Evaluating the effectiveness of clinical decision support systems: the case of multimorbidity care

Grace, Audrey; Mahony, Carolanne; O’Donoghue, John; Heffernan, Tony; Molony, David; Carroll, Thomas

doi:10.1080/12460125.2013.780320

Cited by 12 publications

(9 citation statements)

References 32 publications

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“…579 To date, a high-quality CDS system for the management of multimorbidity is yet to be developed and more innovative approaches may be needed. 580,581 Improving the coordination and integration of care Digital technologies can also be used to enhance integrated care by providing a platform for multiple HCPs to exchange and discuss patient information, and ultimately make shared recommendations. In doing so, such platforms could be expected to improve the continuity of care while also reducing the management inefficiencies often experienced by multimorbid patients.…”

Section: Supporting Clinical Decision Makingmentioning

confidence: 99%

Use of an Electronic Clinical Decision Support System in Primary Care to Assess Inappropriate Polypharmacy in Young Seniors With Multimorbidity: Observational, Descriptive, Cross-Sectional Study

et al. 2020

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Background Multimorbidity is a global health problem that is usually associated with polypharmacy, which increases the risk of potentially inappropriate prescribing (PIP). PIP entails higher hospitalization rates and mortality and increased usage of services provided by the health system. Tools exist to improve prescription practices and decrease PIP, including screening tools and explicit criteria that can be applied in an automated manner. Objective This study aimed to describe the prevalence of PIP in primary care consultations among patients aged 65-75 years with multimorbidity and polypharmacy, detected by an electronic clinical decision support system (ECDSS) following the 2015 American Geriatrics Society Beers Criteria, the European Screening Tool of Older Person’s Prescription (STOPP), and the Screening Tool to Alert doctors to Right Treatment (START). Methods This was an observational, descriptive, cross-sectional study. The sample included 593 community-dwelling adults aged 65-75 years (henceforth called young seniors), with multimorbidity (≥3 diseases) and polypharmacy (≥5 medications), who had visited their primary care doctor at least once over the last year at 1 of the 38 health care centers participating in the Multimorbidity and Polypharmacy in Primary Care (Multi-PAP) trial. Sociodemographic data, clinical and pharmacological treatment variables, and PIP, as detected by 1 ECDSS, were recorded. A multivariate logistic regression model with robust estimators was built to assess the factors affecting PIP according to the STOPP criteria. Results PIP was detected in 57.0% (338/593; 95% CI 53-61) and 72.8% (432/593; 95% CI 69.3-76.4) of the patients according to the STOPP criteria and the Beers Criteria, respectively, whereas 42.8% (254/593; 95% CI 38.9-46.8) of the patients partially met the START criteria. The most frequently detected PIPs were benzodiazepines (BZD) intake for more than 4 weeks (217/593, 36.6%) using the STOPP version 2 and the prolonged use of proton pump inhibitors (269/593, 45.4%) using the 2015 Beers Criteria. Being a woman (odds ratio [OR] 1.43, 95% CI 1.01-2.01; P=.04), taking a greater number of medicines (OR 1.25, 95% CI 1.14-1.37; P<.04), working in the primary sector (OR 1.91, 95% CI 1.25-2.93; P=.003), and being prescribed drugs for the central nervous system (OR 3.75, 95% CI 2.45-5.76; P<.001) were related to a higher frequency of PIP. Conclusions There is a high prevalence of PIP in primary care as detected by an ECDSS in community-dwelling young seniors with comorbidity and polypharmacy. The specific PIP criteria defined by this study are consistent with the current literature. This ECDSS can be useful for supervising prescriptions in primary health care consultations.

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Section: Supporting Clinical Decision Makingmentioning

confidence: 99%

Use of an Electronic Clinical Decision Support System in Primary Care to Assess Inappropriate Polypharmacy in Young Seniors With Multimorbidity: Observational, Descriptive, Cross-Sectional Study

et al. 2020

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“…Despite notable failures [ 36 ], CDS systems have the potential to improve clinical outcomes [ 37 , 38 ]. Indeed, multimorbidity was defined as one of the “grand challenges in clinical decision support” by Sittig et al [ 39 ]; however, this area remains underinvestigated [ 40 , 41 ], with concerns raised over the unmet needs in primary care [ 40 ]. Some of the current challenges are lack of provision of integrated clinical practice guidelines, disease-centered rather than patient-centered approaches, difficulties in embedding CDS into clinical systems, and lack of training to make best use of CDS [ 40 ].…”

Section: Introductionmentioning

confidence: 99%

“…Indeed, multimorbidity was defined as one of the “grand challenges in clinical decision support” by Sittig et al [ 39 ]; however, this area remains underinvestigated [ 40 , 41 ], with concerns raised over the unmet needs in primary care [ 40 ]. Some of the current challenges are lack of provision of integrated clinical practice guidelines, disease-centered rather than patient-centered approaches, difficulties in embedding CDS into clinical systems, and lack of training to make best use of CDS [ 40 ]. EHRs and computerized physician order entry systems include rules that deal with drug-drug interactions; however, the whole patient context is not considered and the system may “overalert” physicians [ 42 ].…”

Section: Introductionmentioning

confidence: 99%

Adoption of Clinical Decision Support in Multimorbidity: A Systematic Review

Fraccaro¹,

Casteleiro²,

Ainsworth³

et al. 2015

JMIR Med Inform

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BackgroundPatients with multiple conditions have complex needs and are increasing in number as populations age. This multimorbidity is one of the greatest challenges facing health care. Having more than 1 condition generates (1) interactions between pathologies, (2) duplication of tests, (3) difficulties in adhering to often conflicting clinical practice guidelines, (4) obstacles in the continuity of care, (5) confusing self-management information, and (6) medication errors. In this context, clinical decision support (CDS) systems need to be able to handle realistic complexity and minimize iatrogenic risks.ObjectiveThe aim of this review was to identify to what extent CDS is adopted in multimorbidity.MethodsThis review followed PRISMA guidance and adopted a multidisciplinary approach. Scopus and PubMed searches were performed by combining terms from 3 different thesauri containing synonyms for (1) multimorbidity and comorbidity, (2) polypharmacy, and (3) CDS. The relevant articles were identified by examining the titles and abstracts. The full text of selected/relevant articles was analyzed in-depth. For articles appropriate for this review, data were collected on clinical tasks, diseases, decision maker, methods, data input context, user interface considerations, and evaluation of effectiveness.ResultsA total of 50 articles were selected for the full in-depth analysis and 20 studies were included in the final review. Medication (n=10) and clinical guidance (n=8) were the predominant clinical tasks. Four studies focused on merging concurrent clinical practice guidelines. A total of 17 articles reported their CDS systems were knowledge-based. Most articles reviewed considered patients’ clinical records (n=19), clinical practice guidelines (n=12), and clinicians’ knowledge (n=10) as contextual input data. The most frequent diseases mentioned were cardiovascular (n=9) and diabetes mellitus (n=5). In all, 12 articles mentioned generalist doctor(s) as the decision maker(s). For articles reviewed, there were no studies referring to the active involvement of the patient in the decision-making process or to patient self-management. None of the articles reviewed adopted mobile technologies. There were no rigorous evaluations of usability or effectiveness of the CDS systems reported.ConclusionsThis review shows that multimorbidity is underinvestigated in the informatics of supporting clinical decisions. CDS interventions that systematize clinical practice guidelines without considering the interactions of different conditions and care processes may lead to unhelpful or harmful clinical actions. To improve patient safety in multimorbidity, there is a need for more evidence about how both conditions and care processes interact. The data needed to build this evidence base exist in many electronic health record systems and are underused.

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“…In this work we consider the medical reasoning aspect of patient management in a multimorbidity setting. Various works acknowledge several principles of patient management [41,49,75,83,99], but their respective analyses are neither systematic nor provide the necessary level of detail. In contrast, [72] stands out with a comprehensive enumeration and description of patient management principles, therein called Ariadne principles.…”

Section: Principles Of Patient Managementmentioning

confidence: 99%

“…These documents are by-and-large designed to target single health conditions, leading to issues in the presence of multiple health conditions (multimorbidities). Indeed, in such situations, clinical guidelines should be combined, hence raising the need to consider multiple interactions that impact the evolution of a patient [41,49]. These interactions may render suggested recommendations inapplicable, conflicting, overlapping and so forth.…”

Section: Introductionmentioning

confidence: 99%

Assumption-based argumentation with preferences and goals for patient-centric reasoning with interacting clinical guidelines

Čyras

Oliveira

Karamlou

et al. 2021

AAC

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A paramount, yet unresolved issue in personalised medicine is that of automated reasoning with clinical guidelines in multimorbidity settings. This entails enabling machines to use computerised generic clinical guideline recommendations and patient-specific information to yield patient-tailored recommendations where interactions arising due to multimorbidities are resolved. This problem is further complicated by patient management desiderata, in particular the need to account for patient-centric goals as well as preferences of various parties involved. We propose to solve this problem of automated reasoning with interacting guideline recommendations in the context of a given patient by means of computational argumentation. In particular, we advance a structured argumentation formalism ABA+G (short for Assumption-Based Argumentation with Preferences (ABA+) and Goals) for integrating and reasoning with information about recommendations, interactions, patient’s state, preferences and prioritised goals. ABA+G combines assumption-based reasoning with preferences and goal-driven selection among reasoning outcomes. Specifically, we assume defeasible applicability of guideline recommendations with the general goal of patient well-being, resolve interactions (conflicts and otherwise undesirable situations) among recommendations based on the state and preferences of the patient, and employ patient-centered goals to suggest interaction-resolving, goal-importance maximising and preference-adhering recommendations. We use a well-established Transition-based Medical Recommendation model for representing guideline recommendations and identifying interactions thereof, and map the components in question, together with the given patient’s state, prioritised goals, and preferences over actions, to ABA+G for automated reasoning. In this, we follow principles of patient management and establish corresponding theoretical properties as well as illustrate our approach in realistic personalised clinical reasoning scenaria.

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Evaluating the effectiveness of clinical decision support systems: the case of multimorbidity care

Cited by 12 publications

References 32 publications

Use of an Electronic Clinical Decision Support System in Primary Care to Assess Inappropriate Polypharmacy in Young Seniors With Multimorbidity: Observational, Descriptive, Cross-Sectional Study

Use of an Electronic Clinical Decision Support System in Primary Care to Assess Inappropriate Polypharmacy in Young Seniors With Multimorbidity: Observational, Descriptive, Cross-Sectional Study

Adoption of Clinical Decision Support in Multimorbidity: A Systematic Review

Assumption-based argumentation with preferences and goals for patient-centric reasoning with interacting clinical guidelines

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