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Pereyra L, Steinberg L, Criniti JM, Luna P, Escobar R, Bun M, Yantorno M, Esteves S, Gonzalez N, Hoffman P, Marcolongo M, Jury G, Topor J, Trelles F, Nazar C, Arantes VN. Usefulness of a mobile app to improve performance of specialists in responding correctly to CRC screening and surveillance clinical scenarios. Endosc Int Open 2021; 9:E1640-E1648. [PMID: 34790526 PMCID: PMC8589534 DOI: 10.1055/a-1544-4773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/08/2021] [Indexed: 12/24/2022] Open
Abstract
Background and study aims The adherence to and knowledge of physicians about colorectal cancer (CRC) screening and surveillance guidelines is still suboptimal, threatening the effectiveness of CRC screening. This study assessed the usefulness of a mobile decision support system (MDSS) to improve physician ability to recommend proper timing of and intervals for CRC screening and surveillance. Patients and methods This was a binational, single-blinded, randomized clinical trial including gastroenterologists and colorectal surgeons from Argentina and Uruguay. The specialists were invited to respond to a questionnaire with 10 CRC screening and surveillance clinical scenarios, randomized into two groups, with and without access to a dedicated app (CaPtyVa). The main outcome measure was the proportion of physicians correctly solving at least 60 % of the clinical cases according to local guidelines. Results A total of 213 physicians were included. The proportion of physicians responding correctly at least 60 % of the vignettes was higher in the app group as compared to the control group (90 % versus 56 %) (relative risk [RR] 1.6 95 % confidence interval [CI] 1.34-1.91). The performance was also higher in the app group for both vignette categories: CRC screening (93 % vs 75 % RR 1.24, 95 %CI 1.01-1.40) and surveillance (85 % vs 47 % RR 1.81 95 %CI 1.46-2.22), respectively. Physicians considered the app easy to use and of great utility in daily practice. Conclusions A MDSS was shown to be a useful tool that improved specialist performance in solving CRC screening and surveillance clinical scenarios. Its implementation in daily practice may facilitate the adherence of physicians to CRC screening and surveillance guidelines.
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Affiliation(s)
| | - Leandro Steinberg
- Gastroenterology Department, Fundación Favaloro, Buenos Aires, Argentina
| | - Juan M. Criniti
- Internal Medicine Department, Hospital Alemán, Buenos Aires, Argentina
| | - Pablo Luna
- Endoscopy Unit, Hospital Alemán, Buenos Aires, Argentina
| | - Rafael Escobar
- Gastroenterology Department, Sanatorio Mendez, Buenos Aires, Argentina
| | | | - Martín Yantorno
- Gastroenterology Department, General San Martín, La Plata, Argentina
| | - Sebastian Esteves
- Gastroenterology and Endoscopy Department, Clínica Cmic, Neuquén, Argentina
| | - Nicolas Gonzalez
- Gastroenterology Department, Hospital Británico Montevideo, Uruguay
| | - Pablo Hoffman
- Gastroenterology Unit, Gedyt, Buenos Aires, Argentina
| | - Mariano Marcolongo
- Gastroenterology and Endoscopy Department, Hospital Italiano, Buenos Aires Argentina
| | - Gastón Jury
- Gastroenterology Unit, Centro de Estudios Digestivos, Mar Del Plata, Argentina
| | - Javier Topor
- Gastroenterology Department, Sanatorio Mater Dei, Buenos Aires, Argentina
| | - Félix Trelles
- Gastroenterology Department, Hospital Durand, Buenos Aires, Argentina
| | - Cristina Nazar
- Gastroenterology Department, Hospital Bonorino Udaondo, Buenos Aires, Argentina
| | - Vitor N. Arantes
- Endoscopy Unit, Clinics Hospital, Federal University of Minas Gerais, Brasil
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Shahmoradi L, Safdari R, Ahmadi H, Zahmatkeshan M. Clinical decision support systems-based interventions to improve medication outcomes: A systematic literature review on features and effects. Med J Islam Repub Iran 2021; 35:27. [PMID: 34169039 PMCID: PMC8214039 DOI: 10.47176/mjiri.35.27] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Indexed: 01/24/2023] Open
Abstract
Background: Clinical decision support systems (CDSSs) interventions were used to improve the life quality and safety in patients and also to improve practitioner performance, especially in the field of medication. Therefore, the aim of the paper was to summarize the available evidence on the impact, outcomes and significant factors on the implementation of CDSS in the field of medicine. Methods: This study is a systematic literature review. PubMed, Cochrane Library, Web of Science, Scopus, EMBASE, and ProQuest were investigated by 15 February 2017. The inclusion requirements were met by 98 papers, from which 13 had described important factors in the implementation of CDSS, and 86 were medicated-related. We categorized the system in terms of its correlation with medication in which a system was implemented, and our intended results were examined. In this study, the process outcomes (such as; prescription, drug-drug interaction, drug adherence, etc.), patient outcomes, and significant factors affecting the implementation of CDSS were reviewed. Results: We found evidence that the use of medication-related CDSS improves clinical outcomes. Also, significant results were obtained regarding the reduction of prescription errors, and the improvement in quality and safety of medication prescribed. Conclusion: The results of this study show that, although computer systems such as CDSS may cause errors, in most cases, it has helped to improve prescribing, reduce side effects and drug interactions, and improve patient safety. Although these systems have improved the performance of practitioners and processes, there has not been much research on the impact of these systems on patient outcomes.
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Affiliation(s)
- Leila Shahmoradi
- Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Safdari
- Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Ahmadi
- OIM Department, Aston Business School, Aston University, Birmingham B4 7ET, United Kingdom
| | - Maryam Zahmatkeshan
- Noncommunicable Diseases Research Center, School of Medicine, Fasa University of Medical Sciences, Fasa, Iran
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Zaman SB, Evans RG, Singh R, Singh A, Singh P, Singh R, Thrift AG. Feasibility of community health workers using a clinical decision support system to screen and monitor non-communicable diseases in resource-poor settings: study protocol. Mhealth 2021; 7:15. [PMID: 33634198 PMCID: PMC7882273 DOI: 10.21037/mhealth-19-258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 06/02/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND It is imperative that coordinated and systematic action is undertaken, at all levels, to minimize the consequences of the growing global burden of non-communicable diseases (NCDs). An integrated multi-disciplinary primary care-based preventive program has the potential to reduce lifestyle-related risk factors contributing to NCDs. Accredited Social Health Activists (ASHAs), who are community health workers (CHWs), may be employed to screen populations for NCDs in rural India. To enable ASHAs to be supported when they are on their own in the community, we have developed a clinical decision support system (CDSS) "Arogya Sahyog" (a Hindi term meaning 'health assistant') to guide them through the process. Herein, we describe the protocol for testing this CDSS and the associated community-based management program for people with NCDs. METHODS This mixed-method study involving both qualitative and quantitative approaches will be conducted in two phases to test: (I) feasibility of the CDSS itself, and (II) feasibility of utilizing the app to develop capacity within the ASHA workforce. First, we will use a semi-structured questionnaire to determine details about the acceptance of using the app, satisfaction with the CDSS, perceived barriers, ideas for improvement, and willingness to use the CDSS. We will also test the usability of this CDSS for the identification of people with hypertension, with or without co-morbidities, by ASHAs and their supervisors. The CDSS will be installed on a tablet and is designed to help ASHAs to screen, provide lifestyle advice, and refer critical patients to primary care physicians. Second, to develop capacity within the ASHA workforce, ASHAs will be taught about NCDs, so they can motivate people to adhere to healthy activities and self-manage their NCDs. We will also test whether this training program improves ASHAs' knowledge about NCDs. We will further evaluate ASHAs' capacity to provide health promotional interventions to patients with, or at risk of, NCDs using the tablet device. DISCUSSION The study will enable us to test a CDSS and an educational training program. Specifically, we will test whether the program is user-friendly, easy-to-comprehend, easy-to-deliver, workflow-oriented, and comprehensive. We will determine whether mobilizing this ASHA workforce with the support of a CDSS could result in better management of hypertension and co-morbidities than usual care.
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Affiliation(s)
- Sojib Bin Zaman
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Roger G. Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - Rajkumari Singh
- Garhwal Community Development and Welfare Society, Chamba, Tehri Garhwal, Uttarakhand, India
| | - Akash Singh
- Garhwal Community Development and Welfare Society, Chamba, Tehri Garhwal, Uttarakhand, India
| | - Parul Singh
- Garhwal Community Development and Welfare Society, Chamba, Tehri Garhwal, Uttarakhand, India
| | - Rajesh Singh
- Garhwal Community Development and Welfare Society, Chamba, Tehri Garhwal, Uttarakhand, India
| | - Amanda G. Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
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Minian N, Baliunas D, Noormohamed A, Zawertailo L, Giesbrecht N, Hendershot CS, Le Foll B, Rehm J, Samokhvalov AV, Selby PL. The effect of a clinical decision support system on prompting an intervention for risky alcohol use in a primary care smoking cessation program: a cluster randomized trial. Implement Sci 2019; 14:85. [PMID: 31443663 PMCID: PMC6708174 DOI: 10.1186/s13012-019-0935-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 08/15/2019] [Indexed: 01/31/2023] Open
Abstract
Background Clinical decision support systems (CDSSs) may promote practitioner adherence to evidence-based guidelines. This study examined if the addition of a CDSS influenced practitioner delivery of a brief intervention with treatment-seeking smokers who were drinking above recommended alcohol consumption guidelines, compared with practitioners who do not receive a CDSS prompt. Methods This was a cluster randomized controlled trial conducted in primary health care clinics across Ontario, Canada, implementing the Smoking Treatment for Ontario Patients (STOP) smoking cessation program. Clinics randomized to the intervention group received a prompt when a patient reported consuming alcohol above the Canadian Cancer Society (CCS) guidelines; the control group did not receive computer alerts. The primary outcome was an offer of an appropriate educational alcohol resource, an alcohol reduction workbook for patients drinking above the CCS guidelines, and an abstinence workbook to patients scoring above 20 points in the AUDIT screening tool; the secondary outcome was patient acceptance of the resource. The tertiary outcome was patient abstinence from smoking, and alcohol consumption within CCS guidelines, at 6-month follow-up. Results were analyzed using a generalized estimation approach for fitting logistic regression using a population-averaged method. Results Two hundred and twenty-one clinics across Ontario were randomized for this study; 110 to the intervention arm and 111 to the control arm. From the 15,222 patients that enrolled in the smoking cessation program, 15,150 (99.6% of patients) were screened for alcohol use and 5715 patients were identified as drinking above the CCS guidelines. No statistically significant difference between groups was seen in practitioner offer of an educational alcohol resource to appropriate patients (OR = 1.19, 95% CI 0.88–1.64, p = 0.261) or in patient abstinence from smoking and drinking within the CCS guidelines at 6-month follow-up (OR = 0.93, 95% CI 0.71–1.22, p = 0.594). However, a significantly greater proportion of patients in the intervention group accepted the alcohol resource offered to them by their practitioner (OR = 1.48, 95% CI 1.01–2.16, p = 0.045). Conclusion A CDSS may not increase the likelihood of practitioners offering an educational alcohol resource, though it may have influenced patients’ acceptance of the resource. Trial registration This trial is registered with ClinicalTrials.gov, number NCT03108144, registered on April 11, 2017, “retrospectively registered”. Electronic supplementary material The online version of this article (10.1186/s13012-019-0935-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nadia Minian
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada
| | - Dolly Baliunas
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada.,Dalla Lana School of Public Health, University of Toronto, 155 College, Toronto, ON, M5T 3M7, Canada
| | - Aliya Noormohamed
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada
| | - Laurie Zawertailo
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada.,Department of Pharmacology and Toxicology, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 1A8, Canada
| | - Norman Giesbrecht
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Russell St, Toronto, ON, M5S 2S1, Canada
| | - Christian S Hendershot
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 60 White Squirrel Way, Toronto, ON, M6J 1H4, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada
| | - Bernard Le Foll
- Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada.,Department of Pharmacology and Toxicology, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 1A8, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 60 White Squirrel Way, Toronto, ON, M6J 1H4, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada
| | - Jürgen Rehm
- Dalla Lana School of Public Health, University of Toronto, 155 College, Toronto, ON, M5T 3M7, Canada.,Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Russell St, Toronto, ON, M5S 2S1, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 60 White Squirrel Way, Toronto, ON, M6J 1H4, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada.,Institute of Medical Science, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 3K1, Canada.,Institute for Clinical Psychology and Psychotherapy, TU Dresden, Chemnitzer Str. 46, 01187, Dresden, Germany
| | - Andriy V Samokhvalov
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Russell St, Toronto, ON, M5S 2S1, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada.,Institute of Medical Science, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 3K1, Canada
| | - Peter L Selby
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada. .,Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada. .,Dalla Lana School of Public Health, University of Toronto, 155 College, Toronto, ON, M5T 3M7, Canada. .,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada.
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Abstract
BACKGROUND Medication-related adverse events in primary care represent an important cause of hospital admissions and mortality. Adverse events could result from people experiencing adverse drug reactions (not usually preventable) or could be due to medication errors (usually preventable). OBJECTIVES To determine the effectiveness of professional, organisational and structural interventions compared to standard care to reduce preventable medication errors by primary healthcare professionals that lead to hospital admissions, emergency department visits, and mortality in adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases, and two trial registries on 4 October 2016, together with reference checking, citation searching and contact with study authors to identify additional studies. We also searched several sources of grey literature. SELECTION CRITERIA We included randomised trials in which healthcare professionals provided community-based medical services. We also included interventions in outpatient clinics attached to a hospital where people are seen by healthcare professionals but are not admitted to hospital. We only included interventions that aimed to reduce medication errors leading to hospital admissions, emergency department visits, or mortality. We included all participants, irrespective of age, who were prescribed medication by a primary healthcare professional. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data. Each of the outcomes (hospital admissions, emergency department visits, and mortality), are reported in natural units (i.e. number of participants with an event per total number of participants at follow-up). We presented all outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). We used the GRADE tool to assess the certainty of evidence. MAIN RESULTS We included 30 studies (169,969 participants) in the review addressing various interventions to prevent medication errors; four studies addressed professional interventions (8266 participants) and 26 studies described organisational interventions (161,703 participants). We did not find any studies addressing structural interventions. Professional interventions included the use of health information technology to identify people at risk of medication problems, computer-generated care suggested and actioned by a physician, electronic notification systems about dose changes, drug interventions and follow-up, and educational interventions on drug use aimed at physicians to improve drug prescriptions. Organisational interventions included medication reviews by pharmacists, nurses or physicians, clinician-led clinics, and home visits by clinicians.There is a great deal of diversity in types of professionals involved and where the studies occurred. However, most (61%) of the interventions were conducted by pharmacists or a combination of pharmacists and medical doctors. The studies took place in many different countries; 65% took place in either the USA or the UK. They all ranged from three months to 4.7 years of follow-up, they all took place in primary care settings such as general practice, outpatients' clinics, patients' homes and aged-care facilities. The participants in the studies were adults taking medications and the interventions were undertaken by healthcare professionals including pharmacists, nurses or physicians. There was also evidence of potential bias in some studies, with only 18 studies reporting adequate concealment of allocation and only 12 studies reporting appropriate protection from contamination, both of which may have influenced the overall effect estimate and the overall pooled estimate. Professional interventionsProfessional interventions probably make little or no difference to the number of hospital admissions (risk ratio (RR) 1.24, 95% confidence interval (CI) 0.79 to 1.96; 2 studies, 3889 participants; moderate-certainty evidence). Professional interventions make little or no difference to the number of participants admitted to hospital (adjusted RR 0.99, 95% CI 0.92 to 1.06; 1 study, 3661 participants; high-certainty evidence). Professional interventions may make little or no difference to the number of emergency department visits (adjusted RR 0.71, 95% CI 0.50 to 1.02; 2 studies, 1067 participants; low-certainty evidence). Professional interventions probably make little or no difference to mortality in the study population (adjusted RR 0.98, 95% CI 0.82 to 1.17; 1 study, 3538 participants; moderate-certainty evidence). Organisational interventionsOverall, it is uncertain whether organisational interventions reduce the number of hospital admissions (adjusted RR 0.85, 95% CI 0.71 to 1.03; 11 studies, 6203 participants; very low-certainty evidence). Overall, organisational interventions may make little difference to the total number of people admitted to hospital in favour of the intervention group compared with the control group (adjusted RR 0.92, 95% CI 0.86 to 0.99; 13 studies, 152,237 participants; low-certainty evidence. Overall, it is uncertain whether organisational interventions reduce the number of emergency department visits in favour of the intervention group compared with the control group (adjusted RR 0.75, 95% CI 0.49 to 1.15; 5 studies, 1819 participants; very low-certainty evidence. Overall, it is uncertain whether organisational interventions reduce mortality in favour of the intervention group (adjusted RR 0.94, 95% CI 0.85 to 1.03; 12 studies, 154,962 participants; very low-certainty evidence. AUTHORS' CONCLUSIONS Based on moderate- and low-certainty evidence, interventions in primary care for reducing preventable medication errors probably make little or no difference to the number of people admitted to hospital or the number of hospitalisations, emergency department visits, or mortality. The variation in heterogeneity in the pooled estimates means that our results should be treated cautiously as the interventions may not have worked consistently across all studies due to differences in how the interventions were provided, background practice, and culture or delivery of the interventions. Larger studies addressing both professional and organisational interventions are needed before evidence-based recommendations can be made. We did not identify any structural interventions and only four studies used professional interventions, and so more work needs to be done with these types of interventions. There is a need for high-quality studies describing the interventions in more detail and testing patient-related outcomes.
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Affiliation(s)
- Hanan Khalil
- Faculty of Medicine, Nursing and Health Sciences, School of Rural Health, PO Box 973, Moe, Victoria, Australia, 3825
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Kannan B, Nagella AB, Sathia Prabhu A, Sasidharan GM, Ramesh AS, Madhugiri V. Incidence of Potential Drug-Drug Interactions in a Limited and Stereotyped Prescription Setting - Comparison of Two Free Online Pharmacopoeias. Cureus 2016; 8:e886. [PMID: 28018756 PMCID: PMC5179105 DOI: 10.7759/cureus.886] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Drug-drug interactions (DDIs) are very common adverse events in health care delivery settings. The use of electronic pharmacopeias can potentially reduce the incidence of DDIs, but they are often thought to be cumbersome to use. This study is aimed at studying the incidence of potential DDIs in a surgical department, where a limited number of drugs are used in stereotyped combinations. We also compared two popular drug compendia in detecting potential DDIs. METHODS The prescriptions of selected patients were entered into Epocrates® and Medscape® for Android smartphones. Potential DDIs were generated and their categories were noted. The warnings generated by Epocrates® were compared with those generated by Medscape® and an agreement index was calculated. RESULTS Three hundred and thirty-one patients were included for analysis who had received a total of 2,878 drug orders. The incidence of potential DDIs was very high - 89% of all prescriptions. Phenytoin was the drug most commonly implicated, followed by furosemide. Of the DDIs detected, 0.14% were potentially serious and the drug combinations were contraindicated. There was a significant discrepancy between the categories of potential DDIs detected by Epocrates® and Medscape®. No clinically significant DDI was detected in any patient in this cohort. CONCLUSIONS Despite routinely using only a limited number of drugs in stereotyped combinations, prescriptions in surgical departments may not be immune from a significant incidence of DDIs. The use of free apps could reduce the incidence of DDIs, enhance patient safety, and also aid in educating trainees.
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Affiliation(s)
- Bhaskar Kannan
- Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Amrutha Bindu Nagella
- Department of Anesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - A Sathia Prabhu
- Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Gopalakrishnan M Sasidharan
- Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - A S Ramesh
- Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Abstract
The authors used a real-time survey instrument and subsequent focus group among primary care clinicians at a large healthcare system to assess usefulness of automated drug alerts. Of 108 alerts encountered, 0.9% (n = 1) represented critical alerts, and 16% (n = 17) were significant drug interaction alerts. Sixty-one percent (n = 66) involved duplication of a medication or medication class. The rest (n = 24) involved topical medications, inhalers, or vaccines. Of the 84 potentially relevant alerts, providers classified 11% (9/84), or about 1 in 9, as useful. Drug interaction alerts were more often deemed useful than drug duplication alerts (44.4% versus 1.5%, P < .001). Focus group participants generally echoed these results when ranking the relevance of 15 selected alerts, although there was wide variance in ratings for individual alerts. Hence, a "smarter" system that utilizes a set of mandatory alerts while allowing providers to tailor use of other automated warnings may improve clinical relevance of drug alert systems.
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Affiliation(s)
- Jeffrey R Spina
- VA Greater Los Angeles Healthcare System-West Los Angeles, CA, USA.
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Bloomfield C, Staatz CE, Unwin S, Hennig S. Assessing Predictive Performance of Published Population Pharmacokinetic Models of Intravenous Tobramycin in Pediatric Patients. Antimicrob Agents Chemother 2016; 60:3407-14. [PMID: 27001806 DOI: 10.1128/AAC.02654-15] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 03/11/2016] [Indexed: 11/20/2022] Open
Abstract
Several population pharmacokinetic models describe the dose-exposure relationship of tobramycin in pediatric patients. Before the implementation of these models in clinical practice for dosage adjustment, their predictive performance should be externally evaluated. This study tested the predictive performance of all published population pharmacokinetic models of tobramycin developed for pediatric patients with an independent patient cohort. A literature search was conducted to identify suitable models for testing. Demographic and pharmacokinetic data were collected retrospectively from the medical records of pediatric patients who had received intravenous tobramycin. Tobramycin exposure was predicted from each model. Predictive performance was assessed by visual comparison of predictions to observations, by calculation of bias and imprecision, and through the use of simulation-based diagnostics. Eight population pharmacokinetic models were identified. A total of 269 concentration-time points from 41 pediatric patients with cystic fibrosis were collected for external evaluation. Three models consistently performed best in all evaluations and had mean errors ranging from -0.4 to 1.8 mg/liter, relative mean errors ranging from 4.9 to 29.4%, and root mean square errors ranging from 47.8 to 66.9%. Simulation-based diagnostics supported these findings. Models that allowed a two-compartment disposition generally had better predictive performance than those that used a one-compartment disposition model. Several published models of the pharmacokinetics of tobramycin showed reasonable low levels of bias, although all models seemed to have some problems with imprecision. This suggests that knowledge of typical pharmacokinetic behavior and patient covariate values alone without feedback concentration measurements from individual patients is not sufficient to make precise predictions.
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Abdel-Rahman SM, Breitkreutz ML, Bi C, Matzuka BJ, Dalal J, Casey KL, Garg U, Winkle S, Leeder JS, Breedlove J, Rivera B. Design and Testing of an EHR-Integrated, Busulfan Pharmacokinetic Decision Support Tool for the Point-of-Care Clinician. Front Pharmacol 2016; 7:65. [PMID: 27065859 PMCID: PMC4811899 DOI: 10.3389/fphar.2016.00065] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/07/2016] [Indexed: 12/12/2022] Open
Abstract
Background: Busulfan demonstrates a narrow therapeutic index for which clinicians routinely employ therapeutic drug monitoring (TDM). However, operationalizing TDM can be fraught with inefficiency. We developed and tested software encoding a clinical decision support tool (DST) that is embedded into our electronic health record (EHR) and designed to streamline the TDM process for our oncology partners. Methods: Our development strategy was modeled based on the features associated with successful DSTs. An initial Requirements Analysis was performed to characterize tasks, information flow, user needs, and system requirements to enable push/pull from the EHR. Back-end development was coded based on the algorithm used when manually performing busulfan TDM. The code was independently validated in MATLAB using 10,000 simulated patient profiles. A 296-item heuristic checklist was used to guide design of the front-end user interface. Content experts and end-users (n = 28) were recruited to participate in traditional usability testing under an IRB approved protocol. Results: Decision support software was developed to systematically walk the point-of-care clinician through the TDM process. The system is accessed through the EHR which transparently imports all of the requisite patient data. Data are visually inspected and then curve fit using a model-dependent approach. Quantitative goodness-of-fit are converted to single tachometer where “green” alerts the user that the model is strong, “yellow” signals caution and “red” indicates that there may be a problem with the fitting. Override features are embedded to permit application of a model-independent approach where appropriate. Simulations are performed to target a desired exposure or dose as entered by the clinician and the DST pushes the user approved recommendation back into the EHR. Usability testers were highly satisfied with our DST and quickly became proficient with the software. Conclusions: With early and broad stake-holder engagement we developed a clinical DST for the non-pharmacologist. This tools affords our clinicians the ability to seamlessly transition from patient assessment, to pharmacokinetic modeling and simulation, and subsequent prescription order entry.
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Affiliation(s)
- Susan M Abdel-Rahman
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy HospitalKansas City, MO, USA; Department of Pediatrics, University of Missouri-Kansas City School of MedicineKansas City, MO, USA
| | | | - Charlie Bi
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy Hospital Kansas City, MO, USA
| | - Brett J Matzuka
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy Hospital Kansas City, MO, USA
| | - Jignesh Dalal
- Division of Hematology/Oncology, Rainbow Babies and Children's Hospital, Case Western Reserve University Cleveland, OH, USA
| | - K Leigh Casey
- Department of Pharmacy, Children's Mercy Hospital Kansas City, MO, USA
| | - Uttam Garg
- Department of Pediatrics, University of Missouri-Kansas City School of MedicineKansas City, MO, USA; Department of Laboratory Medicine, Children's Mercy HospitalKansas City, MO, USA
| | - Sara Winkle
- Department of Information Systems, Children's Mercy Hospital Kansas City, MO, USA
| | - J Steven Leeder
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy HospitalKansas City, MO, USA; Department of Pediatrics, University of Missouri-Kansas City School of MedicineKansas City, MO, USA
| | - JeanAnn Breedlove
- Department of Information Systems, Children's Mercy Hospital Kansas City, MO, USA
| | - Brian Rivera
- Department of Information Systems, Children's Mercy Hospital Kansas City, MO, USA
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Koskela T, Sandström S, Mäkinen J, Liira H. User perspectives on an electronic decision-support tool performing comprehensive medication reviews - a focus group study with physicians and nurses. BMC Med Inform Decis Mak 2016; 16:6. [PMID: 26801630 PMCID: PMC4724080 DOI: 10.1186/s12911-016-0245-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 01/16/2016] [Indexed: 11/12/2022] Open
Abstract
Background Although a number of studies have evaluated the effectiveness of computerized decision-support systems (CDSS), there is lack of data on user perspectives, barriers, and facilitators to the implementation of CDSSs in real-life surroundings. The aim of this study was to assess individually perceived barriers, facilitators and ideas influencing the CDSS implementation and usability. Methods In this qualitative study, five focus groups were carried out with physicians and nurses separately at the Tampere City Health Center, Finland. The participants were end-users of the EBMeDS computerized decision support system. An explorative data content analysis was applied. Results The most important barrier to benefitting from CDSS was the lack of structured and coded diagnosis documentation and outdated medication information in the electronic health records. This led to false alerts and distrust towards the system. Among the major facilitators found were e.g. the beneficial reminders that helped practitioners take into account matters otherwise ignored; automatic glomerular filtration rate (GFR) calculations; medication safety checks; and the summaries in the single medication review at a glance. Conclusions Physicians’ and nurses’ are keen to use the CDSS and it may enhance their inter-professional collaboration. Documenting patient information in a structured, uniform and easy manner is the essential starting point for electronic decision support. When implementing CDSS, managers need to focus on common practices in documenting structured data in their organizations in order to prevent undermining trust in the system.
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Affiliation(s)
- Tuomas Koskela
- University of Tampere, Department of General Practice, Lääkärinkatu 1, 33014, Tampereen yliopisto, Finland. .,Duodecim Medical Publications Ltd, PO Box 874, 00101, Helsinki, Finland.
| | - Saana Sandström
- Nordic Healthcare Group Ltd (at the time of the study), Vattuniemenranta 2, 00210, Helsinki, Finland.
| | - Joonas Mäkinen
- Duodecim Medical Publications Ltd, PO Box 874, 00101, Helsinki, Finland.
| | - Helena Liira
- School of Primary, Aboriginal and Rural Health Care, University of Western Australia (M706), 35 Stirling Highway, Crawley, WA, 6009, Australia.
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Ryan R, Santesso N, Lowe D, Hill S, Grimshaw J, Prictor M, Kaufman C, Cowie G, Taylor M. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database Syst Rev 2014; 2014:CD007768. [PMID: 24777444 PMCID: PMC6491214 DOI: 10.1002/14651858.cd007768.pub3] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use. OBJECTIVES To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence. SEARCH METHODS We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012. SELECTION CRITERIA We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview. DATA COLLECTION AND ANALYSIS We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses. MAIN RESULTS We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity. AUTHORS' CONCLUSIONS This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.
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Affiliation(s)
- Rebecca Ryan
- Centre for Health Communication and Participation, School of Public Health and Human Biosciences, La Trobe University, Bundoora, VIC, Australia, 3086
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Gillaizeau F, Chan E, Trinquart L, Colombet I, Walton RT, Rège-Walther M, Burnand B, Durieux P. Computerized advice on drug dosage to improve prescribing practice. Cochrane Database Syst Rev 2013:CD002894. [PMID: 24218045 DOI: 10.1002/14651858.cd002894.pub3] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Maintaining therapeutic concentrations of drugs with a narrow therapeutic window is a complex task. Several computer systems have been designed to help doctors determine optimum drug dosage. Significant improvements in health care could be achieved if computer advice improved health outcomes and could be implemented in routine practice in a cost-effective fashion. This is an updated version of an earlier Cochrane systematic review, first published in 2001 and updated in 2008. OBJECTIVES To assess whether computerized advice on drug dosage has beneficial effects on patient outcomes compared with routine care (empiric dosing without computer assistance). SEARCH METHODS The following databases were searched from 1996 to January 2012: EPOC Group Specialized Register, Reference Manager; Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Ovid; EMBASE, Ovid; and CINAHL, EbscoHost. A "top up" search was conducted for the period January 2012 to January 2013; these results were screened by the authors and potentially relevant studies are listed in Studies Awaiting Classification. The review authors also searched reference lists of relevant studies and related reviews. SELECTION CRITERIA We included randomized controlled trials, non-randomized controlled trials, controlled before-and-after studies and interrupted time series analyses of computerized advice on drug dosage. The participants were healthcare professionals responsible for patient care. The outcomes were any objectively measured change in the health of patients resulting from computerized advice (such as therapeutic drug control, clinical improvement, adverse reactions). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality. We grouped the results from the included studies by drug used and the effect aimed at for aminoglycoside antibiotics, amitriptyline, anaesthetics, insulin, anticoagulants, ovarian stimulation, anti-rejection drugs and theophylline. We combined the effect sizes to give an overall effect for each subgroup of studies, using a random-effects model. We further grouped studies by type of outcome when appropriate (i.e. no evidence of heterogeneity). MAIN RESULTS Forty-six comparisons (from 42 trials) were included (as compared with 26 comparisons in the last update) including a wide range of drugs in inpatient and outpatient settings. All were randomized controlled trials except two studies. Interventions usually targeted doctors, although some studies attempted to influence prescriptions by pharmacists and nurses. Drugs evaluated were anticoagulants, insulin, aminoglycoside antibiotics, theophylline, anti-rejection drugs, anaesthetic agents, antidepressants and gonadotropins. Although all studies used reliable outcome measures, their quality was generally low.This update found similar results to the previous update and managed to identify specific therapeutic areas where the computerized advice on drug dosage was beneficial compared with routine care:1. it increased target peak serum concentrations (standardized mean difference (SMD) 0.79, 95% CI 0.46 to 1.13) and the proportion of people with plasma drug concentrations within the therapeutic range after two days (pooled risk ratio (RR) 4.44, 95% CI 1.94 to 10.13) for aminoglycoside antibiotics;2. it led to a physiological parameter more often within the desired range for oral anticoagulants (SMD for percentage of time spent in target international normalized ratio +0.19, 95% CI 0.06 to 0.33) and insulin (SMD for percentage of time in target glucose range: +1.27, 95% CI 0.56 to 1.98);3. it decreased the time to achieve stabilization for oral anticoagulants (SMD -0.56, 95% CI -1.07 to -0.04);4. it decreased the thromboembolism events (rate ratio 0.68, 95% CI 0.49 to 0.94) and tended to decrease bleeding events for anticoagulants although the difference was not significant (rate ratio 0.81, 95% CI 0.60 to 1.08). It tended to decrease unwanted effects for aminoglycoside antibiotics (nephrotoxicity: RR 0.67, 95% CI 0.42 to 1.06) and anti-rejection drugs (cytomegalovirus infections: RR 0.90, 95% CI 0.58 to 1.40);5. it tended to reduce the length of time spent in the hospital although the difference was not significant (SMD -0.15, 95% CI -0.33 to 0.02) and to achieve comparable or better cost-effectiveness ratios than usual care;6. there was no evidence of differences in mortality or other clinical adverse events for insulin (hypoglycaemia), anaesthetic agents, anti-rejection drugs and antidepressants.For all outcomes, statistical heterogeneity quantified by I(2) statistics was moderate to high. AUTHORS' CONCLUSIONS This review update suggests that computerized advice for drug dosage has some benefits: it increases the serum concentrations for aminoglycoside antibiotics and improves the proportion of people for which the plasma drug is within the therapeutic range for aminoglycoside antibiotics.It leads to a physiological parameter more often within the desired range for oral anticoagulants and insulin. It decreases the time to achieve stabilization for oral anticoagulants. It tends to decrease unwanted effects for aminoglycoside antibiotics and anti-rejection drugs, and it significantly decreases thromboembolism events for anticoagulants. It tends to reduce the length of hospital stay compared with routine care while comparable or better cost-effectiveness ratios were achieved.However, there was no evidence that decision support had an effect on mortality or other clinical adverse events for insulin (hypoglycaemia), anaesthetic agents, anti-rejection drugs and antidepressants. In addition, there was no evidence to suggest that some decision support technical features (such as its integration into a computer physician order entry system) or aspects of organization of care (such as the setting) could optimize the effect of computerized advice.Taking into account the high risk of bias of, and high heterogeneity between, studies, these results must be interpreted with caution.
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Affiliation(s)
- Florence Gillaizeau
- French Cochrane Center, Hôpital Hôtel-Dieu, 1 place du Parvis Notre-Dame, Paris, France, 75004
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Cheung A, Weir M, Mayhew A, Kozloff N, Brown K, Grimshaw J. Overview of systematic reviews of the effectiveness of reminders in improving healthcare professional behavior. Syst Rev 2012; 1:36. [PMID: 22898173 PMCID: PMC3503870 DOI: 10.1186/2046-4053-1-36] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 07/04/2012] [Indexed: 03/20/2023] Open
Abstract
OBJECTIVE The purpose of this project was to conduct an overview of existing systematic reviews to evaluate the effectiveness of reminders in changing professional behavior in clinical settings. MATERIALS AND METHODS Relevant systematic reviews of reminder interventions were identified through searches in MEDLINE, EMBASE, DARE and the Cochrane Library in conjunction with a larger project examining professional behavioral change interventions. Reviews were appraised using AMSTAR, a validated tool for assessing the quality of systematic reviews. As most reviews only reported vote counting, conclusions about effectiveness for each review were based on a count of positive studies. If available, we also report effect sizes. Conclusions were based on the findings from higher quality and current systematic reviews. RESULTS Thirty-five reviews were eligible for inclusion in this overview. Ten reviews examined the effectiveness of reminders generally, 5 reviews focused on specific health care settings, 14 reviews concentrated on specific behaviors and 6 reviews addressed specific patient populations. The quality of the reviews was variable (median = 3, range = 1 to 8). Seven reviews had AMSTAR scores >5 and were considered in detail. Five of these seven reviews demonstrated positive effects of reminders in changing provider behavior. Few reviews used quantitative pooling methods; in one high quality and current review, the overall observed effects were moderate with an absolute median improvement in performance of 4.2% (IQR: 0.5% to 6.6%). DISCUSSION The results support that modest improvements can occur with the use of reminders. The effect size is consistent with other interventions that have been used to improve professional behavior. CONCLUSION Reminders appear effective in improving different clinical behaviors across a range of settings.
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Affiliation(s)
- Amy Cheung
- Department of Psychiatry, University of Toronto, 33 Russell St,, 3rd Floor Tower, Toronto, ON, Canada.
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Araujo de Carvalho EC, Batilana AP, Claudino W, Lima Reis LF, Schmerling RA, Shah J, Pietrobon R. Workflow in clinical trial sites & its association with near miss events for data quality: ethnographic, workflow & systems simulation. PLoS One 2012; 7:e39671. [PMID: 22768105 PMCID: PMC3387261 DOI: 10.1371/journal.pone.0039671] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 05/29/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND With the exponential expansion of clinical trials conducted in (Brazil, Russia, India, and China) and VISTA (Vietnam, Indonesia, South Africa, Turkey, and Argentina) countries, corresponding gains in cost and enrolment efficiency quickly outpace the consonant metrics in traditional countries in North America and European Union. However, questions still remain regarding the quality of data being collected in these countries. We used ethnographic, mapping and computer simulation studies to identify/address areas of threat to near miss events for data quality in two cancer trial sites in Brazil. METHODOLOGY/PRINCIPAL FINDINGS Two sites in Sao Paolo and Rio Janeiro were evaluated using ethnographic observations of workflow during subject enrolment and data collection. Emerging themes related to threats to near miss events for data quality were derived from observations. They were then transformed into workflows using UML-AD and modeled using System Dynamics. 139 tasks were observed and mapped through the ethnographic study. The UML-AD detected four major activities in the workflow evaluation of potential research subjects prior to signature of informed consent, visit to obtain subject́s informed consent, regular data collection sessions following study protocol and closure of study protocol for a given project. Field observations pointed to three major emerging themes: (a) lack of standardized process for data registration at source document, (b) multiplicity of data repositories and (c) scarcity of decision support systems at the point of research intervention. Simulation with policy model demonstrates a reduction of the rework problem. CONCLUSIONS/SIGNIFICANCE Patterns of threats to data quality at the two sites were similar to the threats reported in the literature for American sites. The clinical trial site managers need to reorganize staff workflow by using information technology more efficiently, establish new standard procedures and manage professionals to reduce near miss events and save time/cost. Clinical trial sponsors should improve relevant support systems.
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Affiliation(s)
- Elias Cesar Araujo de Carvalho
- Research on Research Group, Department of Surgery, Duke University, Durham, North Carolina, United States of America
- Cesumar, Universitary Center of Maringa, Paraná, Brazil
- UEM, State University of Maringa, Paraná, Brazil
| | - Adelia Portero Batilana
- Research on Research Group, Department of Surgery, Duke University, Durham, North Carolina, United States of America
| | | | | | | | - Jatin Shah
- Research on Research Group, Duke-NUS Graduate Medical School, Singapore, Singapore
- Research on Research Group, Duke University, Durham, North Carolina, United States of America
| | - Ricardo Pietrobon
- Department of Surgery, Duke University Health System, Durham, North Carolina, United States of America
- Duke - NUS Graduate Medical School, Singapore, Singapore
- Research on Research Group, Duke University, Durham, North Carolina, United States of America
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Abstract
INTRODUCTION The electronic medical record (EMR) is commonly thought to improve the safety and quality of care; however, there is scant information on the impact the EMR has on graduate medical education (GME). METHODS A review of English language literature was performed using MEDLINE and OVID databases using or combining the terms, EMR, GME, electronic health record, education, medical student, resident, clinical decisions support systems, quality, and safety. RESULTS The EMR has a negative effect on teacher and learner interactions, clinical reasoning, and has an inconsistent impact on resident workflow. Data on the impact of the EMR on patient safety, quality of care, and medical finances are mixed. DISCUSSION Based on the literature to date, the EMR has not had as dramatic an effect on patient outcomes is commonly believed. While the overall impact of the EMR on education seems to be negative, there are actions that can be taken to mitigate this impact.
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Affiliation(s)
- Paul J Schenarts
- Department of Surgery, Division of Surgical Education, Brody School of Medicine, East Carolina University, Greenville, North Carolina 27858, USA.
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Abstract
The purpose of this review is to consolidate existing evidence from published systematic reviews on health information system (HIS) evaluation studies to inform HIS practice and research. Fifty reviews published during 1994-2008 were selected for meta-level synthesis. These reviews covered five areas: medication management, preventive care, health conditions, data quality, and care process/outcome. After reconciliation for duplicates, 1276 HIS studies were arrived at as the non-overlapping corpus. On the basis of a subset of 287 controlled HIS studies, there is some evidence for improved quality of care, but in varying degrees across topic areas. For instance, 31/43 (72%) controlled HIS studies had positive results using preventive care reminders, mostly through guideline adherence such as immunization and health screening. Key factors that influence HIS success included having in-house systems, developers as users, integrated decision support and benchmark practices, and addressing such contextual issues as provider knowledge and perception, incentives, and legislation/policy.
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Affiliation(s)
- Francis Lau
- School of Health Information Science, University of Victoria, Victoria, British Columbia, Canada.
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Fischer SH, Tjia J, Field TS. Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review. J Am Med Inform Assoc 2011; 17:631-6. [PMID: 20962124 DOI: 10.1136/jamia.2009.000794] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Medication errors are a major source of morbidity and mortality. Inadequate laboratory monitoring of high-risk medications after initial prescription is a medical error that contributes to preventable adverse drug events. Health information technology (HIT)-based clinical decision support may improve patient safety by improving the laboratory monitoring of high-risk medications, but the effectiveness of such interventions is unclear. Therefore, the authors conducted a systematic review to identify studies that evaluate the independent effect of HIT interventions on improving laboratory monitoring for high-risk medications in the ambulatory setting using a Medline search from January 1, 1980 through January 1, 2009 and a manual review of relevant bibliographies. All anticoagulation monitoring studies were excluded. Eight articles met the inclusion criteria, including six randomized controlled trials and two pre-post intervention studies. Six of the studies were conducted in two large, integrated healthcare delivery systems in the USA. Overall, five of the eight studies reported statistically significant, but small, improvements in laboratory monitoring; only half of the randomized controlled trials reported statistically significant improvements. Studies that found no improvement were more likely to have used analytic strategies that addressed clustering and confounding. Whether HIT improves laboratory monitoring of certain high-risk medications for ambulatory patients remains unclear, and further research is needed to clarify this important question.
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Affiliation(s)
- Shira H Fischer
- Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01605, USA.
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Moxey A, Robertson J, Newby D, Hains I, Williamson M, Pearson SA. Computerized clinical decision support for prescribing: provision does not guarantee uptake. J Am Med Inform Assoc 2010; 17:25-33. [PMID: 20064798 PMCID: PMC2995634 DOI: 10.1197/jamia.m3170] [Citation(s) in RCA: 175] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Accepted: 09/23/2009] [Indexed: 11/10/2022] Open
Abstract
There is wide variability in the use and adoption of recommendations generated by computerized clinical decision support systems (CDSSs) despite the benefits they may bring to clinical practice. We conducted a systematic review to explore the barriers to, and facilitators of, CDSS uptake by physicians to guide prescribing decisions. We identified 58 studies by searching electronic databases (1990-2007). Factors impacting on CDSS use included: the availability of hardware, technical support and training; integration of the system into workflows; and the relevance and timeliness of the clinical messages. Further, systems that were endorsed by colleagues, minimized perceived threats to professional autonomy, and did not compromise doctor-patient interactions were accepted by users. Despite advances in technology and CDSS sophistication, most factors were consistently reported over time and across ambulatory and institutional settings. Such factors must be addressed when deploying CDSSs so that improvements in uptake, practice and patient outcomes may be achieved.
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Affiliation(s)
- Annette Moxey
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, The University of Newcastle, Australia
| | - Jane Robertson
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, The University of Newcastle, Australia
| | - David Newby
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, The University of Newcastle, Australia
| | - Isla Hains
- UNSW Cancer Research Centre, University of New South Wales, Sydney, Australia
| | | | - Sallie-Anne Pearson
- UNSW Cancer Research Centre, University of New South Wales, Sydney, Australia
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Pearson SA, Moxey A, Robertson J, Hains I, Williamson M, Reeve J, Newby D. Do computerised clinical decision support systems for prescribing change practice? A systematic review of the literature (1990-2007). BMC Health Serv Res 2009; 9:154. [PMID: 19715591 PMCID: PMC2744674 DOI: 10.1186/1472-6963-9-154] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2008] [Accepted: 08/28/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Computerised clinical decision support systems (CDSSs) are used widely to improve quality of care and patient outcomes. This systematic review evaluated the impact of CDSSs in targeting specific aspects of prescribing, namely initiating, monitoring and stopping therapy. We also examined the influence of clinical setting (institutional vs ambulatory care), system- or user-initiation of CDSS, multi-faceted vs stand alone CDSS interventions and clinical target on practice changes in line with the intent of the CDSS. METHODS We searched Medline, Embase and PsychINFO for publications from 1990-2007 detailing CDSS prescribing interventions. Pairs of independent reviewers extracted the key features and prescribing outcomes of methodologically adequate studies (experiments and strong quasi-experiments). RESULTS 56 studies met our inclusion criteria, 38 addressing initiating, 23 monitoring and three stopping therapy. At the time of initiating therapy, CDSSs appear to be somewhat more effective after, rather than before, drug selection has occurred (7/12 versus 12/26 studies reporting statistically significant improvements in favour of CDSSs on = 50% of prescribing outcomes reported). CDSSs also appeared to be effective for monitoring therapy, particularly using laboratory test reminders (4/7 studies reporting significant improvements in favour of CDSSs on the majority of prescribing outcomes). None of the studies addressing stopping therapy demonstrated impacts in favour of CDSSs over comparators. The most consistently effective approaches used system-initiated advice to fine-tune existing therapy by making recommendations to improve patient safety, adjust the dose, duration or form of prescribed drugs or increase the laboratory testing rates for patients on long-term therapy. CDSSs appeared to perform better in institutional compared to ambulatory settings and when decision support was initiated automatically by the system as opposed to user initiation. CDSSs implemented with other strategies such as education were no more successful in improving prescribing than stand alone interventions. Cardiovascular disease was the most studied clinical target but few studies demonstrated significant improvements on the majority of prescribing outcomes. CONCLUSION Our understanding of CDSS impacts on specific aspects of the prescribing process remains relatively limited. Future implementation should build on effective approaches including the use of system-initiated advice to address safety issues and improve the monitoring of therapy.
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Affiliation(s)
- Sallie-Anne Pearson
- UNSW Cancer Research Centre, University of New South Wales and Prince of Wales Clinical School, Sydney, Australia.
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Schedlbauer A, Prasad V, Mulvaney C, Phansalkar S, Stanton W, Bates DW, Avery AJ. What evidence supports the use of computerized alerts and prompts to improve clinicians' prescribing behavior? J Am Med Inform Assoc 2009; 16:531-8. [PMID: 19390110 DOI: 10.1197/jamia.m2910] [Citation(s) in RCA: 186] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Alerts and prompts represent promising types of decision support in electronic prescribing to tackle inadequacies in prescribing. A systematic review was conducted to evaluate the efficacy of computerized drug alerts and prompts searching EMBASE, CINHAL, MEDLINE, and PsychINFO up to May 2007. Studies assessing the impact of electronic alerts and prompts on clinicians' prescribing behavior were selected and categorized by decision support type. Most alerts and prompts (23 out of 27) demonstrated benefit in improving prescribing behavior and/or reducing error rates. The impact appeared to vary based on the type of decision support. Some of these alerts (n = 5) reported a positive impact on clinical and health service management outcomes. For many categories of reminders, the number of studies was very small and few data were available from the outpatient setting. None of the studies evaluated features that might make alerts and prompts more effective. Details of an updated search run in Jan 2009 are included in the supplement section of this review.
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Affiliation(s)
- Angela Schedlbauer
- Division of Primary Care, School of Community Health Sciences, Research and Learning Resources Division, Information Services, University of Nottingham, Nottingham, UK.
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Ammenwerth E, Schnell-Inderst P, Siebert U. Vision and challenges of Evidence-Based Health Informatics: a case study of a CPOE meta-analysis. Int J Med Inform 2010; 79:e83-8. [PMID: 19157969 DOI: 10.1016/j.ijmedinf.2008.11.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2008] [Revised: 09/02/2008] [Accepted: 11/28/2008] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To discuss, taking the example of a meta-analysis on computerized physician order entry (CPOE) systems, the special challenges of Evidence-Based Health Informatics, defined as the conscientious, explicit and judicious use of current best evidence when making decisions about introduction and operation of information technology in a given health care setting. METHODS We conducted a case study by performing a systematic review and meta-analysis of CPOE studies. We collected and discussed the challenges we addressed and how they could be overcome. RESULTS Challenges comprise the correct identification of published health informatics evaluation studies, the low reporting and study quality of studies, the problem of combining evidence from heterogeneous studies, and the problem of publication bias in health informatics. CONCLUSION Based on our experiences while conducting the CPOE meta-analysis, we argue that we are still at the beginning of Evidence-Based Health Informatics. To overcome the discussed challenges, health informatics should strive for harmonized terminology, a study registry, reporting standards, financial or legal incentives for conducting studies, methods to combine evidence from quantitative and qualitative studies, and guidelines for conducting and publishing evaluation studies.
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O'Donnell HC, Kaushal R, Barrón Y, Callahan MA, Adelman RD, Siegler EL. Physicians' attitudes towards copy and pasting in electronic note writing. J Gen Intern Med 2009; 24:63-8. [PMID: 18998191 PMCID: PMC2607489 DOI: 10.1007/s11606-008-0843-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Revised: 09/25/2008] [Accepted: 10/02/2008] [Indexed: 12/15/2022]
Abstract
BACKGROUND The ability to copy and paste text within computerized physician documentation facilitates electronic note writing, but may affect the quality of physician notes and patient care. Little is known about physicians' collective experience with the copy and paste function (CPF). OBJECTIVES To determine physicians' CPF use, perceptions of its impact on notes and patient care, and opinions regarding its future use. DESIGN Cross-sectional survey. PARTICIPANTS Resident and faculty physicians within two affiliated academic medical centers currently using a computerized documentation system. MEASUREMENTS Responses on a self-administered survey. RESULTS A total of 315 (70%) of 451 eligible physicians responded to the survey. Of the 253 (80%) physicians who wrote inpatient notes electronically, 226 (90%) used CPF, and 177 (70%) used it almost always or most of the time when writing daily progress notes. While noting that inconsistencies (71%) and outdated information (71%) were more common in notes containing copy and pasted text, few physicians felt that CPF had a negative impact on patient documentation (19%) or led to mistakes in patient care (24%). The majority of physicians (80%) wanted to continue to use CPF. CONCLUSIONS Although recognizing deficits in notes written using CPF, the majority of physicians used CPF to write notes and did not perceive an overall negative impact on physician documentation or patient care. Further studies of the effects of electronic note writing on the quality and safety of patient care are required.
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Affiliation(s)
- Heather C O'Donnell
- Department of Public Health, Weill Cornell Medical College, New York, NY, USA.
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Tisnado DM, Malin JL, Tao ML, Ganz P, Rose-Ash D, Hu AF, Adams J, Kahn KL. The structural landscape of the health care system for breast cancer care: results from the Los Angeles Women's Health Study. Breast J 2008; 15:17-25. [PMID: 19120382 DOI: 10.1111/j.1524-4741.2008.00666.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The structure of health care has been rapidly evolving in response to financial pressures and demands to improve quality. Little work has documented the structure of care and its impact in the context of breast cancer care. We conducted a survey to characterize Los Angeles physicians caring for breast cancer patients and the structural landscape of the healthcare system in which they practice. Cross-sectional survey of physicians who treated a population-based cohort of breast cancer patients. We surveyed 477 physicians, targeting all Los Angeles County medical oncologists, radiation oncologists, and surgeons reported by patients participating in the Los Angeles Women's Health Study (77% response rate). Specialty-specific questionnaires were developed. Items were based on the structure and quality of care literature, cognitive interviews with cancer care specialists, and existing physician survey instruments. Breast cancer care providers in Los Angeles are diverse, with one-third non-white and 46% speaking a non-English language. Group practice is most common, (37% single specialty, 16% group-model HMO, 8% multi-specialty group). Minimal teaching involvement predominates. Mean new breast cancer patient volumes are relatively high (8 per month overall; six for surgeons), representing 46% of new cancer patients. Physicians reported high career satisfaction levels (83-92%). Physicians were least satisfied with the amount of time spent with patients (82%). Data from this study represent important building blocks for further analyses to determine the impact of structural characteristics on the quality of care that breast cancer patient's experience.
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Affiliation(s)
- Diana M Tisnado
- Division of General Internal Medicine and Health Services Research, School of Medicine, University of California, Los Angeles, California 90095-1736, USA.
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Bywood PT, Lunnay B, Roche AM. Strategies for facilitating change in alcohol and other drugs (AOD) professional practice: a systematic review of the effectiveness of reminders and feedback. Drug Alcohol Rev 2008; 27:548-58. [PMID: 18696301 DOI: 10.1080/09595230802245535] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In all areas of health research, including the alcohol and other drugs (AOD) field, funds are committed to developing and evaluating research and resources, yet little is invested into helping potential resource users understand, adopt and implement innovations. This study evaluated the effectiveness of two professional practice change interventions (reminders and feedback) that are designed to bridge the 'research-practice gap' by increasing knowledge and changing behaviour of health-care professionals and specialist AOD workers. We conducted a systematic review of general health, AOD and mental health literature (1966 to March 2005). Fourteen existing systematic reviews and 15 primary studies were assessed. Because few studies evaluated the effectiveness of reminders and feedback in the AOD context, evidence is drawn largely from the general health-care literature. Use of reminders and feedback is supported for a range of health behaviours. AOD-specific clinical behaviours that are most likely to be improved with the use of reminders or feedback include pharmacotherapy prescribing, AOD education, screening and counselling and monitoring/management of AOD treatment and/or related problems (e.g. depression). Reminders and feedback are effective strategies to facilitate professional practice change and have potential in the AOD field. However, further well-designed empirical studies are needed to assess fully the effectiveness of these professional practice change strategies in AOD-specific contexts.
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Affiliation(s)
- Petra T Bywood
- National Centre for Education and Training on Addiction, Flinders University, South Australia, Australia.
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Durieux P, Trinquart L, Colombet I, Niès J, Walton R, Rajeswaran A, Rège Walther M, Harvey E, Burnand B. Computerized advice on drug dosage to improve prescribing practice. Cochrane Database Syst Rev 2008:CD002894. [PMID: 18646085 DOI: 10.1002/14651858.cd002894.pub2] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Maintaining therapeutic concentrations of drugs with a narrow therapeutic window is a complex task. Several computer systems have been designed to help doctors determine optimum drug dosage. Significant improvements in health care could be achieved if computer advice improved health outcomes and could be implemented in routine practice in a cost effective fashion. This is an updated version of an earlier Cochrane systematic review, by Walton et al, published in 2001. OBJECTIVES To assess whether computerised advice on drug dosage has beneficial effects on the process or outcome of health care. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care Group specialized register (June 1996 to December 2006), MEDLINE (1966 to December 2006), EMBASE (1980 to December 2006), hand searched the journal Therapeutic Drug Monitoring (1979 to March 2007) and the Journal of the American Medical Informatics Association (1996 to March 2007) as well as reference lists from primary articles. SELECTION CRITERIA Randomized controlled trials, controlled trials, controlled before and after studies and interrupted time series analyses of computerized advice on drug dosage were included. The participants were health professionals responsible for patient care. The outcomes were: any objectively measured change in the behaviour of the health care provider (such as changes in the dose of drug used); any change in the health of patients resulting from computerized advice (such as adverse reactions to drugs). DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data and assessed study quality. MAIN RESULTS Twenty-six comparisons (23 articles) were included (as compared to fifteen comparisons in the original review) including a wide range of drugs in inpatient and outpatient settings. Interventions usually targeted doctors although some studies attempted to influence prescriptions by pharmacists and nurses. Although all studies used reliable outcome measures, their quality was generally low. Computerized advice for drug dosage gave significant benefits by:1.increasing the initial dose (standardised mean difference 1.12, 95% CI 0.33 to 1.92)2.increasing serum concentrations (standradised mean difference 1.12, 95% CI 0.43 to 1.82)3.reducing the time to therapeutic stabilisation (standardised mean difference -0.55, 95%CI -1.03 to -0.08)4.reducing the risk of toxic drug level (rate ratio 0.45, 95% CI 0.30 to 0.70)5.reducing the length of hospital stay (standardised mean difference -0.35, 95% CI -0.52 to -0.17). AUTHORS' CONCLUSIONS This review suggests that computerized advice for drug dosage has some benefits: it increased the initial dose of drug, increased serum drug concentrations and led to a more rapid therapeutic control. It also reduced the risk of toxic drug levels and the length of time spent in the hospital. However, it had no effect on adverse reactions. In addition, there was no evidence to suggest that some decision support technical features (such as its integration into a computer physician order entry system) or aspects of organization of care (such as the setting) could optimise the effect of computerised advice.
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Affiliation(s)
- Pierre Durieux
- Service de Santé Publique, Hôpital Cochin, 27 rue du Faubourg Saint Jacques, Paris, France, 75014.
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Abstract
Monitoring describes the prospective supervision, observation, and testing of an ongoing process. The result of monitoring provides reassurance that the goal has been or will be achieved, or suggests changes that will allow it to be achieved. In therapeutics, most thought has been given to Therapeutic Drug Monitoring, that is, monitoring of drug concentrations to achieve benefit or avoid harm, or both. Patients and their clinicians can also monitor the progress of a disease, and adjust treatment accordingly, for example, to achieve optimum glycaemic control. Very little consideration has been given to the development of effective schemes for monitoring for the occurrence of adverse effects, such as biochemical or haematological disturbance. Significant harm may go undetected in controlled clinical trials. Even where harm is detected, published details of trials are usually insufficient to allow a practical monitoring scheme to be introduced. The result is that information available to prescribers, such as the Summary of Product Characteristics, frequently provides advice that is incomplete or impossible to follow. We discuss here the elements of logical schemes for monitoring for adverse drug reactions, and the possible contributions that computerized decision support can make. We should require evidence that if a monitoring scheme is proposed, it can be put into practice, will prove effective, and is affordable.
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Affiliation(s)
- J J Coleman
- West Midlands Centre for Adverse Drug Reaction ReportingCity Hospital
- Department of Medicine, Section of Clinical Pharmacology, Medical SchoolUniversity of Birmingham, Birmingham
| | - R E Ferner
- West Midlands Centre for Adverse Drug Reaction ReportingCity Hospital
- Department of Medicine, Section of Clinical Pharmacology, Medical SchoolUniversity of Birmingham, Birmingham
- Correspondence R. E. Ferner, West Midlands Centre for Adverse Drug Reaction Reporting, City Hospital, Birmingham B18 7QH, UK. Tel: + 44 12 1554 3801 or + 44 12 1507 4499 Fax: + 44 12 1507 5820 E-mail:
| | - S J W Evans
- London School of Hygiene & Tropical MedicineLondon, UK
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Bloom BS. Effects of continuing medical education on improving physician clinical care and patient health: a review of systematic reviews. Int J Technol Assess Health Care 2006; 21:380-5. [PMID: 16110718 DOI: 10.1017/s026646230505049x] [Citation(s) in RCA: 264] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The objective of physician continuing medical education (CME) is to help them keep abreast of advances in patient care, to accept new more-beneficial care, and discontinue use of existing lower-benefit diagnostic and therapeutic interventions. The goal of this review was to examine effectiveness of current CME tools and techniques in changing physician clinical practices and improving patient health outcomes. METHODS Results of published systematic reviews were examined to determine the spectrum from most- to least-effective CME techniques. We searched multiple databases, from 1 January 1984 to 30 October 2004, for English-language, peer-reviewed meta-analyses and other systematic reviews of CME programs that alter physician behavior and/or patient outcomes. RESULTS Twenty-six reviews met inclusion criteria, that is, were either formal meta-analyses or other systematic reviews. Interactive techniques (audit/feedback, academic detailing/outreach, and reminders) are the most effective at simultaneously changing physician care and patient outcomes. Clinical practice guidelines and opinion leaders are less effective. Didactic presentations and distributing printed information only have little or no beneficial effect in changing physician practice. CONCLUSIONS Even though the most-effective CME techniques have been proven, use of least-effective ones predominates. Such use of ineffective CME likely reduces patient care quality and raises costs for all, the worst of both worlds.
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Affiliation(s)
- Bernard S Bloom
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104-2676, USA.
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Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, Holmes A, Ramsay C, Taylor E, Wilcox M, Wiffen P. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2005:CD003543. [PMID: 16235326 DOI: 10.1002/14651858.cd003543.pub2] [Citation(s) in RCA: 155] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Up to 50% of antibiotic usage in hospitals is inappropriate. In hospitals infections caused by antibiotic-resistant bacteria are associated with higher mortality, morbidity and prolonged hospital stay compared with infections caused by antibiotic-susceptible bacteria. Clostridium difficile associated diarrhoea (CDAD) is a hospital acquired infection that is caused by antibiotic prescribing. OBJECTIVES To estimate the effectiveness of professional interventions that alone, or in combination, are effective in promoting prudent antibiotic prescribing to hospital inpatients, to evaluate the impact of these interventions on reducing the incidence of antimicrobial resistant pathogens or CDAD and their impact on clinical outcome. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care (EPOC) specialized register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE from 1980 to November 2003. Additional studies were obtained from the bibliographies of retrieved articles SELECTION CRITERIA We included all randomised and controlled clinical trials (RCT/CCT), controlled before and after studies (CBA) and interrupted time series (ITS) studies of antibiotic prescribing to hospital inpatients. Interventions included any professional or structural interventions as defined by EPOC. DATA COLLECTION AND ANALYSIS Two reviewers extracted data and assessed quality. MAIN RESULTS Sixty six studies were included and 51 (77%) showed a significant improvement in at least one outcome. Six interventions only aimed to increase treatment, 57 interventions aimed to decrease treatment and three interventions aimed to both increase and decrease treatment. The intervention target was the decision to prescribe antibiotics (one study), timing of first dose (six studies), the regimen (drug, dosing interval etc, 61 studies) or the duration of treatment (10 studies); 12 studies had more than one target. Of the six interventions that aimed to increase treatment, five reported a significant improvement in drug outcomes and one a significant improvement in clinical outcome. Of the 60 interventions that aimed to decrease treatment 47 reported drug outcomes of which 38 (81%) significantly improved, 16 reported microbiological outcomes of which 12 (75%) significantly improved and nine reported clinical outcomes of which two (22%) significantly deteriorated and 3 (33%) significantly improved. Five studies aimed to reduce CDAD. Three showed a significant reduction in CDAD. Due to differences in study design and duration of follow up it was only possible to perform meta-regression on a few studies. AUTHORS' CONCLUSIONS The results show that interventions to improve antibiotic prescribing to hospital inpatients are successful, and can reduce antimicrobial resistance or hospital acquired infections.
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Affiliation(s)
- P Davey
- Ninewells Hospital and Medical School, MEMO, Department of Clinical Pharmacology, Dundee, Scotland, UK DD1 9SY.
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Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ 2005; 330:765. [PMID: 15767266 PMCID: PMC555881 DOI: 10.1136/bmj.38398.500764.8f] [Citation(s) in RCA: 1445] [Impact Index Per Article: 76.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To identify features of clinical decision support systems critical for improving clinical practice. DESIGN Systematic review of randomised controlled trials. DATA SOURCES Literature searches via Medline, CINAHL, and the Cochrane Controlled Trials Register up to 2003; and searches of reference lists of included studies and relevant reviews. STUDY SELECTION Studies had to evaluate the ability of decision support systems to improve clinical practice. DATA EXTRACTION Studies were assessed for statistically and clinically significant improvement in clinical practice and for the presence of 15 decision support system features whose importance had been repeatedly suggested in the literature. RESULTS Seventy studies were included. Decision support systems significantly improved clinical practice in 68% of trials. Univariate analyses revealed that, for five of the system features, interventions possessing the feature were significantly more likely to improve clinical practice than interventions lacking the feature. Multiple logistic regression analysis identified four features as independent predictors of improved clinical practice: automatic provision of decision support as part of clinician workflow (P < 0.00001), provision of recommendations rather than just assessments (P = 0.0187), provision of decision support at the time and location of decision making (P = 0.0263), and computer based decision support (P = 0.0294). Of 32 systems possessing all four features, 30 (94%) significantly improved clinical practice. Furthermore, direct experimental justification was found for providing periodic performance feedback, sharing recommendations with patients, and requesting documentation of reasons for not following recommendations. CONCLUSIONS Several features were closely correlated with decision support systems' ability to improve patient care significantly. Clinicians and other stakeholders should implement clinical decision support systems that incorporate these features whenever feasible and appropriate.
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Affiliation(s)
- Kensaku Kawamoto
- Division of Clinical Informatics, Department of Community and Family Medicine, Box 2914, Duke University Medical Center, Durham, NC 27710, USA
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Abstract
About every second decision of a medical doctor concerns drug therapy. On the basis of a representative Norwegian study, which analyzed fatal drug reactions in stationary patients of internal medicine wards by autopsy and plasma drug concentrations, in Germany 58,000 fatalities are occurring in this patient population. The treating physicians classified only 6% of drug induced fatalities as such. Therefore, the risk of drug therapy is grossly underestimated. In half of the cases medication errors were causative and therefore these could potentially all be avoided. In addition to improved pre- and postgraduate education in clinical pharmacology the use of computer-based expert systems would be a decisive step to optimize drug therapy.
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Affiliation(s)
- J U Schnurrer
- Institut für Klinische Pharmakologie, Medizinische Hochschule Hannover
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Flottorp S, Oxman AD. Identifying barriers and tailoring interventions to improve the management of urinary tract infections and sore throat: a pragmatic study using qualitative methods. BMC Health Serv Res 2003; 3:3. [PMID: 12622873 PMCID: PMC150569 DOI: 10.1186/1472-6963-3-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2002] [Accepted: 02/04/2003] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Theories of behaviour change indicate that an analysis of factors that facilitate or impede change is helpful when trying to influence professional practice. The aim of this study was to identify barriers to implementing evidence-based guidelines for urinary tract infection and sore throat in general practice in Norway, and to tailor interventions to address these barriers. METHODS We used a checklist to identify barriers and possible interventions to address these in an iterative process that included a review of the literature, brainstorming, focus groups, a pilot study, small group discussions and interviews. RESULTS We identified at least one barrier for each category. Both guidelines recommended increased use of telephone consultations and reduced use of laboratory tests, and the barriers and the interventions were similar for the two guidelines. The complexity of changing routines involving patients, general practitioners and general practitioner assistants, loss of income with telephone consultations, fear of overlooking serious disease, perceived patient expectations and lack of knowledge about the evidence for the guidelines were the most prominent barriers. The interventions that were tailored to address these barriers included support for change processes in the practices, increasing the fee for telephone consultations, patient information leaflets and computer-based decision support and reminders. CONCLUSION A systematic approach using qualitative methods helped identify barriers and generate ideas for tailoring interventions to support the implementation of guidelines for the management of urinary tract infections and sore throat. Lack of resources limited our ability to address all of the barriers adequately.
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Affiliation(s)
- Signe Flottorp
- Department of Health Services Research, Directorate for Health and Social Affairs, PO Box 8054 Dep, 0031 Oslo, Norway
| | - Andrew D Oxman
- Department of Health Services Research, Directorate for Health and Social Affairs, PO Box 8054 Dep, 0031 Oslo, Norway
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Abstract
As the ultimate consumers, patients play an important role in the emergence, spread and control of bacterial resistance to antibiotics. Improved knowledge of antibiotics and the problem of resistance, as well as a better understanding of beliefs, pressures/concerns, and expectations, from both the patient's and physician's perspectives, are fundamental for controlling antibiotic use. There is growing evidence to suggest that empowering patients through implementation of patient-centered health-care strategies, such as shared decision-making, in conjunction with educational initiatives help to change attitudes and behavior, and improve access to and completion of appropriate antimicrobial therapy. This, in turn, may help to control the development and spread of resistance to antibiotics.
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Affiliation(s)
- Peter Davey
- MEMO, University of Dundee, Dundee, UK, Tayside Center for General Practice, Dundee, UK.
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