Effectiveness of Computer Automation for the Diagnosis and Management of Childhood Type 2 Diabetes: A Randomized Clinical Trial

Applications of Clinical Decision Support Systems in Diabetes Care: Scoping Review

BACKGROUND

Providing comprehensive and individualized diabetes care remains a significant challenge in the face of the increasing complexity of diabetes management and a lack of specialized endocrinologists to support diabetes care. Clinical decision support systems (CDSSs) are progressively being used to improve diabetes care, while many health care providers lack awareness and knowledge about CDSSs in diabetes care. A comprehensive analysis of the applications of CDSSs in diabetes care is still lacking.

OBJECTIVE

This review aimed to summarize the research landscape, clinical applications, and impact on both patients and physicians of CDSSs in diabetes care.

METHODS

We conducted a scoping review following the Arksey and O'Malley framework. A search was conducted in 7 electronic databases to identify the clinical applications of CDSSs in diabetes care up to June 30, 2022. Additional searches were conducted for conference abstracts from the period of 2021-2022. Two researchers independently performed the screening and data charting processes.

RESULTS

Of 11,569 retrieved studies, 85 (0.7%) were included for analysis. Research interest is growing in this field, with 45 (53%) of the 85 studies published in the past 5 years. Among the 58 (68%) out of 85 studies disclosing the underlying decision-making mechanism, most CDSSs (44/58, 76%) were knowledge based, while the number of non-knowledge-based systems has been increasing in recent years. Among the 81 (95%) out of 85 studies disclosing application scenarios, the majority of CDSSs were used for treatment recommendation (63/81, 78%). Among the 39 (46%) out of 85 studies disclosing physician user types, primary care physicians (20/39, 51%) were the most common, followed by endocrinologists (15/39, 39%) and nonendocrinology specialists (8/39, 21%). CDSSs significantly improved patients' blood glucose, blood pressure, and lipid profiles in 71% (45/63), 67% (12/18), and 38% (8/21) of the studies, respectively, with no increase in the risk of hypoglycemia.

CONCLUSIONS

CDSSs are both effective and safe in improving diabetes care, implying that they could be a potentially reliable assistant in diabetes care, especially for physicians with limited experience and patients with limited access to medical resources.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.37766/inplasy2022.9.0061.

The Application of Knowledge-Based Clinical Decision Support Systems to Enhance Adherence to Evidence-Based Medicine in Chronic Disease

Among the technology-based solutions, clinical decision support systems (CDSSs) have the ability to keep up with clinicians with the latest evidence in a smart way. Hence, the main objective of our study was to investigate the applicability and characteristics of CDSSs regarding chronic disease. The Web of Science, Scopus, OVID, and PubMed databases were searched using keywords from January 2000 to February 2023. The review was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Then, an analysis was done to determine the characteristics and applicability of CDSSs. The quality of the appraisal was assessed using the Mixed Methods Appraisal Tool checklist (MMAT). A systematic database search yielded 206 citations. Eventually, 38 articles from sixteen countries met the inclusion criteria and were accepted for final analysis. The main approaches of all studies can be classified into adherence to evidence-based medicine (84.2%), early and accurate diagnosis (81.6%), identifying high-risk patients (50%), preventing medical errors (47.4%), providing up-to-date information to healthcare providers (36.8%), providing patient care remotely (21.1%), and standardizing care (71.1%). The most common features among the knowledge-based CDSSs included providing guidance and advice for physicians (92.11%), generating patient-specific recommendations (84.21%), integrating into electronic medical records (60.53%), and using alerts or reminders (60.53%). Among thirteen different methods to translate the knowledge of evidence into machine-interpretable knowledge, 34.21% of studies utilized the rule-based logic technique while 26.32% of studies used rule-based decision tree modeling. For CDSS development and translating knowledge, diverse methods and techniques were applied. Therefore, the development of a standard framework for the development of knowledge-based decision support systems should be considered by informaticians.

Optimal Frequency of Urinary Albumin Screening in Type 1 Diabetes

OBJECTIVE

Kidney disease screening recommendations include annual urine testing for albuminuria after 5 years' duration of type 1 diabetes. We aimed to determine a simple, risk factor-based screening schedule that optimizes early detection and testing frequency.

RESEARCH DESIGN AND METHODS

Urinary albumin excretion measurements from 1,343 participants in the Diabetes Control and Complications Trial and its long-term follow-up were used to create piecewise-exponential incidence models assuming 6-month constant hazards. Likelihood of the onset of moderately or severely elevated albuminuria (confirmed albumin excretion rate AER ≥30 or ≥300 mg/24 h, respectively) and its risk factors were used to identify individualized screening schedules. Time with undetected albuminuria and number of tests were compared with annual screening.

RESULTS

The 3-year cumulative incidence of elevated albuminuria following normoalbuminuria at any time during the study was 3.2%, which was strongly associated with higher glycated hemoglobin (HbA1c) and AER. Personalized screening in 2 years for those with current AER ≤10 mg/24 h and HbA1c ≤8% (low risk [0.6% three-year cumulative incidence]), in 6 months for those with AER 21-30 mg/24 h or HbA1c ≥9% (high risk [8.9% three-year cumulative incidence]), and in 1 year for all others (average risk [2.4% three-year cumulative incidence]) was associated with 34.9% reduction in time with undetected albuminuria and 20.4% reduction in testing frequency as compared with annual screening. Stratification by categories of HbA1c or AER alone was associated with reductions of lesser magnitude.

CONCLUSIONS

A personalized alternative to annual screening in type 1 diabetes can substantially reduce both the time with undetected kidney disease and the frequency of urine testing.

ARTICLE HIGHLIGHTS

Kidney disease screening recommendations include annual urine testing for albuminuria after 5 years' duration of type 1 diabetes. We investigated simple screening schedules that optimize early detection and testing frequency. Personalized screening in 2 years for those with current AER ≤10 mg/24 h and HbA1c ≤8%, in 6 months for those with AER 21-30 mg/24 h or HbA1c ≥9%, and in 1 year for all others yielded 34.9% reduction in time with undetected albuminuria and 20.4% fewer evaluations compared with annual screening. A personalized alternative to annual screening in type 1 diabetes can substantially reduce both the time with undetected kidney disease and the frequency of urine testing.

Systematic review identifies deficiencies in reporting of diagnostic test accuracy among clinical decision support systems

OBJECTIVES

This systematic review assesses the reporting quality and risk of bias in studies evaluating the diagnostic test accuracy (DTA) of clinical decision support systems (CDSS).

STUDY DESIGN AND SETTING

The Cochrane Library, PubMed/MEDLINE, Scopus, and Web of Science were searched for studies, published between January 1, 2016 and May 31, 2021, evaluating the DTA of CDSS for human patients. Articles using a patient's self-diagnosis, assessing disease severity, focusing on treatment/follow-up, or comparing pre-post CDSS implementation periods were excluded. All eligible studies were assessed for reporting quality using STARD 2015 and for risk of bias using QUADAS-2. Item ratings were presented using heat maps. This study was reported as per PRISMA-DTA.

RESULTS

In total, 158 of 2,820 screened articles were included in the analysis. The studies were heterogeneous in terms of study characteristics, reporting quality, risk of biases, and applicability concerns with few highly rated studies. Mostly the overall quality was deficient for items addressing the domains 'methodology,' 'results,' and 'other information'.

CONCLUSION

Our analysis revealed shortcomings in critical domains of reporting quality and risk of bias, indicating the need for additional guidance and training in an interdisciplinary scientific field with mixed biostatistical expertise.

Screening for Prediabetes and Type 2 Diabetes in Children and Adolescents: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

The Centers for Disease Control and Prevention estimates that 210 000 children and adolescents younger than 20 years had diabetes as of 2018; of these, approximately 23 000 had type 2 diabetes. Youth with type 2 diabetes have an increased prevalence of associated chronic comorbid conditions, including hypertension, dyslipidemia, and nonalcoholic fatty liver disease. Data indicate that the incidence of type 2 diabetes is rising; from 2002-2003 to 2014-2015, incidence increased from 9.0 cases per 100 000 children and adolescents to 13.8 cases per 100 000 children and adolescents.

OBJECTIVE

The US Preventive Services Task Force (USPSTF) commissioned a review of the evidence on screening for prediabetes and type 2 diabetes in asymptomatic, nonpregnant persons younger than 18 years. This is a new recommendation.

POPULATION

Children and adolescents younger than 18 years without known diabetes or prediabetes or symptoms of diabetes or prediabetes.

EVIDENCE ASSESSMENT

The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in children and adolescents. There is a lack of evidence on the effect of screening for, and early detection and treatment of, type 2 diabetes on health outcomes in youth, and the balance of benefits and harms cannot be determined.

RECOMMENDATION

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in children and adolescents. (I statement).

Improving Patient-Centered Communication about Sudden Unexpected Death in Epilepsy through Computerized Clinical Decision Support

BACKGROUND

Sudden unexpected death in epilepsy (SUDEP) is a rare but fatal risk that patients, parents, and professional societies clearly recommend discussing with patients and families. However, this conversation does not routinely happen.

OBJECTIVES

This pilot study aimed to demonstrate whether computerized decision support could increase patient communication about SUDEP.

METHODS

A prospective before-and-after study of the effect of computerized decision support on delivery of SUDEP counseling. The intervention was a screening, alerting, education, and follow-up SUDEP module for an existing computerized decision support system (the Child Health Improvement through Computer Automation [CHICA]) in five urban pediatric primary care clinics. Families of children with epilepsy were contacted by telephone before and after implementation to assess if the clinician discussed SUDEP at their respective encounters.

RESULTS

The CHICA-SUDEP module screened 7,154 children age 0 to 21 years for seizures over 7 months; 108 (1.5%) reported epilepsy. We interviewed 101 families after primary care encounters (75 before and 26 after implementation) over 9 months. After starting CHICA-SUDEP, the number of caregivers who reported discussing SUDEP with their child's clinician more than doubled from 21% (16/75) to 46% (12/26; p = 0.03), and when the parent recalled who brought up the topic, 80% of the time it was the clinician. The differences between timing and sampling methodologies of before and after intervention cohorts could have led to potential sampling and recall bias.

CONCLUSION

Clinician-family discussions about SUDEP significantly increased in pediatric primary care clinics after introducing a systematic, computerized screening and decision support module. These tools demonstrate potential for increasing patient-centered education about SUDEP, as well as incorporating other guideline-recommended algorithms into primary and subspecialty cares.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov, NCT03502759.

Sex-based differences in screening and recognition of pre-diabetes and type 2 diabetes in pediatric primary care

BACKGROUND

Risk-based screening for type 2 diabetes (T2D) in youth with overweight/obesity is recommended, but rates remain low in practice. Identification of factors impacting provider ordering and patient completion of testing may guide strategies to improve screening.

OBJECTIVE

To evaluate predictors of hemoglobin A1c (A1c)-based T2D screening in pediatric primary care.

METHODS

This retrospective cohort study included 10 to 18 year-old patients with overweight/obesity (body mass index [BMI] Z-score ≥1.04) followed in a large academic-affiliated pediatric primary care network, 2009 to 2018. Percentages of patients with ordered and completed A1c were determined, and multivariable Cox proportional hazards regression was used to evaluate independent predictors of screening.

RESULTS

34 927 (48.0% female; 52.5% with BMI Z-score ≥1.64) youth followed for a median of 3.0 years were included. 21% (7457) of patients had screening ordered and 14% (4966) completed screening during follow-up. In multivariable regression, after controlling for race/ethnicity, BMI, family history of diabetes and age, males were significantly less likely to have ordered screening, but were equally or more likely to complete screening if ordered.

CONCLUSIONS

Male adolescents were less likely to undergo A1c-based T2D screening due to differential ordering practices. The source of this differential practice should be pursued to avoid under-recognition of cardiometabolic risk in at-risk male youth.

Assessment of Pediatrician Awareness and Implementation of the Addendum Guidelines for the Prevention of Peanut Allergy in the United States

Importance

The 2017 Addendum Guidelines for the Prevention of Peanut Allergy in the United States recommend that pediatricians assess infant peanut allergy risk and introduce peanut in the diet at age 4 to 6 months. Early introduction has the potential to prevent peanut allergy development.

Objectives

To measure the rates of guideline awareness and implementation and to identify barriers to and factors associated with implementation among US pediatricians.

Design, Setting, and Participants

This population-based study survey used a 29-item electronic survey instrument that was administered to pediatricians practicing across the United States from June 1, 2018, to December 1, 2018. Invitations to complete a survey were emailed to all pediatricians in the American Academy of Pediatrics vendor database. Eligible participants were nonretired US-based pediatricians providing general care to infants aged 12 months or younger.

Main Outcomes and Measures

The primary outcome was the prevalence of guideline implementation, which was measured by 1 survey item about awareness followed by a second item about implementation. Secondary outcomes included identification of guidelines-focused services provided by pediatricians, knowledge of the guidelines (measured with 3 clinical scenarios), barriers to guideline implementation, need for training, and facilitators of guideline implementation.

Results

A total of 1781 pediatricians were eligible to participate and completed the entire survey. Most respondents self-identified as white (1287 [72.5%]) and female (1210 [67.4%]) individuals. Overall, 1725 (93.4%; 95% CI, 92.2%-94.5%) pediatricians reported being aware of the guidelines. Of those pediatricians who had knowledge of the guidelines, 497 (28.9%; 95% CI, 26.8%-31.1%) reported full implementation and 1105 (64.3%; 95% CI, 62.0%-66.6%) reported partial implementation. Common barriers to implementation included parental concerns about allergic reactions (reported by 575 respondents [36.6%; 95% CI, 34.3%-39.1%]), uncertainty in understanding and correctly applying the guidelines (reported by 521 respondents [33.2%; 95% CI, 30.9%-35.6%]), and conducting in-office supervised feedings (reported by 509 respondents [32.4%; 95% CI, 30.1%-34.8%]). Many pediatricians (1175 [68.4%; 95% CI, 66.1%-70.5%]) reported a need for further training on the guidelines.

Conclusions and Relevance

This survey found that most pediatrician respondents appeared to know of the 2017 guidelines, but less than one-third of respondents reported full implementation. Results of this study may inform future efforts to eliminate barriers to guideline implementation and adherence, thereby reducing the incidence of peanut allergy in infants.

Clinician Perceptions of a Computerized Decision Support System for Pediatric Type 2 Diabetes Screening

OBJECTIVE

With the increasing prevalence of type 2 diabetes (T2D) in youth, primary care providers must identify patients at high risk and implement evidence-based screening promptly. Clinical decision support systems (CDSSs) provide clinicians with personalized reminders according to best evidence. One example is the Child Health Improvement through Computer Automation (CHICA) system, which, as we have previously shown, significantly improves screening for T2D. Given that the long-term success of any CDSS depends on its acceptability and its users' perceptions, we examined what clinicians think of the CHICA diabetes module.

METHODS

CHICA users completed an annual quality improvement and satisfaction questionnaire. Between May and August of 2015 and 2016, the survey included two statements related to the T2D-module: (1) "CHICA improves my ability to identify patients who might benefit from screening for T2D" and (2) "CHICA makes it easier to get the lab tests necessary to identify patients who have diabetes or prediabetes." Answers were scored using a 5-point Likert scale and were later converted to a 2-point scale: agree and disagree. The Pearson chi-square test was used to assess the relationship between responses and the respondents. Answers per cohort were compared using the Mann-Whitney U-test.

RESULTS

The majority of respondents (N = 60) agreed that CHICA improved their ability to identify patients who might benefit from screening but disagreed as to whether it helped them get the necessary laboratories. Scores were comparable across both years.

CONCLUSION

CHICA was endorsed as being effective for T2D screening. Research is needed to improve satisfaction for getting laboratories with CHICA.

Patient-focused outcomes are infrequently reported in pediatric health information technology trials: a systematic review

OBJECTIVES

Billions of dollars have been invested in Health Information Technologies (HITs), and randomized controlled trials (RCTs) have been conducted to identify the effects of these interventions. Our objective was to identify the types of outcomes that were measured and reported in these RCTs.

STUDY DESIGN AND SETTING

We completed a systematic review (Medline, EMBASE, and CENTRAL databases) of RCTs involving children (<18 years) and utilizing HIT interventions.

RESULTS

We identified 45 RCTs involving 323,945 children. Most studies reported process outcomes (n = 40/45 (88.9%)) but did not include patient-focused outcomes such as patient/carer functioning (n = 12/45 (26.7%)), clinical/physiological health (n = 10/45, 22.2%), quality of life (n = 3/45, 6.7%), or mortality (n = 1/45, 2.2%). Only 3 of 45 (6.7%) studies reported an evaluation of adverse events. In only 14 of 45 (31.1%) studies was it clear that all outcomes that were measured were reported.

CONCLUSION

It is difficult to use RCTs to fully evaluate the benefits and risks of using HIT interventions in pediatric health care settings because patient-focused outcomes and adverse events are rarely reported. Measures to improve the quality of future trials may include the publication of study protocols and the development of an outcome reporting framework or core outcome set.

Effect of a Computer-Based Decision Support Intervention on Autism Spectrum Disorder Screening in Pediatric Primary Care Clinics: A Cluster Randomized Clinical Trial

IMPORTANCE

Universal early screening for autism spectrum disorder (ASD) is recommended but not routinely performed.

OBJECTIVE

To determine whether computer-automated screening and clinical decision support can improve ASD screening rates in pediatric primary care practices.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized clinical trial, conducted between November 16, 2010, and November 21, 2012, compared ASD screening rates among a random sample of 274 children aged 18 to 24 months in urban pediatric clinics of an inner-city county hospital system with or without an ASD screening module built into an existing decision support software system. Statistical analyses were conducted from February 6, 2017, to June 1, 2018.

INTERVENTIONS

Four clinics were matched in pairs based on patient volume and race/ethnicity, then randomized within pairs. Decision support with the Child Health Improvement Through Computer Automation system (CHICA) was integrated with workflow and with the electronic health record in intervention clinics.

MAIN OUTCOMES AND MEASURES

The main outcome was screening rates among children aged 18 to 24 months. Because the intervention was discontinued among children aged 18 months at the request of the participating clinics, only results for those aged 24 months were collected and analyzed. Rates of positive screening results, clinicians' response rates to screening results in the computer system, and new cases of ASD identified were also measured. Main results were controlled for race/ethnicity and intracluster correlation.

RESULTS

Two clinics were randomized to receive the intervention, and 2 served as controls. Records from 274 children (101 girls, 162 boys, and 11 missing information on sex; age range, 23-30 months) were reviewed (138 in the intervention clinics and 136 in the control clinics). Of 263 children, 242 (92.0%) were enrolled in Medicaid, 138 (52.5%) were African American, and 96 (36.5%) were Hispanic. Screening rates in the intervention clinics increased from 0% (95% CI, 0%-5.5%) at baseline to 68.4% (13 of 19) (95% CI, 43.4%-87.4%) in 6 months and to 100% (18 of 18) (95% CI, 81.5%-100%) in 24 months. Control clinics had no significant increase in screening rates (baseline, 7 of 64 children [10.9%]; 6-24 months after the intervention, 11 of 72 children [15.3%]; P = .46). Screening results were positive for 265 of 980 children (27.0%) screened by CHICA during the study period. Among the 265 patients with positive screening results, physicians indicated any response in CHICA in 151 (57.0%). Two children in the intervention group received a new diagnosis of ASD within the time frame of the study.

CONCLUSIONS AND RELEVANCE

The findings suggest that computer automation, when integrated with clinical workflow and the electronic health record, increases screening of children for ASD, but follow-up by physicians is still flawed. Automation of the subsequent workup is still needed.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01612897.

Attention Deficit-Hyperactivity Disorder Group Visits Improve Parental Emotional Health and Perceptions of Child Behavior

OBJECTIVE

Group visits (GVs) are a promising intervention, but more work is needed to establish intervention effects. The objective was to evaluate the effectiveness of GVs and compare them with individual visits (INDs) for chronic care of attention deficit-hyperactivity disorder (ADHD).

METHODS

Caregivers and children (6-12 yrs) with ADHD participated in a comparative effectiveness trial from April 2014 to June 2015. Families were offered ADHD follow-up every 3 months as GVs versus INDs. Outcomes included ADHD core symptoms, child functioning at home, quality of life, perceived social support, and ADHD-related parenting challenges. Change scores from baseline to the study end were examined for parent and child outcomes within and between treatment conditions.

RESULTS

Ninety-one children from 84 families participated. Eighteen families withdrew or were lost to follow-up. GV families attended more visits over 12 months, had significant improvement in mean parental emotional health (p = 0.04), and had a greater decrease in challenges related to misbehavior compared with IND families (p < 0.03). GV families experienced significant improvements in child functioning at home (p = 0.01) and reported more time for themselves, other siblings, and routine household activities (p < 0.01). Children receiving care as INDs reported a significant drop in mean emotional health. There were no significant changes in other outcomes.

CONCLUSION

Families participating in GVs experienced multiple improvements related to family functioning and attended more follow-up visits. Findings confirm the effectiveness of the GV intervention in delivering critical parenting support as part of ADHD management.

Adolescent type 2 diabetes: Comparing the Pediatric Diabetes Consortium and Germany/Austria/Luxemburg Pediatric Diabetes Prospective registries

OBJECTIVE

To examine and compare the clinical characteristics and treatment of youth with type 2 diabetes (T2D) in two registries: one in Europe and one in the United States.

METHODS

Youth with onset of T2D at 10 to 18 years of age with current age <20 years and an office visit after diabetes duration >1 year were identified in the European (Prospective Diabetes Follow-up, DPV) and the United States (Pediatric Diabetes Consortium, PDC) databases. Demographic, physical and clinical characteristics and treatment at diagnosis as well as physical characteristics, treatment, laboratory data, and diabetes adverse events at most recent visit were analyzed from both registries.

RESULTS

At diagnosis, the majority were female and obese; 70% of DPV vs 34% of PDC youth were diagnosed by targeted diabetes testing. PDC youth were younger, 12 vs 13 years (P < 0.001), had a greater body mass index-SDS, 3.07 vs 2.74 (P < 0.001), a higher hemoglobin A1c (HbA1c), 9.9% vs 7.1% (P < 0.001), were more likely to present in DKA, 7.5% vs 1.3% (P < 0.001) and more likely to be treated with insulin, 62% vs 32% (P < 0.001); insulin treatment difference was not significant when adjusted for HbA1c. At follow-up, DPV youth had shorter diabetes duration, 2.1 vs 3.2 years (P < 0.001), lower HbA1c, 6.5% vs 7.8% (P < 0.001), were less likely to be treated with insulin, 36% vs 56%, (P < 0.001), and were more likely to have dyslipidemia and hypertension than PDC youth. PDC youth had a higher rate of microalbuminuria.

CONCLUSIONS

Both DPV and PDC youth have multiple risks for diabetes complications. Understanding reasons for persistently higher HbA1c in PDC youth requires further study.