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Evans AR, Wilkes ER, Absolon PJ, Denner TJ, Kaye G. An Interactive Computerised Protocol for the Management of Hypertension. Methods Inf Med 2018. [DOI: 10.1055/s-0038-1635348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
SummaryThe management of hypertension using a computer within a hospital environment is well documented [4, 5, 6, 11, 15]. This paper describes the background, structure and use of an interactive care system designed to be used by general medical practitioners in their consulting rooms.A management plan (protocol) for the care of an “ideal hypertensive” patient was defined by a group of general practitioners. The method by which this plan was adapted and converted for use on the computer is described. The computer handles patient information according to the protocol, prompting and interacting with the physician in attempting to improve the delivery of care to his hypertensive patients.The physicians’ acceptance of and compliance with such a care system is examined, and the implications for the future are discussed.
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Arditi C, Rège-Walther M, Wyatt JC, Durieux P, Burnand B. Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2012; 12:CD001175. [PMID: 23235578 DOI: 10.1002/14651858.cd001175.pub3] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting the doctor to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time. OBJECTIVES To evaluate the effects of reminders automatically generated through a computerized system and delivered on paper to healthcare professionals on processes of care (related to healthcare professionals' practice) and outcomes of care (related to patients' health condition). SEARCH METHODS For this update the EPOC Trials Search Co-ordinator searched the following databases between June 11-19, 2012: The Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Library (Economics, Methods, and Health Technology Assessment sections), Issue 6, 2012; MEDLINE, OVID (1946- ), Daily Update, and In-process; EMBASE, Ovid (1947- ); CINAHL, EbscoHost (1980- ); EPOC Specialised Register, Reference Manager, and INSPEC, Engineering Village. The authors reviewed reference lists of related reviews and studies. SELECTION CRITERIA We included individual or cluster-randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals on processes and/or outcomes of care. DATA COLLECTION AND ANALYSIS Review authors working in pairs independently screened studies for eligibility and abstracted data. We contacted authors to obtain important missing information for studies that were published within the last 10 years. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median absolute improvement and interquartile range (IQR) in process adherence across included studies using the primary outcome or median outcome as representative outcome. MAIN RESULTS In the 32 included studies, computer-generated reminders delivered on paper to healthcare professionals achieved moderate improvement in professional practices, with a median improvement of processes of care of 7.0% (IQR: 3.9% to 16.4%). Implementing reminders alone improved care by 11.2% (IQR 6.5% to 19.6%) compared with usual care, while implementing reminders in addition to another intervention improved care by 4.0% only (IQR 3.0% to 6.0%) compared with the other intervention. The quality of evidence for these comparisons was rated as moderate according to the GRADE approach. Two reminder features were associated with larger effect sizes: providing space on the reminder for provider to enter a response (median 13.7% versus 4.3% for no response, P value = 0.01) and providing an explanation of the content or advice on the reminder (median 12.0% versus 4.2% for no explanation, P value = 0.02). Median improvement in processes of care also differed according to the behaviour the reminder targeted: for instance, reminders to vaccinate improved processes of care by 13.1% (IQR 12.2% to 20.7%) compared with other targeted behaviours. In the only study that had sufficient power to detect a clinically significant effect on outcomes of care, reminders were not associated with significant improvements. AUTHORS' CONCLUSIONS There is moderate quality evidence that computer-generated reminders delivered on paper to healthcare professionals achieve moderate improvement in process of care. Two characteristics emerged as significant predictors of improvement: providing space on the reminder for a response from the clinician and providing an explanation of the reminder's content or advice. The heterogeneity of the reminder interventions included in this review also suggests that reminders can improve care in various settings under various conditions.
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Affiliation(s)
- Chantal Arditi
- Institute of Social and Preventive Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.
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Roshanov PS, Misra S, Gerstein HC, Garg AX, Sebaldt RJ, Mackay JA, Weise-Kelly L, Navarro T, Wilczynski NL, Haynes RB. Computerized clinical decision support systems for chronic disease management: a decision-maker-researcher partnership systematic review. Implement Sci 2011; 6:92. [PMID: 21824386 PMCID: PMC3170626 DOI: 10.1186/1748-5908-6-92] [Citation(s) in RCA: 146] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 08/03/2011] [Indexed: 11/13/2022] Open
Abstract
Background The use of computerized clinical decision support systems (CCDSSs) may improve chronic disease management, which requires recurrent visits to multiple health professionals, ongoing disease and treatment monitoring, and patient behavior modification. The objective of this review was to determine if CCDSSs improve the processes of chronic care (such as diagnosis, treatment, and monitoring of disease) and associated patient outcomes (such as effects on biomarkers and clinical exacerbations). Methods We conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid's EBM Reviews database, Inspec, and reference lists for potentially eligible articles published up to January 2010. We included randomized controlled trials that compared the use of CCDSSs to usual practice or non-CCDSS controls. Trials were eligible if at least one component of the CCDSS was designed to support chronic disease management. We considered studies 'positive' if they showed a statistically significant improvement in at least 50% of relevant outcomes. Results Of 55 included trials, 87% (n = 48) measured system impact on the process of care and 52% (n = 25) of those demonstrated statistically significant improvements. Sixty-five percent (36/55) of trials measured impact on, typically, non-major (surrogate) patient outcomes, and 31% (n = 11) of those demonstrated benefits. Factors of interest to decision makers, such as cost, user satisfaction, system interface and feature sets, unique design and deployment characteristics, and effects on user workflow were rarely investigated or reported. Conclusions A small majority (just over half) of CCDSSs improved care processes in chronic disease management and some improved patient health. Policy makers, healthcare administrators, and practitioners should be aware that the evidence of CCDSS effectiveness is limited, especially with respect to the small number and size of studies measuring patient outcomes.
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Affiliation(s)
- Pavel S Roshanov
- Health Research Methodology Program, McMaster University, 1280 Main Street West, Hamilton, ON, Canada
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Hemens BJ, Holbrook A, Tonkin M, Mackay JA, Weise-Kelly L, Navarro T, Wilczynski NL, Haynes RB. Computerized clinical decision support systems for drug prescribing and management: a decision-maker-researcher partnership systematic review. Implement Sci 2011; 6:89. [PMID: 21824383 PMCID: PMC3179735 DOI: 10.1186/1748-5908-6-89] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 08/03/2011] [Indexed: 02/02/2023] Open
Abstract
Background Computerized clinical decision support systems (CCDSSs) for drug therapy management are designed to promote safe and effective medication use. Evidence documenting the effectiveness of CCDSSs for improving drug therapy is necessary for informed adoption decisions. The objective of this review was to systematically review randomized controlled trials assessing the effects of CCDSSs for drug therapy management on process of care and patient outcomes. We also sought to identify system and study characteristics that predicted benefit. Methods We conducted a decision-maker-researcher partnership systematic review. We updated our earlier reviews (1998, 2005) by searching MEDLINE, EMBASE, EBM Reviews, Inspec, and other databases, and consulting reference lists through January 2010. Authors of 82% of included studies confirmed or supplemented extracted data. We included only randomized controlled trials that evaluated the effect on process of care or patient outcomes of a CCDSS for drug therapy management compared to care provided without a CCDSS. A study was considered to have a positive effect (i.e., CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive. Results Sixty-five studies met our inclusion criteria, including 41 new studies since our previous review. Methodological quality was generally high and unchanged with time. CCDSSs improved process of care performance in 37 of the 59 studies assessing this type of outcome (64%, 57% of all studies). Twenty-nine trials assessed patient outcomes, of which six trials (21%, 9% of all trials) reported improvements. Conclusions CCDSSs inconsistently improved process of care measures and seldomly improved patient outcomes. Lack of clear patient benefit and lack of data on harms and costs preclude a recommendation to adopt CCDSSs for drug therapy management.
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Affiliation(s)
- Brian J Hemens
- Health Information Research Unit, Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, Canada
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Glynn LG, Murphy AW, Smith SM, Schroeder K, Fahey T. Self-monitoring and other non-pharmacological interventions to improve the management of hypertension in primary care: a systematic review. Br J Gen Pract 2010; 60:e476-88. [PMID: 21144192 PMCID: PMC2991764 DOI: 10.3399/bjgp10x544113] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 04/14/2010] [Accepted: 05/04/2010] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals: a condition labelled as 'uncontrolled' hypertension. The optimal way to organise and deliver care to hypertensive patients has not been clearly identified. AIM To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension. DESIGN OF STUDY Systematic review of randomised controlled trials. SETTING Primary and ambulatory care. METHOD Interventions were categorised as following: self-monitoring; educational interventions directed to the patient; educational interventions directed to the health professional; health professional- (nurse or pharmacist) led care; organisational interventions that aimed to improve the delivery of care; and appointment reminder systems. Outcomes assessed were mean systolic and diastolic blood pressure, control of blood pressure and proportion of patients followed up at clinic. RESULTS Seventy-two RCTs met the inclusion criteria. The trials showed a wide variety of methodological quality. Self-monitoring was associated with net reductions in systolic blood pressure (weighted mean difference [WMD] -2.5 mmHg, 95%CI = -3.7 to -1.3 mmHg) and diastolic blood pressure (WMD -1.8 mmHg, 95%CI = -2.4 to -1.2 mmHg). An organised system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce blood pressure and all-cause mortality in a single large randomised controlled trial. CONCLUSION Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels. Self-monitoring is a useful adjunct to care while reminder systems and nurse/pharmacist -led care require further evaluation.
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Glynn LG, Murphy AW, Smith SM, Schroeder K, Fahey T. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev 2010:CD005182. [PMID: 20238338 DOI: 10.1002/14651858.cd005182.pub4] [Citation(s) in RCA: 242] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals - a condition labelled as "uncontrolled" hypertension. The optimal way to organize and deliver care to hypertensive patients has not been clearly identified. OBJECTIVES To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension. To evaluate the effectiveness of reminders on improving the follow-up of patients with hypertension. SEARCH STRATEGY All-language search of all articles (any year) in the Cochrane Controlled Trials Register (CCTR) and Medline; and Embase from January 1980. SELECTION CRITERIA Randomized controlled trials (RCTs) of patients with hypertension that evaluated the following interventions: (1) self-monitoring (2) educational interventions directed to the patient (3) educational interventions directed to the health professional (4) health professional (nurse or pharmacist) led care (5) organisational interventions that aimed to improve the delivery of care (6) appointment reminder systemsOutcomes assessed were: (1) mean systolic and diastolic blood pressure (2) control of blood pressure (3) proportion of patients followed up at clinic DATA COLLECTION AND ANALYSIS Two authors extracted data independently and in duplicate and assessed each study according to the criteria outlined by the Cochrane Handbook. MAIN RESULTS 72 RCTs met our inclusion criteria. The methodological quality of included studies varied. An organized system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce systolic blood pressure (weighted mean difference (WMD) -8.0 mmHg, 95% CI: -8.8 to -7.2 mmHg) and diastolic blood pressure (WMD -4.3 mmHg, 95% CI: -4.7 to -3.9 mmHg) for three strata of entry blood pressure, and all-cause mortality at five years follow-up (6.4% versus 7.8%, difference 1.4%) in a single large RCT- the Hypertension Detection and Follow-Up study. Other interventions had variable effects. Self-monitoring was associated with moderate net reduction in systolic blood pressure (WMD -2.5 mmHg, 95% CI: -3.7 to -1.3 mmHg) and diastolic blood pressure (WMD -1.8 mmHg, 95% CI: -2.4 to -1.2 mmHg). RCTs of educational interventions directed at patients or health professionals were heterogeneous but appeared unlikely to be associated with large net reductions in blood pressure by themselves. Nurse or pharmacist led care may be a promising way forward, with the majority of RCTs being associated with improved blood pressure control and mean SBP and DBP but these interventions require further evaluation. Appointment reminder systems also require further evaluation due to heterogeneity and small trial numbers, but the majority of trials increased the proportion of individuals who attended for follow-up (odds ratio 0.41, 95% CI 0.32 to 0.51) and in two small trials also led to improved blood pressure control, odds ratio favouring intervention 0.54 (95% CI 0.41 to 0.73). AUTHORS' CONCLUSIONS Family practices and community-based clinics need to have an organized system of regular follow-up and review of their hypertensive patients. Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels. Self-monitoring and appointment reminders may be useful adjuncts to the above strategies to improve blood pressure control but require further evaluation.
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Affiliation(s)
- Liam G Glynn
- Department of General Practice, National University of Ireland, No 1, Distillery Road,, Galway, Ireland
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Improvement of hypertension management by structured physician education and feedback system: cluster randomized trial. ACTA ACUST UNITED AC 2009; 17:271-9. [DOI: 10.1097/hjr.0b013e328330be62] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Critical care pathways, protocols, and guidelines have become an everyday feature of clinical practice and represent a distillation of the best available evidence. Chronic heart failure guidelines can be complex, and it is acknowledged that a combination of knowledge and expert advice, in addition to guidelines, is required to optimally treat these patients. This current article describes the potential value of clinical decision support software (CDSS) in the treatment of patients with chronic heart failure and practical aspects of using such a tool. Barriers to implementation of our tool included relatively low computer skills among family physicians and a lack of complexity within CDSS in addressing the wider nonmedical needs of patients. Improving computer skills, integrating CDSS into referral pathways, and requests for investigation may be ways of enhancing the use of this technology.
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Affiliation(s)
- Stephen J Leslie
- Highland Heartbeat Centre, Raigmore Hospital, Inverness, United Kingdom
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Fahey T, Schroeder K, Ebrahim S. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev 2006:CD005182. [PMID: 16625627 DOI: 10.1002/14651858.cd005182.pub2] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND It is well recognized that patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals - a condition labeled as "uncontrolled" hypertension. The optimal way in which to organize and deliver care to patients who have hypertension so that they reach treatment goals has not been clearly identified. OBJECTIVES To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension. To evaluate the effectiveness of reminders on improving the follow-up of patients with hypertension. SEARCH STRATEGY All-language search of all articles (any year) in the Cochrane Controlled Trials Register (CCTR), Medline and Embase from June 2000. SELECTION CRITERIA Randomized controlled trials (RCTs) of patients with hypertension that evaluated the following interventions: (1) self-monitoring (2) educational interventions directed to the patient (3) educational interventions directed to the health professional (4) health professional (nurse or pharmacist) led care (5) organisational interventions that aimed to improve the delivery of care (6) appointment reminder systems. Outcomes assessed were: (1) mean systolic and diastolic blood pressure( 2) control of blood pressure (3) proportion of patients followed up at clinic. DATA COLLECTION AND ANALYSIS Two authors extracted data independently and in duplicate and assessed each study according to the criteria outlined by the Cochrane Collaboration Handbook. MAIN RESULTS 56 RCTs met our inclusion criteria. The methodological quality of included studies was variable. An organized system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce blood pressure (weighted mean difference -8.2/-4.2 mmHg, -11.7/-6.5 mmHg, -10.6/-7.6 mmHg for 3 strata of entry blood pressure) and all-cause mortality at five years follow-up (6.4% versus 7.8%, difference 1.4%) in a single large RCT- the Hypertension Detection and Follow-Up study. Other interventions had variable effects. Self-monitoring was associated with moderate net reduction in diastolic blood pressure (weighted mean difference (WMD): -2.0 mmHg, 95%CI: -2.7 to -1.4 mmHg, respectively. Appointment reminders increased the proportion of individuals who attended for follow-up. RCTs of educational interventions directed at patients or health professionals were heterogeneous but appeared unlikely to be associated with large net reductions in blood pressure by themselves. Health professional (nurse or pharmacist) led care may be a promising way of delivering care, with the majority of RCTs being associated with improved blood pressure control, but requires further evaluation. AUTHORS' CONCLUSIONS Family practices and community-based clinics need to have an organized system of regular follow-up and review of their hypertensive patients. Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels.
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Affiliation(s)
- T Fahey
- University of Dundee,Tayside Centre for General Practice, Kirsty Semple Way, Dundee, UK, DD2 4AD.
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Leslie SJ, Hartswood M, Meurig C, McKee SP, Slack R, Procter R, Denvir MA. Clinical decision support software for management of chronic heart failure: development and evaluation. Comput Biol Med 2005; 36:495-506. [PMID: 15927176 DOI: 10.1016/j.compbiomed.2005.02.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2004] [Accepted: 02/17/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To develop and evaluate clinical decision support software (CDSS) to aid physicians treat patients with chronic heart failure (CHF). METHODS The CDSS was developed after discussions with a multidisciplinary panel. Evaluation was performed in three stages over a 6 month period including an editorial check, one-to-one interviews with potential users and educational meetings with general practitioners (GPs), junior doctors and medical students during which the CDSS was assessed in a cross-over design against paper guidelines. Opinions of the CDSS and the computer literacy of the participants were assessed by questionnaire. RESULTS There were several changes to the CDSS at various stages of development and evaluation. One-to-one interviews generated extensive qualitative feedback. GPs had lower computer literacy scores than junior doctors and students (both p<0.01). There were small trends when comparing the CDSS with paper guidelines. GPs scored less well (CDSS 75% vs. 80%, p=0.41), while junior doctors and medical students appeared to improve their scores (72%-84%, p=0.32 and 66%-77%, p=0.19, respectively). Most (70%) found the CDSS more useful than the written guidelines. CONCLUSION Development of CDSS using guidelines and expert opinion requires a multidisciplinary iterative process of feedback and software adaptation. Barriers to implementation identified include lower computer literacy among GPs, a lack of complexity within CDSS in addressing non-medical needs of patients and a reluctance among medical staff to consult guidelines during patient consultations. Improving computer skills, integrating CDSS into referral pathways and requests for investigations may be ways of enhancing use of this emerging technology.
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Affiliation(s)
- Stephen J Leslie
- Department of Cardiology, Western General Hospital, Edinburgh EH4 2XU, UK
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Affiliation(s)
- Ann M Borzecki
- Center for Health Quality, Outcomes, and Economic Research, Bedford Veterans Affairs Hospital, Bedford, Mass, USA
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Affiliation(s)
- E John Gallagher
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467-2490, USA.
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Treweek SP, Glenton C, Oxman AD, Penrose A. Computer-generated patient education materials: do they affect professional practice? A systematic review. J Am Med Inform Assoc 2002; 9:346-58. [PMID: 12087116 PMCID: PMC346622 DOI: 10.1197/jamia.m1070] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2001] [Accepted: 03/11/2002] [Indexed: 11/10/2022] Open
Abstract
A systematic search of seven electronic databases was done to identify randomized controlled trials that assessed the effect of computer-generated patient education material (PEM) on professional practice. Three studies met the authors' criteria. All three studies involved preventive care. All used a complex intervention of which computer-generated PEM was a major component. Improvements in practice were seen in all studies, although these gains were generally modest. One study showed improvement in patient outcomes. Mann-Whitney statistics calculated for the studies' outcome measures ranged from 0.48 to 0.66, equivalent to risk differences of -4 to 32 percent. Computer-generated PEM seems to have a small, positive effect on professional practice. The small number of included studies and the complex nature of the interventions makes it difficult to draw conclusions about the ability of computer-generated PEM to change professional practice. Future work should involve well-defined interventions that can be clearly evaluated in terms of effect and cost.
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Gill PS, Mäkelä M, Vermeulen KM, Freemantle N, Ryan G, Bond C, Thorsen T, Haaijer-Ruskamp FM. Changing doctor prescribing behaviour. PHARMACY WORLD & SCIENCE : PWS 1999; 21:158-67. [PMID: 10483603 DOI: 10.1023/a:1008719129305] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The aim of this overview was to identify interventions that change doctor prescribing behaviour and to derive conclusions for practice and further research. Relevant studies (indicating prescribing as a behaviour change) were located from a database of studies maintained by the Cochrane Collaboration on Effective Professional Practice. This register is kept up to date by searching the following databases for reports of relevant research: DHSS-DATA; EMBASE; MEDLINE; SIGLE; Resource Database in Continuing Medical Education (1975-1994), along with bibliographies of related topics, hand searching of key journals and personal contact with content area experts. Randomised controlled trials and non-equivalent group designs with pre- and post-intervention measures were included. Outcome measures were those used by the study authors. For each study we determined whether these were positive, negative or inconclusive. Positive studies (+) were those that demonstrated a statistically significant change in the majority of outcomes measured at level of p < or = 0.05 between the intervention and control groups. Negative studies (-) showed a significant change in the opposite direction and inconclusive studies (approximately) showed no significant change compared to control or no overall positive findings. We identified 79 eligible studies which described 96 separate interventions to change prescribing behaviour. Of these interventions, 49 (51%, 41%-61%) showed a positive significant change compared to the control group but interpretation of specific interventions is limited due to wide and overlapping confidence intervals.
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Affiliation(s)
- P S Gill
- Department of Primary Care and General Practice, University of Birmingham, UK.
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Worrall G. Clinical practice guidelines: questions family physicians should ask themselves. COMPREHENSIVE THERAPY 1999; 25:46-9. [PMID: 9987592 DOI: 10.1007/bf02889835] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Family physicians increasingly are being pressured to use clinical practice guidelines. This article reviews the methods of developing, disseminating and implementing guidelines, and suggests a list of questions that family physicians should ask themselves before accepting any clinical practice guidelines.
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Affiliation(s)
- G Worrall
- Memorial University of Newfoundland, Centre for Rural Health Studies, Whitbourne, Canada
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Montgomery AA, Fahey T. A systematic review of the use of computers in the management of hypertension. J Epidemiol Community Health 1998; 52:520-5. [PMID: 9876364 PMCID: PMC1756753 DOI: 10.1136/jech.52.8.520] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
STUDY OBJECTIVE To assess the effect of computers and computer-based clinical decision support systems on the management of hypertension. DESIGN Systematic review of randomised controlled trials. SETTING Ambulatory hypertension clinics, community-based health centres, and general practices. PARTICIPANTS 11,962 patients enrolled in seven trials retrieved from a systematic search (electronic databases, contact with authors, reference lists; no restriction on language). MAIN RESULTS Individual trials report on a diverse population of patients (newly diagnosed or established hypertensive patients), interventions (computers used for case finding, recall and registration, feedback on quality of blood pressure control and prescribing information), and outcomes (administration, physician performance and blood pressure control). Four of five trials reported an improvement in patient administration using a computer. Two of three trials reported an improvement in physician performance using a computer. Two of six trials. reported an improvement in blood pressure control in patients using a computer. However, positive findings in two trials should be regarded cautiously because of the potential effects of cluster randomisation. CONCLUSIONS It seems that computers have a favourable effect on the uptake and follow up of patients in hypertension management. The effect of computers on physician knowledge, recording of information, and blood pressure control in patients is less conclusive and further studies are required.
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Lobach DF, Hammond WE. Computerized decision support based on a clinical practice guideline improves compliance with care standards. Am J Med 1997; 102:89-98. [PMID: 9209205 DOI: 10.1016/s0002-9343(96)00382-8] [Citation(s) in RCA: 170] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Clinical guidelines are designed to assist in the management of specific diseases; however, these guidelines are often neglected in the delivery of care. The purpose of this study was to determine whether clinician use of an clinical practice guideline would increase in response to having, at the patient visit, a decision support system based on a practice guideline that generates a customized management protocol for the individual patient using data from the patient's electronic medical record. SUBJECTS AND METHODS In a 6-month controlled trial at a primary care clinic, 58 primary care clinicians were randomized to receive either a special encounter form with the computer-generated guideline recommendations or a standard encounter form. The effect of computer-generated advice on clinician behavior was measured as rate of compliance with guideline recommendations. Data from 30 clinicians were analyzed; data from 28 clinicians were excluded because these clinicians did not meet predefined criteria for minimum exposure to diabetic patient care. RESULTS Availability of patient management recommendations generated by the decision support system resulted in a two-fold increase in clinician compliance with care guidelines for diabetes mellitus (P = 0.01). Median compliance for the group receiving the recommendations was 32.0% versus 15.6% for the control group. CONCLUSION Decision support based on a clinical practice guideline is an effective tool for assisting clinicians in the management of diabetic patients. This decision support system provides a model for how a clinical practice guideline can be integrated into the care process by computer to assist clinicians in managing a specific disease through helping them comply with care standards. Use of decision support systems based on clinical practice guidelines could ultimately improve the quality of medical care.
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Affiliation(s)
- D F Lobach
- Department of Community and Family Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA
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Grimshaw J, Freemantle N, Wallace S, Russell I, Hurwitz B, Watt I, Long A, Sheldon T. Developing and implementing clinical practice guidelines. Qual Health Care 1995; 4:55-64. [PMID: 10142039 PMCID: PMC1055269 DOI: 10.1136/qshc.4.1.55] [Citation(s) in RCA: 257] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- J Grimshaw
- Health Services Research Unit, University of Aberdeen
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Peterson GM. Computer-assisted drug therapy for epilepsy. DRUG INTELLIGENCE & CLINICAL PHARMACY 1983; 17:123-5. [PMID: 6687454 DOI: 10.1177/106002808301700207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Monitoring serum concentrations of anticonvulsant drugs has improved substantially the treatment of epilepsy. However, a sound knowledge of the pharmacokinetics of anticonvulsant drugs is necessary when interpreting serum concentration results and considering dosage adjustments of these drugs. A computer program developed to assist physicians and pharmacists in designing individualized medication regimens for patients with epilepsy is described. The program also can be used as an interactive educational device for medical and clinical pharmacy students.
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Capocaccia R, Mariotti S, Menotti A, Verdecchia A. Evaluation of risk factor variations in relation to their baseline values in a controlled preventive trial. Application to the Rome Project of CHD Prevention. JOURNAL OF CHRONIC DISEASES 1982; 35:509-20. [PMID: 7045149 DOI: 10.1016/0021-9681(82)90070-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
This paper proposes a method for separating intervention impact, regression to the mean and spontaneous evolution effects in a controlled preventive trial. Variation dependence on baseline values is estimated by means of corresponding regression lines. Regression line slopes are adjusted to eliminate bias due to the difference between observed and 'true' values. Intervention impact is then evaluated using the control group as reference. Possible differences in factor baseline values are adjusted for. The method is used to analyse variation patterns for body mass index, serum cholesterol, systolic blood pressure, diastolic blood pressure and cigarette smoking in four years in the Rome Project of Coronary Heart Disease Prevention cohorts. All regression lines of variations vs baseline values show a negative slope. A highly significant improvement due to treatment is observed for blood pressure and body mass index, a less substantial but significant improvement is observed for serum cholesterol, and no effect is observed for cigarette smoking.
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Degoulet P, an Vu H, Chatellier G, Devries C, Plouin PF, Menard J. Hypertension management: the role of the computer in improving patient compliance. MEDICAL INFORMATICS = MEDECINE ET INFORMATIQUE 1982; 7:49-55. [PMID: 7109779 DOI: 10.3109/14639238209020642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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Young DW. Clinical information system for junior doctors. INTERNATIONAL JOURNAL OF BIO-MEDICAL COMPUTING 1980; 11:241-6. [PMID: 7203706 DOI: 10.1016/0020-7101(80)90047-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The effect of a computer-based clinical information system is described. The information system, called House Officer Information and Scheduling System, was designed to guide junior medical staff in their decisions about the investigation of common medical problems. By comparing the management of similar groups of patients at two hospitals it is demonstrated that the system influences decisions concerning investigations. In particular, the least common condition reviewed was most affected.
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Abstract
A computerized system called ARTEMIS has been taking part in the management of a referral hypertension clinic since September 1975. From January 1, 1976 to January 1, 1979, 3,624 patients' records were set up and updated, all of them accessible on line. The mean rate of response to 17 questions with obligatory answers concerning patients' past history was 97.6 per cent. The 10 routine laboratory tests included in the initial in-hospital work-up were registered in over 92 per 100 of the 2,651 hospital records examined. Negative responses were registered with the same accuracy as positive ones, when the computerized questionnaires were appropriately drafted. Standardized collection of information insured homogeneity of the medical staff and has already made possible epidemiologic studies. ARTEMIS has detected strategical errors such as the lack of yearly programmed tests for cardiovascular risk-factors associated with hypertension. The computer has helped to achieve a high rate of patient compliance at one year (81.3 per cent), by providing patients up-dated editions of their personal summary reports as well as sending periodical letters of recall to them and to their physicians. At a total annual cost of 11 dollars per patient, the computer provides continuous information on process and outcome, for each patient and physician, and for the entire population followed up at the clinic. It facilitates physician adherence to predefined protocols and reinforces follow-up continuity by creating a communications network between the referral clinic, the patient and the general practitioner.
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