35.27] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Indexed: 01/24/2023] Open
Abstract
Background: Clinical decision support systems (CDSSs) interventions were used to improve the life quality and safety in patients and also to improve practitioner performance, especially in the field of medication. Therefore, the aim of the paper was to summarize the available evidence on the impact, outcomes and significant factors on the implementation of CDSS in the field of medicine. Methods: This study is a systematic literature review. PubMed, Cochrane Library, Web of Science, Scopus, EMBASE, and ProQuest were investigated by 15 February 2017. The inclusion requirements were met by 98 papers, from which 13 had described important factors in the implementation of CDSS, and 86 were medicated-related. We categorized the system in terms of its correlation with medication in which a system was implemented, and our intended results were examined. In this study, the process outcomes (such as; prescription, drug-drug interaction, drug adherence, etc.), patient outcomes, and significant factors affecting the implementation of CDSS were reviewed. Results: We found evidence that the use of medication-related CDSS improves clinical outcomes. Also, significant results were obtained regarding the reduction of prescription errors, and the improvement in quality and safety of medication prescribed. Conclusion: The results of this study show that, although computer systems such as CDSS may cause errors, in most cases, it has helped to improve prescribing, reduce side effects and drug interactions, and improve patient safety. Although these systems have improved the performance of practitioners and processes, there has not been much research on the impact of these systems on patient outcomes.
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Affiliation(s)
- Leila Shahmoradi
- Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Safdari
- Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Ahmadi
- OIM Department, Aston Business School, Aston University, Birmingham B4 7ET, United Kingdom
| | - Maryam Zahmatkeshan
- Noncommunicable Diseases Research Center, School of Medicine, Fasa University of Medical Sciences, Fasa, Iran
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Grout RW, Buchhalter J, Patel AD, Brin A, Clark AA, Holmay M, Story TJ, Downs SM. Improving Patient-Centered Communication about Sudden Unexpected Death in Epilepsy through Computerized Clinical Decision Support. Appl Clin Inform 2021; 12:90-99. [PMID: 33598905 DOI: 10.1055/s-0040-1722221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Sudden unexpected death in epilepsy (SUDEP) is a rare but fatal risk that patients, parents, and professional societies clearly recommend discussing with patients and families. However, this conversation does not routinely happen. OBJECTIVES This pilot study aimed to demonstrate whether computerized decision support could increase patient communication about SUDEP. METHODS A prospective before-and-after study of the effect of computerized decision support on delivery of SUDEP counseling. The intervention was a screening, alerting, education, and follow-up SUDEP module for an existing computerized decision support system (the Child Health Improvement through Computer Automation [CHICA]) in five urban pediatric primary care clinics. Families of children with epilepsy were contacted by telephone before and after implementation to assess if the clinician discussed SUDEP at their respective encounters. RESULTS The CHICA-SUDEP module screened 7,154 children age 0 to 21 years for seizures over 7 months; 108 (1.5%) reported epilepsy. We interviewed 101 families after primary care encounters (75 before and 26 after implementation) over 9 months. After starting CHICA-SUDEP, the number of caregivers who reported discussing SUDEP with their child's clinician more than doubled from 21% (16/75) to 46% (12/26; p = 0.03), and when the parent recalled who brought up the topic, 80% of the time it was the clinician. The differences between timing and sampling methodologies of before and after intervention cohorts could have led to potential sampling and recall bias. CONCLUSION Clinician-family discussions about SUDEP significantly increased in pediatric primary care clinics after introducing a systematic, computerized screening and decision support module. These tools demonstrate potential for increasing patient-centered education about SUDEP, as well as incorporating other guideline-recommended algorithms into primary and subspecialty cares. CLINICAL TRIAL REGISTRATION clinicaltrials.gov, NCT03502759.
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Affiliation(s)
- Randall W Grout
- Department of Pediatrics, Children's Health Services Research, Indiana University, Indianapolis, Indiana, United States.,Center for Biomedical Informatics, Regenstrief Institute, Inc., Indianapolis, Indiana, United States
| | - Jeffrey Buchhalter
- Department of Pediatrics, University of Calgary, Section of Neurology, Alberta Children's Hospital, Calgary, Canada
| | - Anup D Patel
- Division of Neurology, Nationwide Children's Hospital and Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Amy Brin
- Child Neurology Foundation, Minneapolis, Minnesota, United States
| | - Ann A Clark
- Department of Pediatrics, Children's Health Services Research, Indiana University, Indianapolis, Indiana, United States
| | - Mary Holmay
- Greenwich Biosciences, Carlsbad, California, United States (at the time of this study)
| | - Tyler J Story
- Greenwich Biosciences, Carlsbad, California, United States (at the time of this study).,UCB, Inc., Smyrna, Georgia, United States
| | - Stephen M Downs
- Department of Pediatrics, Children's Health Services Research, Indiana University, Indianapolis, Indiana, United States.,Center for Biomedical Informatics, Regenstrief Institute, Inc., Indianapolis, Indiana, United States
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29
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Siegel BI, Johnson M, Dawson TE, Kurzen E, Holt PJ, Wolf DS, Orenstein EW. Reducing Prescribing Errors in Hospitalized Children on the Ketogenic Diet. Pediatr Neurol 2021; 115:42-47. [PMID: 33333459 DOI: 10.1016/j.pediatrneurol.2020.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/11/2020] [Accepted: 11/14/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Children on the ketogenic diet must limit carbohydrate intake to maintain ketosis and reduce seizure burden. Patients on ketogenic diet are vulnerable to harm in the hospital setting where carbohydrate-containing medications are commonly prescribed. We developed clinical decision support to reduce inappropriate prescription of carbohydrate-containing medications in hospitalized children on ketogenic diet. METHODS A clinical decision support alert was developed through formative and summative usability testing. The alert warned prescribers when they entered an order for a carbohydrate-containing medication in patients on ketogenic diet. The alert was implemented using a quasi-experimental design with sequential crossover from control to intervention at two tertiary care pediatric hospitals within a single health system. The primary outcome was carbohydrate-containing medication orders per patient-day. RESULTS During the study period, there were 280 ketogenic diet patient admissions totaling 1219 patient-days. The carbohydrate-containing medication order rate declined from 0.69 to 0.35 orders per patient-day (absolute rate reduction 0.34, 95% confidence interval 0.25-0.43), corresponding to 256 inappropriate orders prevented. The alert fired 398 times and was accepted (i.e., the order was removed) 227 times for an overall acceptance rate of 57%. CONCLUSIONS Implementation of a clinical decision support alert at order-entry resulted in a sustained reduction in carbohydrate-containing medication orders for hospitalized patients on ketogenic diet without an increase in alert burden. Clinical decision support developed with user-centered design principles can improve patient safety for children on ketogenic diet by influencing prescriber behavior.
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Affiliation(s)
- Benjamin I Siegel
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.
| | | | | | - Emily Kurzen
- Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Philip J Holt
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia
| | - David S Wolf
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Evan W Orenstein
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia
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30
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Hughes MS, Apostolou A, Reilley B, Leston J, McCollum J, Iralu J. Electronic Health Record Reminders for Chlamydia Screening in an American Indian Population. Public Health Rep 2020; 136:320-326. [PMID: 33301693 DOI: 10.1177/0033354920970947] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Indian Health Service (IHS) screening rates for Chlamydia trachomatis are lower than national rates of chlamydia screening in the Southwest. We describe and evaluate the effect of a public health intervention consisting of electronic health record (EHR) reminders to alert health care providers to screen for chlamydia at an IHS facility. We also conducted an awareness presentation among health care providers on chlamydia screening. METHODS We conducted our intervention from November 1, 2013, through October 31, 2015, at an IHS facility in the Southwest. We implemented algorithms that queried database values to assess chlamydia screening performance in 6 clinical departments. We presented data on the screening performance of clinical departments and health care providers (de-identified) in the awareness presentations. We re-queried database values 1 and 2 years after implementation of the EHR reminder intervention to evaluate before-and-after screening rates, comparing data among all patients and among female patients only. RESULTS We found small, sustained relative increases in chlamydia screening rates during the 2012-2015 evaluation period: 20.8% pre-intervention to 24.9% and 24.2% one and two years postintervention, respectively, across all patients; 32.3% preintervention to 36.6% and 35.6% one and two years postintervention, respectively, among female patients. Increases in clinical department-specific screening rates varied and were most prominent in internal medicine (35.8% preintervention to peak 65.8% postintervention). The 1 clinic (obstetrics-gynecology) that did not receive an awareness presentation showed a consistent downward trend in screening rates, although absolute rates were consistently higher in that clinic than in other clinics. CONCLUSIONS Awareness presentations that offer feedback to health care providers on screening performance, heighten provider awareness of the importance of chlamydia screening, and promote development of novel provider-initiated screening protocols may help to increase screening rates when combined with EHR reminders.
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Affiliation(s)
| | - Andria Apostolou
- 1246 Indian Health Service, Rockville, MD, USA.,SciMetrika, LLC, McLean, VA, USA
| | - Brigg Reilley
- 23762 Northwest Portland Area Indian Health Board, Portland, OR, USA
| | - Jessica Leston
- 23762 Northwest Portland Area Indian Health Board, Portland, OR, USA
| | | | - Jonathan Iralu
- 1811 Harvard Medical School, Boston, MA, USA.,1246 Indian Health Service, Gallup, NM, USA
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Clark RE, Milligan J, Ashe MC, Faulkner G, Canfield C, Funnell L, Brien S, Butt DA, Mehan U, Samson K, Papaioannou A, Giangregorio L. A patient-oriented approach to the development of a primary care physical activity screen for embedding into electronic medical records. Appl Physiol Nutr Metab 2020; 46:589-596. [PMID: 33226847 DOI: 10.1139/apnm-2020-0356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Physical activity questionnaires exist, but effective implementation in primary care remains an issue. We sought to develop a physical activity screen (PAS) for electronic medical record (EMR) integration by 1) identifying healthcare professionals' (HCPs), patients' and stakeholders' barriers to and preferences for physical activity counselling in primary care; and 2) using the information to co-create the PAS. We conducted semi-structured interviews with primary care HCPs, patients and stakeholders, and used content and thematic analyses to inform iterative co-design of the PAS. Interviews with 38 participants (mean age 41 years) resulted in 2 themes: 1) HCPs are willing to conduct physical activity screening, but acknowledge they don't do it well; and 2) HCPs have limited opportunity and capacity to discuss physical activity, and need a streamlined process for EMR that goes beyond quantifying physical activity. HCPs, patients and stakeholders co-designed a physical activity screen for integration into the EMR that can be tested for feasibility and effects on HCP behaviour and patients' physical activity levels. Novelty: EMR-integration of physical activity screening needs to go beyond just asking about physical activity minutes. Primary care professionals have variable knowledge and time, and need physical activity counselling prompts and resources. We co-developed a physical activity EMR tool with patients and primary care providers.
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Affiliation(s)
- Rebecca E Clark
- Faculty of Health, University of Waterloo, Waterloo, ON N2L 3G1, Canada
| | - James Milligan
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Maureen C Ashe
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Guy Faulkner
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Carolyn Canfield
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Larry Funnell
- Canadian Osteoporosis Patient Network, Osteroporosis Canada, ON M3C 3G8, Canada
| | - Sheila Brien
- Canadian Osteoporosis Patient Network, Osteroporosis Canada, ON M3C 3G8, Canada
| | - Debra A Butt
- Department of Family and Community Medicine, University of Toronto, ON M5G 1V7, Canada
| | - Upender Mehan
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Kevin Samson
- East Wellington Family Health Team, Rockwood, ON N0B 2K0, Canada
| | | | - Lora Giangregorio
- Schlegel Research Institute for Aging, Waterloo, ON N2J 0E2, Canada.,Faculty of Applied Health Sciences, University of Waterloo, Waterloo, ON N2L 3G1, Canada
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Gupta A, Houchens N. Quality & Safety in the Literature: January 2021. BMJ Qual Saf 2020; 30:83-88. [PMID: 33154109 DOI: 10.1136/bmjqs-2020-012602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 10/21/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Ashwin Gupta
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA .,Internal Medicine, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Nathan Houchens
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Internal Medicine, University of Michigan Hospital, Ann Arbor, Michigan, USA
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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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Patterson ES, DiLoreto GN, Vanam R, Hade E, Hebert C. ENHANCING USEFULNESS AND USABILITY OF A CLINICAL DECISION SUPPORT PROTOTYPE FOR ANTIBIOTIC STEWARDSHIP. ACTA ACUST UNITED AC 2020; 9:61-65. [PMID: 33959671 DOI: 10.1177/2327857920091034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Human factors engineering can enhance software usefulness and usability. We describe a multi-method approach to improve clinical decision support (CDS) for antibiotic stewardship. We employed a heuristic review to generate recommendations to improve the usability of a prototype CDS to support empiric antibiotic prescribing in the hospital setting. We then engaged in a design improvement cycle in collaboration with software programmers, which resulted in additional enhancements to our prototype. Finally, we used the revised prototype during three walkthrough demonstration interviews with physician and pharmacist subject matter experts. These walkthrough interviews generated recommendations to improve the interface, functionality, and tailoring for groups of users. We discuss common elements of the recommendations for models for using clinical decision support in general.
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Affiliation(s)
- Emily S Patterson
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH
| | - Giavanna N DiLoreto
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH
| | - Rohith Vanam
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH.,Office of Research, The Ohio State University, Columbus, OH
| | - Erinn Hade
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH
| | - Courtney Hebert
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH
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35
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Valvona SN, Rayo MF, Abdel-Rasoul M, Locke LJ, Rizer MK, Moffatt-Bruce SD, Patterson ES. Comparative Effectiveness of Best Practice Alerts with Active and Passive Presentations: A Retrospective Study. ACTA ACUST UNITED AC 2020. [DOI: 10.1177/2327857920091023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We assess the relationship of active or passive presentation of Best Practice Advisories (BPAs) for hospital clinicians with compliance rates of recommended actions. We identify the design characteristics of alerts that can be used to assess the effectiveness of design choices with superior usability. Alerts in Electronic Health Records (EHRs) are frequently overridden by healthcare providers. Identifying characteristics of effective alerts can increase the frequency that actions recommended in evidence-based care guidelines are done, reduce user frustration, and improve interface usability along with the willingness to use alerts. We conducted a retrospective analysis of data for 11 BPAs between June 2014 and May 2015. The outcome measure was the percent correspondence with recommended actions. A repeated measures regression model was used for the correlation of the BPA presentation type with the outcome measure. The BPA presentation type was significant such that the odds are 7.7 times greater that a recommended action would be taken by a provider with an active BPA presentation type after adjusting for whether an action was required. Active presentation alerts achieve higher compliance rates. CDS alerts that actively interrupted the provider’s workflow were associated with a higher compliance rate with recommended actions.
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Affiliation(s)
| | - Michael F. Rayo
- Department of Integrated Systems Engineering, The Ohio State University, Columbus, OH
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, OH
| | - Linda J. Locke
- Ohio State University Wexner Medical Center, Columbus, OH
| | - Milisa K. Rizer
- Ohio State University Wexner Medical Center, Columbus, OH
- Departments of Family Medicine and Biomedical Informatics, The Ohio State University, Columbus, OH
| | - Susan D. Moffatt-Bruce
- Ohio State University Wexner Medical Center, Columbus, OH
- Department of Surgery, The Ohio State University, Columbus, OH
| | - Emily S. Patterson
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus OH
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36
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Redón P, Shahzad A, Iqbal T, Wijns W. Benefits of Home-Based Solutions for Diagnosis and Treatment of Acute Coronary Syndromes on Health Care Costs: A Systematic Review. SENSORS (BASEL, SWITZERLAND) 2020; 20:E5006. [PMID: 32899338 PMCID: PMC7506920 DOI: 10.3390/s20175006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/29/2020] [Accepted: 09/01/2020] [Indexed: 01/06/2023]
Abstract
Diagnosing and treating acute coronary syndromes consumes a significant fraction of the healthcare budget worldwide. The pressure on resources is expected to increase with the continuing rise of cardiovascular disease, other chronic diseases and extended life expectancy, while expenditure is constrained. The objective of this review is to assess if home-based solutions for measuring chemical cardiac biomarkers can mitigate or reduce the continued rise in the costs of ACS treatment. A systematic review was performed considering published literature in several relevant public databases (i.e., PUBMED, Cochrane, Embase and Scopus) focusing on current biomarker practices in high-risk patients, their cost-effectiveness and the clinical evidence and feasibility of implementation. Out of 26,000 references screened, 86 met the inclusion criteria after independent full-text review. Current clinical evidence highlights that home-based solutions implemented in primary and secondary prevention reduce health care costs by earlier diagnosis, improved patient outcomes and quality of life, as well as by avoidance of unnecessary use of resources. Economical evidence suggests their potential to reduce health care costs if the incremental cost-effectiveness ratio or the willingness-to-pay does not surpass £20,000/QALY or €50,000 limit per 20,000 patients, respectively. The cost-effectiveness of these solutions increases when applied to high-risk patients.
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Affiliation(s)
- Pau Redón
- CÚRAM Center for Research in Medical Devices, H91 W2TY Galway, Ireland;
- Smart Sensor Lab, School of Medicine, National University of Ireland, Galway (NUIG), H91 TK33 Galway, Ireland; (A.S.); (T.I.)
| | - Atif Shahzad
- Smart Sensor Lab, School of Medicine, National University of Ireland, Galway (NUIG), H91 TK33 Galway, Ireland; (A.S.); (T.I.)
| | - Talha Iqbal
- Smart Sensor Lab, School of Medicine, National University of Ireland, Galway (NUIG), H91 TK33 Galway, Ireland; (A.S.); (T.I.)
| | - William Wijns
- CÚRAM Center for Research in Medical Devices, H91 W2TY Galway, Ireland;
- Smart Sensor Lab, School of Medicine, National University of Ireland, Galway (NUIG), H91 TK33 Galway, Ireland; (A.S.); (T.I.)
- Saolta University Healthcare Group, University Hospital Galway, Newcastle Road, H91 YR71 Galway, Ireland
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Fan M, Trbovich P. Simulation: a key tool for refining guidelines and demonstrating they produce the desired behavioural change. BMJ Qual Saf 2020; 30:4-6. [PMID: 32732338 DOI: 10.1136/bmjqs-2020-011999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2020] [Indexed: 01/24/2023]
Affiliation(s)
- Mark Fan
- Research and Innovation, North York General Hospital, Toronto, Ontario, Canada
| | - Patricia Trbovich
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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38
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The Influence of an Electronic Medical Record Embedded Best Practice Alert on Rate of Hospital Acquired Catheter Associated Urinary Tract Infections: Do Best Practice Alerts Reduce CAUTIs? Urology 2020; 141:71-76. [DOI: 10.1016/j.urology.2020.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/21/2020] [Accepted: 02/16/2020] [Indexed: 11/23/2022]
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39
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Newell J, Averch TD. EDITORIAL COMMENT. Urology 2020; 141:76. [DOI: 10.1016/j.urology.2020.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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40
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Finney Rutten LJ, Ruddy KJ, Chlan LL, Griffin JM, Herrin J, Leppin AL, Pachman DR, Ridgeway JL, Rahman PA, Storlie CB, Wilson PM, Cheville AL. Pragmatic cluster randomized trial to evaluate effectiveness and implementation of enhanced EHR-facilitated cancer symptom control (E2C2). Trials 2020; 21:480. [PMID: 32503661 PMCID: PMC7275300 DOI: 10.1186/s13063-020-04335-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/21/2020] [Indexed: 01/01/2023] Open
Abstract
Background The prevalence of inadequate symptom control among cancer patients is quite high despite the availability of definitive care guidelines and accurate and efficient assessment tools. Methods We will conduct a hybrid type 2 stepped wedge pragmatic cluster randomized clinical trial to evaluate a guideline-informed enhanced, electronic health record (EHR)-facilitated cancer symptom control (E2C2) care model. Teams of clinicians at five hospitals that care for patients with various cancers will be randomly assigned in steps to the E2C2 intervention. The E2C2 intervention will have two levels of care: level 1 will offer low-touch, automated self-management support for patients reporting moderate sleep disturbance, pain, anxiety, depression, and energy deficit symptoms or limitations in physical function (or both). Level 2 will offer nurse-managed collaborative care for patients reporting more intense (severe) symptoms or functional limitations (or both). By surveying and interviewing clinical staff, we will also evaluate whether the use of a multifaceted, evidence-based implementation strategy to support adoption and use of the E2C2 technologies improves patient and clinical outcomes. Finally, we will conduct a mixed methods evaluation to identify disparities in the adoption and implementation of the E2C2 intervention among elderly and rural-dwelling patients with cancer. Discussion The E2C2 intervention offers a pragmatic, scalable approach to delivering guideline-based symptom and function management for cancer patients. Since discrete EHR-imbedded algorithms drive defining aspects of the intervention, the approach can be efficiently disseminated and updated by specifying and modifying these centralized EHR algorithms. Trial registration ClinicalTrials.gov, NCT03892967. Registered on 25 March 2019.
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Affiliation(s)
- Lila J Finney Rutten
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA. .,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | - Kathryn J Ruddy
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Linda L Chlan
- Department of Nursing, Mayo Clinic, Rochester, MN, USA
| | - Joan M Griffin
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Jeph Herrin
- Yale University School of Medicine, New Haven, CT, USA
| | - Aaron L Leppin
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.,Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | | | - Jennifer L Ridgeway
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Parvez A Rahman
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Curtis B Storlie
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Patrick M Wilson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Andrea L Cheville
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Community Palliative Medicine, Mayo Clinic, Rochester, MN, USA
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Choosing quality problems wisely: identifying improvements worth developing and sustaining. BMJ Qual Saf 2020; 29:1-2. [DOI: 10.1136/bmjqs-2020-011054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2020] [Indexed: 12/21/2022]
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Jeffries M, Gude WT, Keers RN, Phipps DL, Williams R, Kontopantelis E, Brown B, Avery AJ, Peek N, Ashcroft DM. Understanding the utilisation of a novel interactive electronic medication safety dashboard in general practice: a mixed methods study. BMC Med Inform Decis Mak 2020; 20:69. [PMID: 32303219 PMCID: PMC7164282 DOI: 10.1186/s12911-020-1084-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 03/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improving medication safety is a major concern in primary care settings worldwide. The Salford Medication safety dASHboard (SMASH) intervention provided general practices in Salford (Greater Manchester, UK) with feedback on their safe prescribing and monitoring of medications through an online dashboard, and input from practice-based trained clinical pharmacists. In this study we explored how staff working in general practices used the SMASH dashboard to improve medication safety, through interactions with the dashboard to identify potential medication safety hazards and their workflow to resolve identified hazards. METHODS We used a mixed-methods study design involving quantitative data from dashboard user interaction logs from 43 general practices during the first year of receiving the SMASH intervention, and qualitative data from semi-structured interviews with 22 pharmacists and physicians from 18 practices in Salford. RESULTS Practices interacted with the dashboard a median of 12.0 (interquartile range, 5.0-15.2) times per month during the first quarter of use to identify and resolve potential medication safety hazards, typically starting with the most prevalent hazards or those they perceived to be most serious. Having observed a potential hazard, pharmacists and practice staff worked together to resolve that in a sequence of steps (1) verifying the dashboard information, (2) reviewing the patient's clinical records, and (3) deciding potential changes to the patient's medicines. Over time, dashboard use transitioned towards regular but less frequent (median of 5.5 [3.5-7.9] times per month) checks to identify and resolve new cases. The frequency of dashboard use was higher in practices with a larger number of at-risk patients. In 24 (56%) practices only pharmacists used the dashboard; in 12 (28%) use by other practice staff increased as pharmacist use declined after the initial intervention period; and in 7 (16%) there was mixed use by both pharmacists and practice staff over time. CONCLUSIONS An online medication safety dashboard enabled pharmacists to identify patients at risk of potentially hazardous prescribing. They subsequently worked with GPs to resolve risks on a case-by-case basis, but there were marked variations in processes between some practices. Workload diminished over time as it shifted towards resolving new cases of hazardous prescribing.
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Affiliation(s)
- Mark Jeffries
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Wouter T. Gude
- Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Richard N. Keers
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Denham L. Phipps
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Richard Williams
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- Health eResearch Centre, School of Health Sciences, University of Manchester, Manchester, UK
| | - Evangelos Kontopantelis
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- NIHR School for Primary Care Research, University of Manchester, Manchester, UK
| | - Benjamin Brown
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- Health eResearch Centre, School of Health Sciences, University of Manchester, Manchester, UK
| | - Anthony J. Avery
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Niels Peek
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- Health eResearch Centre, School of Health Sciences, University of Manchester, Manchester, UK
| | - Darren M. Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
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Goehler A, Moore C, Manne-Goehler JM, Arango J, D'Amato L, Forman HP, Weinreb J. Clinical Decision Support for Ordering CTA-PE Studies in the Emergency Department-A Pilot on Feasibility and Clinical Impact in a Tertiary Medical Center. Acad Radiol 2019; 26:1077-1083. [PMID: 30389307 DOI: 10.1016/j.acra.2018.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 09/08/2018] [Accepted: 09/12/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE To determine the feasibility and impact of Clinical Decision Support for imaging ordering. METHODS A survey of 231 emergency providers identified Computed tomography angiography (CTA)-Pulmonary embolism (PE) as an overutilized study. We developed an algorithm that combined established risk scores to stratify patients for PE work-up (recommendations: CTA, D-dimer or no further testing); the algorithm was integrated into the Epic Radiology Information Ordering System. RESULTS Among 872 studies requested, 479 (55%) received a recommendation to change their order: 6 (1.3%) were cancelled; 13 (2.7%) changed to a D-dimer, and 460 (96%) proceeded with CTA. Of the 853 studies conducted, 8.2% were positive for PE. The algorithm had good discriminatory power with positivity rates of 12.0% (CT), 10.0% (D-dimer), and 2.6% (no further testing). Compliance with the recommendation ranged from 12%-68% (mean 45%) with 10% correlation between compliance and positivity rates. CONCLUSION While the CDS algorithm was accurate, it had only a minimal impact on ordering practices, in part due to heterogeneity in physician adherence.
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Yarahuan JW, Billet A, Hron JD. A Quality Improvement Initiative to Decrease Platelet Ordering Errors and a Proposed Model for Evaluating Clinical Decision Support Effectiveness. Appl Clin Inform 2019; 10:505-512. [PMID: 31291678 DOI: 10.1055/s-0039-1693123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Clinical decision support (CDS) and computerized provider order entry have been shown to improve health care quality and safety, but may also generate previously unanticipated errors. We identified multiple CDS tools for platelet transfusion orders. In this study, we sought to evaluate and improve the effectiveness of those CDS tools while creating and testing a framework for future evaluation of other CDS tools. METHODS Using a query of an enterprise data warehouse at a tertiary care pediatric hospital, we conducted a retrospective analysis to assess baseline use and performance of existing CDS for platelet transfusion orders. Our outcome measure was the percentage of platelet undertransfusion ordering errors. Errors were defined as platelet transfusion volumes ordered which were less than the amount recommended by the order set used. We then redesigned our CDS and measured the impact of our intervention prospectively using statistical process control methodology. RESULTS We identified that 62% of all platelet transfusion orders were placed with one of two order sets (Inpatient Service 1 and Inpatient Service 2). The Inpatient Service 1 order set had a significantly higher occurrence of ordering errors (3.10% compared with 1.20%). After our interventions, platelet transfusion order error occurrence on Inpatient Service 1 decreased from 3.10 to 0.33%. CONCLUSION We successfully reduced platelet transfusion ordering errors by redesigning our CDS tools. We suggest that the use of collections of clinical data may help identify patterns in erroneous ordering, which could otherwise go undetected. We have created a framework which can be used to evaluate the effectiveness of other similar CDS tools.
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Affiliation(s)
- Julia Whitlow Yarahuan
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Amy Billet
- Division of Hematologic Malignancies and Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Jonathan D Hron
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
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Abstract
Clinical guidelines that support practice and improve care are essential in this era of evidence-based medicine. However, implementing this guidance often falls short in practice. Sharing knowledge and auditing practice are important, but not sufficient to implement change. This article brings together evidence from the study of behaviour, education and clinical practice and offers practical tips on how practising neurologists might bring about change in the healthcare environment. Common themes include the importance of team working, multidisciplinary engagement, taking time to identify who and what needs changing, and selecting the most appropriate tool(s) for the job. Engaging with the challenge is generally more rewarding than resisting and is important for the effective provision of care.
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Affiliation(s)
- Josephine Mayer
- Institute of Medical and Biomedical Education, University of London Saint George's, London, UK
| | - Christopher Kipps
- Department of Neurology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Hannah R Cock
- Institute of Medical and Biomedical Education, University of London Saint George's, London, UK
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Garneau WM, Knight AM, Pahwa AK. Effectiveness of a Best Practice Alert to Reduce Telemetry Orders. JAMA Intern Med 2019; 179:844. [PMID: 31157837 DOI: 10.1001/jamainternmed.2019.0708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Amy M Knight
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amit K Pahwa
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Determining Root Causes and Designing Change Ideas in a Quality Improvement Project. Can J Diabetes 2019; 43:241-248. [DOI: 10.1016/j.jcjd.2019.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/04/2019] [Accepted: 03/05/2019] [Indexed: 11/19/2022]
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Wai JM, Aloezos C, Mowrey WB, Baron SW, Cregin R, Forman HL. Using clinical decision support through the electronic medical record to increase prescribing of high-dose parenteral thiamine in hospitalized patients with alcohol use disorder. J Subst Abuse Treat 2019; 99:117-123. [PMID: 30797383 DOI: 10.1016/j.jsat.2019.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 01/20/2019] [Accepted: 01/23/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with alcohol use disorder (AUD) are at an increased risk of developing Wernicke's encephalopathy (WE), a devastating and difficult diagnosis caused by thiamine deficiency. Even as AUD is present in up to 25% of hospitalized patients on medical floors, appropriate thiamine supplementation in the hospital setting remains inadequate. These patients are particularly susceptible to thiamine deficiency and subsequent WE due to both their alcohol use and active medical illnesses. The electronic medical record (EMR) has become ubiquitous in health care systems and can be used as a tool to improve the care of hospitalized patients. METHODS As a quality improvement initiative, we implemented a medication order panel in the EMR with autopopulated orders for thiamine dosing to increase the appropriate use of high-dose parenteral thiamine (HPT) for hospitalized patients with AUD. We conducted a retrospective cohort study of all inpatients with AUD who received an Addiction Psychiatry Consult Service consult three months before and after the EMR change. We compared the proportion of patients receiving HPT prior to consultation (primary outcome) and the length of stay (secondary outcome) between the historical control group and the EMR intervention group. RESULTS Patients in the EMR intervention group were significantly more likely to receive HPT than the historical control group (20.2% vs. 2.7%, p < 0.0001). This difference remained statistically significant when adjusted for potential confounders (OR: 9.89, 95% CI: [2.77, 35.34], p = 0.0004). There was a trend towards statistical significance that the intervention group had a higher likelihood of being prescribed any thiamine (76.6% vs. 64.6%, p = 0.06) and had a shorter length of stay (median (IQR): 3.8 (2.4, 7.0) vs. 4.6 (2.9, 7.8) days, p = 0.06). CONCLUSION These results indicate that providing autopopulated thiamine order panels for patients with AUD can be an effective method for specialty services to increase appropriate care practices without additional education or training for providers. Further research should consider the clinical outcomes of increasing HPT for patients with AUD.
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Affiliation(s)
- Jonathan M Wai
- Department of Psychiatry, Columbia University, 1051 Riverside Drive, Unit 66, Office 3705, New York, NY 10032, USA; Division on Substance Use Disorders, New York State Psychiatric Institute, Unit 66, Office 3705, New York, NY 10032, USA; Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA.
| | - Christopher Aloezos
- Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA; Department of Psychiatry, NYU School of Medicine, One Park Avenue, New York, NY 10016, USA
| | - Wenzhu B Mowrey
- Division of Biostatistics, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA
| | - Sarah W Baron
- Department of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA
| | - Regina Cregin
- Department of Pharmacy, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA
| | - Howard L Forman
- Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA
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Timely Interventions for Children with ADHD through Web-Based Monitoring Algorithms. Diseases 2019; 7:diseases7010020. [PMID: 30736492 PMCID: PMC6473761 DOI: 10.3390/diseases7010020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/30/2019] [Accepted: 02/01/2019] [Indexed: 01/27/2023] Open
Abstract
The aim of this study was to evaluate an automated trigger algorithm designed to detect potentially adverse events in children with Attention-Deficit/Hyperactivity Disorder (ADHD), who were monitored remotely between visits. We embedded a trigger algorithm derived from parent-reported ADHD rating scales within an electronic patient monitoring system. We categorized clinicians’ alert resolution outcomes and compared Vanderbilt ADHD rating scale scores between patients who did or did not have triggered alerts. A total of 146 out of 1738 parent reports (8%) triggered alerts for 98 patients. One hundred and eleven alerts (76%) required immediate clinician review. Nurses successfully contacted parents for 68 (61%) of actionable alerts; 46% (31/68) led to a change in care plan prior to the next scheduled appointment. Compared to patients without alerts, patients with alerts demonstrated worsened ADHD severity (β = 5.8, 95% CI: 3.5–8.1 [p < 0.001] within 90 days prior to an alert. The trigger algorithm facilitated timely changes in the care plan in between face-to-face visits.
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Raymundo SRDO, Lobo SMA, Hussain KMK, Hussein KG, Secches IT. What has changed in venous thromboembolism prophylaxis for hospitalized patients over recent decades: review article. J Vasc Bras 2019; 18:e20180021. [PMID: 31191626 PMCID: PMC6542320 DOI: 10.1590/1677-5449.002118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 11/13/2018] [Indexed: 11/21/2022] Open
Abstract
Venous thromboembolism (VTE) is a common disease with high rates of morbidity and mortality and is considered the number one cause of avoidable mortality among hospitalized patients. Although VTE incidence is extremely high in all countries and there is ample evidence that thromboprophylaxis inexpensively reduces the rate of thromboembolic complications in both clinical and surgical patients, a great deal of doubt remains with respect to patient safety with this type of intervention and in relation to the ideal thromboprophylaxis methods. Countless studies and evidence-based recommendations confirm the efficacy of prophylaxis for prevention of VTE and/or patient deaths, but it remains underutilized to this day. This article presents a wide-ranging review of existing prophylaxis methods up to the present, from guidelines and national and international studies of thromboprophylaxis.
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Affiliation(s)
- Selma Regina de Oliveira Raymundo
- Faculdade Regional de Medicina de São José do Rio Preto – FAMERP, Hospital de Base, São José do Rio Preto, SP, Brasil.
- Hospital Austa, São José do Rio Preto, SP, Brasil.
| | - Suzana Margareth Ajeje Lobo
- Faculdade Regional de Medicina de São José do Rio Preto – FAMERP, Hospital de Base, São José do Rio Preto, SP, Brasil.
| | | | - Kassim Guzzon Hussein
- Faculdade de Medicina em São José do Rio Preto – FACERES, São José do Rio Preto, SP, Brasil.
| | - Isabela Tobal Secches
- Faculdade de Medicina em São José do Rio Preto – FACERES, São José do Rio Preto, SP, Brasil.
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