ObjectivesChronic diseases are the leading cause of disability globally. Most chronic disease management occurs in primary care with outcomes varying across primary care providers. Computerised clinical decision support systems (CDSS) have been shown to positively affect clinician behaviour by improving adherence to clinical guidelines. This study provides a summary of the available evidence on the effect of CDSS embedded in electronic health records on patient-reported and clinical outcomes of adult patients with chronic disease managed in primary care.Design and eligibility criteriaSystematic review, including randomised controlled trials (RCTs), cluster RCTs, quasi-RCTs, interrupted time series and controlled before-and-after studies, assessing the effect of CDSS (vs usual care) on patient-reported or clinical outcomes of adult patients with selected common chronic diseases (asthma, chronic obstructive pulmonary disease, heart failure, myocardial ischaemia, hypertension, diabetes mellitus, hyperlipidaemia, arthritis and osteoporosis) managed in primary care.Data sourcesMedline, Embase, CENTRAL, Scopus, Health Management Information Consortium and trial register clinicaltrials.gov were searched from inception to 24 June 2020.Data extraction and synthesisScreening, data extraction and quality assessment were performed by two reviewers independently. The Cochrane risk of bias tool was used for quality appraisal.ResultsFrom 5430 articles, 8 studies met the inclusion criteria. Studies were heterogeneous in population characteristics, intervention components and outcome measurements and focused on diabetes, asthma, hyperlipidaemia and hypertension. Most outcomes were clinical with one study reporting on patient-reported outcomes. Quality of the evidence was impacted by methodological biases of studies.ConclusionsThere is inconclusive evidence in support of CDSS. A firm inference on the intervention effect was not possible due to methodological biases and study heterogeneity. Further research is needed to provide evidence on the intervention effect and the interplay between healthcare setting features, CDSS characteristics and implementation processes.PROSPERO registration numberCRD42020218184.

Objective: To analyze the effect of drain placement on postoperative hematoma formation and other associated outcomes post-thyroid surgery in a large national cohort.Methods: This was a retrospective study that analyzed data from the 2016-2017 National Surgical Quality Improvement Program (NSQIP) public use files. Baseline characteristics and perioperative outcomes were compared between drain and no drain cohorts.Results: A total of 11,626 patients were included; 3281 had a drain placed intraoperatively and 8345 did not. Otolaryngologists were 6.98 times more likely to place a drain after thyroidectomy than general surgeons (P < .001), and patients undergoing subtotal or total thyroidectomy were 2.17 times more likely to have a drain placed than if undergoing partial thyroidectomy (P < .001). Drain placement did not reduce hematoma formation on both univariate and multivariate analyses (adjusted OR = 0.93, P = .696). A slightly larger proportion of patients underwent unplanned intubation postoperatively among those who had a drain placed (0.76% vs. 0.29%, P < .001). Patients who received a drain were on average 4.63 times as likely to remain in the hospital for 2 or more days compared to those who did not receive a drain.Conclusion: Drain placement did not significantly affect postoperative hematoma formation following thyroidectomy. Drain placement should not be routinely employed in these patients. However, surgeon judgement and intraoperative considerations should be taken into account, as to when to place a drain.

Background In the context of a deepening global shortage of health workers and, in particular, the COVID-19 pandemic, there is growing international interest in, and use of, online symptom checkers (OSCs). However, the evidence surrounding the triage and diagnostic accuracy of these tools remains inconclusive. Objective This systematic review aimed to summarize the existing peer-reviewed literature evaluating the triage accuracy (directing users to appropriate services based on their presenting symptoms) and diagnostic accuracy of OSCs aimed at lay users for general health concerns. Methods Searches were conducted in MEDLINE, Embase, CINAHL, Health Management Information Consortium (HMIC), and Web of Science, as well as the citations of the studies selected for full-text screening. We included peer-reviewed studies published in English between January 1, 2010, and February 16, 2022, with a controlled and quantitative assessment of either or both triage and diagnostic accuracy of OSCs directed at lay users. We excluded tools supporting health care professionals, as well as disease- or specialty-specific OSCs. Screening and data extraction were carried out independently by 2 reviewers for each study. We performed a descriptive narrative synthesis. Results A total of 21,296 studies were identified, of which 14 (0.07%) were included. The included studies used clinical vignettes, medical records, or direct input by patients. Of the 14 studies, 6 (43%) reported on triage and diagnostic accuracy, 7 (50%) focused on triage accuracy, and 1 (7%) focused on diagnostic accuracy. These outcomes were assessed based on the diagnostic and triage recommendations attached to the vignette in the case of vignette studies or on those provided by nurses or general practitioners, including through face-to-face and telephone consultations. Both diagnostic accuracy and triage accuracy varied greatly among OSCs. Overall diagnostic accuracy was deemed to be low and was almost always lower than that of the comparator. Similarly, most of the studies (9/13, 69 %) showed suboptimal triage accuracy overall, with a few exceptions (4/13, 31%). The main variables affecting the levels of diagnostic and triage accuracy were the severity and urgency of the condition, the use of artificial intelligence algorithms, and demographic questions. However, the impact of each variable differed across tools and studies, making it difficult to draw any solid conclusions. All included studies had at least one area with unclear risk of bias according to the revised Quality Assessment of Diagnostic Accuracy Studies-2 tool. Conclusions Although OSCs have potential to provide accessible and accurate health advice and triage recommendations to users, more research is needed to validate their triage and diagnostic accuracy before widescale adoption in community and health care settings. Future studies should aim to use a common methodology and agreed standard for evaluation to facilitate objective benchmarking and validation. Trial Registration PROSPERO CRD42020215210; https://tinyurl.com/3949zw83

BACKGROUND In the context of a deepening global shortage of health workers, and particularly the COVID-19 pandemic, there is growing international interest in and use of online symptom checkers (OSCs). However, the evidence surrounding the safety and accuracy of OSCs remains inconclusive so far. The triage and diagnostic accuracy of these tools is an essential aspect that needs to be addressed before pushing any further implementation. OBJECTIVE This systematic review aimed to summarize the existing peer-reviewed literature evaluating the triage accuracy (directing users to appropriate services based on their presenting symptoms) and diagnostic accuracy of OSCs aimed at lay users for general health concerns. METHODS Searches were conducted in Medline, Embase, CINAHL, HMIC and Web of Science. We included peer-reviewed studies published in English between 1 January 2010 and 17 February 2022 with a quantitative assessment of triage and/or diagnostic accuracy of OSCs directed at lay users. We excluded tools supporting health professionals, and disease- or speciality-specific OSCs. Screening and data extraction were carried out independently by two reviewers for each study. We performed a descriptive narrative synthesis. RESULTS 21,284 studies were screened and 15 were included. Six studies reported on both triage and diagnostic accuracy, eight focused on triage accuracy, and one on diagnostic accuracy. Diagnostic and triage accuracy varied between studies and OSCs; most studies showed suboptimal diagnostic and triage accuracy. Frequency and urgency of the condition were the main variables that affected the levels of diagnostic and triage accuracy, along with specific features of the OSCs. The impact of each variable differed across tools and studies, making it difficult to draw any solid conclusions. Included studies had either a moderate or high risk of bias according to the revised tool for the Quality Assessment of Diagnostic Accuracy Studies 2. CONCLUSIONS While OSCs have significant potential to provide accessible and accurate health advice and triage recommendations to users, more research is needed to validate their triage and diagnostic accuracy prior to wide scale adoption in community and healthcare settings. Future studies should aim to use a common methodology and/or agreed standard for evaluation to facilitate objective benchmarking and validation.