Abstract:Objectives
(1) Systematically review the literature on computerized audit and feedback (e-A&F) systems in healthcare. (2) Compare features of current systems against e-A&F best practices. (3) Generate hypotheses on how e-A&F systems may impact patient care and outcomes.
Methods
We searched MEDLINE (Ovid), EMBASE (Ovid), and CINAHL (Ebsco) databases to December 31, 2020. Two reviewers independently performed select… Show more
“…Therefore, an initial set of search terms was developed based on manuscripts known to the authors [11][12][13][14][15] and refined through iterative explorations of English language records in PubMed. Given the considerable heterogeneity in [16] terminology and the existence of a prior systematic review that did not capture all papers known to the authors [16], a systematic, three-tiered search strategy was implemented (Appendix A). A search utilizing a narrow set of terms supplemental to the prior systematic review was performed for January 1, 2015 through January 31, 2021, and a search using an expanded term list was performed for manuscripts more recent than that systematic review (January 1, 2021-May 31, 2022).…”
Section: Methodsmentioning
confidence: 99%
“…1 Dashboard definition. *Figure based on inclusion and exclusion criteria utilized by Tsang et al [ 16 ] Fig. 2 Comparing and contrasting digital tool characteristics …”
Section: Methodsmentioning
confidence: 99%
“… Dashboard definition. *Figure based on inclusion and exclusion criteria utilized by Tsang et al [ 16 ] …”
This scoping review summarizes the extent and characteristics of the published literature describing digital population management dashboards implemented to improve the quality of anticoagulant management. A standardized search protocol was executed to identify relevant manuscripts published between January 1, 2015 and May 31, 2022. The resulting records were systematically evaluated by multiple blinded reviewers and the findings from selected papers were evaluated and summarized. Twelve manuscripts were identified, originating from 5 organizations within the US and 2 from other countries. The majority (75%) described implementation in the outpatient setting. The identified papers described a variety of positive results of dashboard use, including a 24.5% reduction of questionable direct oral anticoagulant dosing in one organization, a 33.3% relative improvement in no-show appointments in an ambulatory care clinic, and a 75% improvement in intervention efficiency. One medical center achieved a 98.4% risk-appropriate venous thromboembolism risk prophylaxis prescribing rate and 40.6% reduction in anticoagulation-related adverse event rates. The manuscripts primarily described retrospective findings from single-center dashboard implementation experiences. Digital dashboards have been successfully implemented to support the anticoagulation of acute and ambulatory patients and available manuscripts suggest a positive impact on care-related processes and relevant patient outcomes. Prospective studies are needed to better characterize the implementation and impact of dashboards for anticoagulation management. Published reports suggest that digital dashboards may improve the quality, safety, and efficiency of anticoagulation management. Additional research is needed to validate these findings and to understand how best to implement these tools.
“…Therefore, an initial set of search terms was developed based on manuscripts known to the authors [11][12][13][14][15] and refined through iterative explorations of English language records in PubMed. Given the considerable heterogeneity in [16] terminology and the existence of a prior systematic review that did not capture all papers known to the authors [16], a systematic, three-tiered search strategy was implemented (Appendix A). A search utilizing a narrow set of terms supplemental to the prior systematic review was performed for January 1, 2015 through January 31, 2021, and a search using an expanded term list was performed for manuscripts more recent than that systematic review (January 1, 2021-May 31, 2022).…”
Section: Methodsmentioning
confidence: 99%
“…1 Dashboard definition. *Figure based on inclusion and exclusion criteria utilized by Tsang et al [ 16 ] Fig. 2 Comparing and contrasting digital tool characteristics …”
Section: Methodsmentioning
confidence: 99%
“… Dashboard definition. *Figure based on inclusion and exclusion criteria utilized by Tsang et al [ 16 ] …”
This scoping review summarizes the extent and characteristics of the published literature describing digital population management dashboards implemented to improve the quality of anticoagulant management. A standardized search protocol was executed to identify relevant manuscripts published between January 1, 2015 and May 31, 2022. The resulting records were systematically evaluated by multiple blinded reviewers and the findings from selected papers were evaluated and summarized. Twelve manuscripts were identified, originating from 5 organizations within the US and 2 from other countries. The majority (75%) described implementation in the outpatient setting. The identified papers described a variety of positive results of dashboard use, including a 24.5% reduction of questionable direct oral anticoagulant dosing in one organization, a 33.3% relative improvement in no-show appointments in an ambulatory care clinic, and a 75% improvement in intervention efficiency. One medical center achieved a 98.4% risk-appropriate venous thromboembolism risk prophylaxis prescribing rate and 40.6% reduction in anticoagulation-related adverse event rates. The manuscripts primarily described retrospective findings from single-center dashboard implementation experiences. Digital dashboards have been successfully implemented to support the anticoagulation of acute and ambulatory patients and available manuscripts suggest a positive impact on care-related processes and relevant patient outcomes. Prospective studies are needed to better characterize the implementation and impact of dashboards for anticoagulation management. Published reports suggest that digital dashboards may improve the quality, safety, and efficiency of anticoagulation management. Additional research is needed to validate these findings and to understand how best to implement these tools.
“…1 Dashboard definition. Figure based on inclusion and exclusion criteria utilized by Tsang et al [ 21 ]; To assure clarity for respondents, this figure was accompanied by a 2 min audio narration in the digital survey …”
Direct oral anticoagulants (DOAC) are the most widely prescribed oral anticoagulants in the United States. Despite advantages over warfarin, system-level improvements are needed to optimize outcomes. While Veterans Health Administration and others have described successful DOAC management dashboard implementation, the extent of use nationally is unknown. A survey of Anticoagulation Forum’s members was conducted to assess access to digital tools available within a dashboard and to describe implementation models. An Expert Forum was subsequently convened to identify barriers to dashboard development and adoption. Responses were received from 340 targeted recipients (8.5% of invitees). Only a minority of inpatient (25/52, 48.1%) and outpatient (47/133, 35.3%) respondents outside of Veterans Health Administration were able to generate rosters of DOAC users on-demand, and fewer had the ability to digitally display key clinical data elements, identify drug-related problems, document interventions, or generate reports. The lack of regulatory requirements regarding Anticoagulation Stewardship was identified by the Expert Forum as the major barrier to widespread development of digital tools for improved anticoagulation management. While some health systems have demonstrated the feasibility of DOAC dashboards and described their impact on quality and efficiency, these tools do not appear to be widely available in the United States apart from Veterans Health Administration. The lack of regulatory requirements for Anticoagulation Stewardship may be the primary barrier to the development of digital resources to better manage anticoagulants. Efforts to secure regulatory requirements for Anticoagulation Stewardship are needed, and evidence of improvements in clinical and financial outcomes through DOAC dashboard use will likely bolster such efforts.
“…Clinical audit, with feedback and reflection on practice, is a well-evidenced intervention to enhance health professional adherence to guidelines, 33 and is readily implemented using data from electronic clinical records. 34 …”
Summary
Therapeutic inertia, sometimes referred to as clinical inertia, has been defined as failure to initiate or intensify therapy when therapeutic goals are not reached.
Lack of initiation or intensification of treatment according to clinical guidelines has been linked to suboptimal control of a range of chronic conditions.
Clinician factors contributing to therapeutic inertia include knowledge gaps; discomfort with uncertainty about the diagnosis, therapeutic target, or evidence; concerns about the safety of treatment intensification; and time constraints. Patient characteristics that may be associated with therapeutic inertia include male sex, older age, lower life expectancy, multiple comorbidities and clinical parameters that are close to target.
There may be reasons other than therapeutic inertia that explain apparent undertreatment. Apparent inertia in prescribing may be accompanied by appropriate actions, such as provision of lifestyle advice or interventions to promote adherence to existing medication. Some patients choose not to intensify treatment.
Interventions to reduce therapeutic inertia include access to evidence-based treatment guidelines and point-of-care tools, preferably integrated with clinical record systems; clinician education including educational visits; reminders; clinical audits with feedback and reflection on practice; shared decision-making; prompting by patients; and ambulatory or home monitoring (e.g. ambulatory blood pressure monitoring).
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