A clinical decision support tool for improving adherence to guidelines on anticoagulant therapy in patients with atrial fibrillation at risk of stroke: A cluster-randomized trial in a Swedish primary care setting (the CDS-AF study)

Karlsson, Lars; Nilsson, Staffan; Bång, Magnus; Nilsson, Lennart; Charitakis, Emmanouil; Janzon, Magnus

doi:10.1371/journal.pmed.1002528

Cited by 91 publications

(61 citation statements)

References 38 publications

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“…Three recent trials12, 13, 14 found mixed results for clinical decision support, although the trial12 which obligated intervention providers to explain why his or her patient was not on AC achieved a 1.6% increase in rate of AC use compared with control providers. In 1 cluster‐randomized, multisite trial conducted in the United States,23 there was no added benefit of site visits and direct engagement with providers compared with the distribution of paper‐based reports of AC prescription percentages.…”

Section: Discussionmentioning

confidence: 99%

“…In contrast to the PINNACLE registry, we include primary care providers (in addition to cardiology providers) in our intervention in order to understand their contribution to AC decision making. Our intervention also stands in contrast to 3 recent publications12, 13, 14 that assess the impact of clinical decision support interventions, but without peer comparison.…”

Section: Introductionmentioning

confidence: 99%

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SUPPORT‐AF: Piloting a Multi‐Faceted, Electronic Medical Record‐Based Intervention to Improve Prescription of Anticoagulation

Kapoor

Amroze

Golden

et al. 2018

JAHA

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BackgroundOnly 50% of eligible atrial fibrillation (AF) patients receive anticoagulation (AC). Feasibility and effectiveness of electronic medical record (EMR)–based interventions to profile and raise provider AC percentage is poorly understood. The SUPPORT‐AF (Supporting Use of AC Through Provider Profiling of Oral AC Therapy for AF) study aims to improve rates of adherence to AC guidelines by developing and delivering supportive tools based on the EMR to providers treating patients with AF.Methods and ResultsWe emailed cardiologists and community‐based primary care providers affiliated with our institution reports of their AC percentage relative to peers. We also sent an electronic medical record–based message to these providers the day before an appointment with an atrial fibrillation patient who was eligible but not receiving AC. The electronic medical record message asked the provider to discuss AC with the patient if he or she deemed it appropriate. To assess feasibility, we tracked provider review of our correspondence. We also tracked the change in AC for intervention providers relative to alternate primary care providers not receiving our intervention. We identified 3786, 1054, and 566 patients cared for by 49 cardiology providers, 90 community‐based primary care providers, and 88 control providers, respectively. At baseline, the percentage of AC was 71.3%, 63.5%, and 58.3% for these 3 respective groups. Intervention providers reviewed our e‐mails and electronic medical record messages 45% and 96% of the time, respectively. For providers responding, patient refusal was the most common reason for patients not being on AC (21%) followed by high bleeding risk (19%). At follow‐up 10 weeks later, change in AC was no different for either cardiology or community‐based primary care providers relative to controls (0.2% lower and 0.01% higher, respectively).ConclusionsOur intervention profiling AC was feasible, but not sufficient to increase AC in our population.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

SUPPORT‐AF: Piloting a Multi‐Faceted, Electronic Medical Record‐Based Intervention to Improve Prescription of Anticoagulation

Kapoor

Amroze

Golden

et al. 2018

JAHA

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“…In another study, differences among physicians over the thromboprophylaxis treatment effect decreased with the help of CDSS providing treatment recommendation (p-value=0.02) [13]. In other studies, alert based CDSSs have been effective in physician behavior and progressive treatment improvement in anti-inflammatory drugs and lipid-lowering drugs, which has also been statistically significant [14][15][16]. As stated in another study, by following medical recommendations, doctors in the intervention group were able to improve the prescribing level of secondary preventive medication with the help of a regular CDSS [17].…”

Section: The Effect Of Cdss On Cardiovascular Diseasesmentioning

confidence: 85%

“…[47,56]. The system's userfriendliness and low running CDSS cost resulted in system efficiency in the care delivery process [12,14,15,20].…”

Section: Discussionmentioning

confidence: 99%

“…The effect of CDSS was measured using different methods in included studies. In most cases, the effect of these programs on physicians' performance and patient outcomes was positive and in others was ineffective.The results show that the use of CDSSs in cardiovascular patients has positive effects on physicians' performance through increasing the prescription of anticoagulants, anti-inflammatory drugs, antithrombotic drugs, lipid-lowering drugs, blood pressure drugs, cardiovascular drugs recommended for the reduction of cardiovascular diseases in patients with diabetes, observing clinical guidelines and improving the quality of patients[12,14,15,20]. The results of the current study are consistent with the results of Brokel et al and Duke et al in reducing inadequate prescriptions and enhancing the process of observing clinical guidelines in the positive effect of CDSS…”

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confidence: 99%

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The effects of clinical decision support system for prescribing on patient outcomes and physician practice performance: A systematic review

Moghadam¹,

Velayati²,

Sadoughi³

et al. 2020

Preprint

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Background The clinical decision support systems(CDSSs) for prescription medications is one of the technologies aimed at improving physician practice behavior and patient outcomes by reducing drug prescription errors. This study was conducted to investigate the effect of various CDSSs on physician practice behavior and patient outcomes.Methods This systematic review was conducted by searching in PubMed, EMBASE, Web of Science, Scopus and Cochrane Library from January 2005 to November 2019. Two researchers independently evaluated the studies. Any discrepancies over the eligibility of the studies between the two researchers were then resolved by consulting a third researcher. Finally, data were extracted from the articles; however, we could not able to conduct meta-analysis due to the heterogeneity of the studies and the narrative form of the findings.Results Based on the inclusion criteria, 46 studies were considered eligible for the analysis in this review. The CDSS for prescription medications had been used for various diseases, namely cardiovascular diseases, hypertension, diabetes, gastrointestinal and respiratory diseases, AIDS, appendicitis, kidney disease, malaria, high blood potassium, mental disease. Meanwhile, other cases such as the concurrent prescription of multiple drugs for the patient and its effects on the above-mentioned outcomes were evaluated. The analysis shows that in some cases the application of CDSS provides positive effects on patient outcomes and physician practice behaviors. No significant difference was observed in comparison between some other cases and conventional methods. We think that this could be due to the disease type, the quantity and type of CDSS requirements that influence the comparison.Conclusions Our findings suggest that the positive effects of the CDSS are due to factors such as user-friendliness, compliance with clinical guidelines, patient and doctor cooperation, integration of electronic health records, CDSS and pharmaceutical systems, consideration of the views of physicians in assessing the importance of CDSS alerts and their real-time alerts in the prescription.Registration number on PROSPERO CRD42018079936.

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The effects of on-screen, point of care computer reminders on processes and outcomes of care

Shojania

Jennings²,

Mayhew

et al. 2009

Cochrane Database of Systematic Reviews

360

339

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Background The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering ‘computer reminders’. Objectives To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care. Search methods We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles. Selection criteria Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care. Data collection and analysis Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome. Main results Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering. In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase). Authors’ conclusions Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.

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A clinical decision support tool for improving adherence to guidelines on anticoagulant therapy in patients with atrial fibrillation at risk of stroke: A cluster-randomized trial in a Swedish primary care setting (the CDS-AF study)

Cited by 91 publications

References 38 publications

SUPPORT‐AF: Piloting a Multi‐Faceted, Electronic Medical Record‐Based Intervention to Improve Prescription of Anticoagulation

SUPPORT‐AF: Piloting a Multi‐Faceted, Electronic Medical Record‐Based Intervention to Improve Prescription of Anticoagulation

The effects of clinical decision support system for prescribing on patient outcomes and physician practice performance: A systematic review

The effects of on-screen, point of care computer reminders on processes and outcomes of care

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