Implementing Clinical Guidelines in the Treatment of Diabetes Mellitus in 
General Practice

Hetlevik, Irene; Holmen, Jostein; Krüger, Ø; Kristensen, Pâl; Iversen, Hege; Furuseth, Kristian

doi:10.1017/s0266462300161185

Cited by 81 publications

(76 citation statements)

References 14 publications

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“…In addition, it should be noted that this is not unique to the U.K. Trials of guidelines and educational interventions have not met with unqualified success in other health care systems (for example, a trial of an educational strategy to reduce investigation rates for dysfunctional uterine bleeding in Australian women, and a trial of a computer-based guideline implementation system for the treatment of hypertension in Norway) (29,30).…”

Section: Conclusion: Implications For Epilepsy Carementioning

confidence: 99%

Implementation Strategies for a Scottish National Epilepsy Guideline in Primary Care: Results of the Tayside Implementation of Guidelines in Epilepsy Randomized (TIGER) Trial

et al. 2003

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Summary: Purpose: To determine the effectiveness of two dissemination and implementation strategies to implement a national guideline for epilepsy management in primary care settings. Methods: Three‐arm cluster‐randomized controlled trial. The participants were general practitioners from 68 practices in Tayside, Scotland, and 1,133 of their patients with self‐reported epilepsy treated with antiepileptic medications (AEDs). Practices were randomized blind to a control, intermediate, or intensive intervention. Control: Postal dissemination of a nationally developed clinical guideline. Intermediate intervention: Postal dissemination of the guideline supported by interactive, accredited workshops, and dedicated, structured protocol documents. Intensive intervention: Intermediate intervention plus a nurse specialist who supported and educated practices in the establishment of epilepsy review clinics. The primary outcome was the SF‐36 health‐related quality‐of‐life instrument. Secondary measures were a battery of prevalidated epilepsy‐specific quality‐of‐life instruments. These were administered at baseline and after the intervention phase. Process of care was assessed by case‐note review on number of review meetings and counseling sessions for epilepsy before and after the interventions. Results: None of the intervention groups showed any change in the primary or secondary outcome measures or process‐of‐care measures. Conclusions: None of the intervention strategies led to improvements in patient quality of life or quality of epilepsy care. Further research is needed to discover why the interventions failed, to identify barriers to adoption of guidelines, and to develop strategies that might improve implementation and uptake in the future.

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Section: Conclusion: Implications For Epilepsy Carementioning

confidence: 99%

Implementation Strategies for a Scottish National Epilepsy Guideline in Primary Care: Results of the Tayside Implementation of Guidelines in Epilepsy Randomized (TIGER) Trial

et al. 2003

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“…We defined compliance with recommendations as the percentage of recommended tests that were ordered or the percentage of redundant tests that were cancelled. The effect sizes varied strongly, ranging from the largest effect measured by van Wyk et al 45 (30% increase of appropriate ordering; risk ratio, 2.55; 95% CI, 2.26-2.87) to a negative effect measured by Hetlevik et al 42,43 (risk ratio, 0.9; 95% CI, 0.8-1.01). Bates et al 25 evaluated the effect of a CCDSS that notified when a potentially redundant laboratory test was ordered for 13 different tests.…”

Section: Discussionmentioning

confidence: 96%

“…[20][21][22][24][25][26][27][28][29][30][31][32][33][34][35][36][37] Eight studies (35%) were conducted in Europe. 23,[38][39][40][41][42][43][44][45] One study (4%) was conducted in Europe and Australia. 46,47 Thirteen studies (57%) evaluated CCDSSs in primary care,* 5 (22%) in hospital outpatient ambulatory care, 26,31,33,36,44 and 5 (22%) in hospital inpatient care.…”

Section: Included Studiesmentioning

confidence: 99%

“…46,47 Thirteen studies (57%) evaluated CCDSSs in primary care,* 5 (22%) in hospital outpatient ambulatory care, 26,31,33,36,44 and 5 (22%) in hospital inpatient care. 22,25,32,34 Intervention.-Fifteen different CCDSSs were studied, of which 6 (40%) were focused solely on laboratory testing, † 5 (33%) also included other reminders such as treatment options, [27][28][29]31,39,[41][42][43] and 4 (27%) were not stand-alone systems, but were developed by an EHR software vendor. ‡ Of the CCDSSs focused solely on laboratory testing, 3 (50%) were targeted at regulating blood clotting in patients using anticoagulants.…”

Section: Included Studiesmentioning

confidence: 99%

“…MacLean et al 27,28 studied the Vermont Diabetes Information System (Burlington, Vermont), which generates reminders based on the results from independent laboratories and sends these to the primary care physicians either through the EHR, by fax, or by mail, depending on their network capabilities. 43 studied a CCDSS service for the implementation of guidelines on diabetes and hypertension, including recommendations on diagnostics and laboratory tests. They noticed no significant effect on HbA 1c values after 18 months.…”

Section: 10])mentioning

confidence: 99%

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The Effects of Computerized Clinical Decision Support Systems on Laboratory Test Ordering: A Systematic Review

Delvaux¹,

Thienen²,

Heselmans³

et al. 2017

Archives of Pathology &Amp; Laboratory Medicine

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Context.-Inappropriate laboratory test ordering has been shown to be as high as 30%. This can have an important impact on quality of care and costs because of downstream consequences such as additional diagnostics, repeat testing, imaging, prescriptions, surgeries, or hospital stays.Objective.-To evaluate the effect of computerized clinical decision support systems on appropriateness of laboratory test ordering.Data Sources.-We used MEDLINE, Embase, CINAHL, MEDLINE In-Process and Other Non-Indexed Citations, Clinicaltrials.gov, Cochrane Library, and Inspec through December 2015. Investigators independently screened articles to identify randomized trials that assessed a computerized clinical decision support system aimed at improving laboratory test ordering by providing patientspecific information, delivered in the form of an on-screen management option, reminder, or suggestion through a computerized physician order entry using a rule-based or algorithm-based system relying on an evidence-based knowledge resource. Investigators extracted data from 30 papers about study design, various study characteristics, study setting, various intervention characteristics, involvement of the software developers in the evaluation of the computerized clinical decision support system, outcome types, and various outcome characteristics.Conclusions.-Because of heterogeneity of systems and settings, pooled estimates of effect could not be made. Data showed that computerized clinical decision support systems had little or no effect on clinical outcomes but some effect on compliance. Computerized clinical decision support systems targeted at laboratory test ordering for multiple conditions appear to be more effective than those targeted at a single condition.(Arch Pathol Lab Med. 2017;141:585-595; doi: 10.5858/ arpa.2016-0115-RA) A fter years of persistent increase, laboratory test ordering has become the highest-volume medical act. In the United States 1 and Europe, 55 the annual increase in the use of laboratory tests averaged around 5% during the last decade. Medicare 2 spending for clinical laboratory testing has peaked at almost $10 billion, accounting for 1.7% of the total health care budget. However, it has been estimated that when including non-Medicare spending, the figures for the United States are up to 7 times higher.3 In Europe, laboratory spending accounted for 1.8% of total health care spending in 2012, totaling E17 billion. Overuse of laboratory test ordering has been shown to be at 20%. 4 Even though reducing the overuse of laboratory testing may not seem very important in relation to the whole of health care spending, the true benefits are to be found in reducing downstream costs.5 These downstream activities include additional diagnostics such as repeat testing or imaging, prescriptions, surgeries, and hospital stays. Besides reducing costs, improving appropriate laboratory test ordering improves the quality of care by avoiding false-positive results and accidental findings of unknown significance, 6 and is not ass...

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Shared Electronic Vascular Risk Decision Support in Primary Care

Holbrook¹

2011

Arch Intern Med

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Implementing Clinical Guidelines in the Treatment of Diabetes Mellitus in General Practice

Abstract: Implementation of clinical guidelines for diabetes mellitus in general practice, by means of a CDSS and several procedures for implementation, did not result in a clinically significant change in doctors' behavior or in patient outcome.

Cited by 81 publications

References 14 publications

Implementation Strategies for a Scottish National Epilepsy Guideline in Primary Care: Results of the Tayside Implementation of Guidelines in Epilepsy Randomized (TIGER) Trial

Implementation Strategies for a Scottish National Epilepsy Guideline in Primary Care: Results of the Tayside Implementation of Guidelines in Epilepsy Randomized (TIGER) Trial

The Effects of Computerized Clinical Decision Support Systems on Laboratory Test Ordering: A Systematic Review

Shared Electronic Vascular Risk Decision Support in Primary Care

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