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Tang AB, Brownell NK, Roberts JS, Haidar A, Osuna-Garcia A, Cho DJ, Bokhoor P, Fonarow GC. Interventions for Optimization of Guideline-Directed Medical Therapy: A Systematic Review. JAMA Cardiol 2024; 9:397-404. [PMID: 38381449 DOI: 10.1001/jamacardio.2023.5627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Importance Implementation of guideline-directed medical therapy (GDMT) in real-world practice remains suboptimal. It is unclear which interventions are most effective at addressing current barriers to GDMT in patients with heart failure with reduced ejection fraction (HFrEF). Objective To perform a systematic review to identify which types of system-level initiatives are most effective at improving GDMT use among patients with HFrEF. Evidence Review PubMed, Embase, Cochrane, CINAHL, and Web of Science databases were queried from January 2010 to November 2023 for randomized clinical trials that implemented a quality improvement intervention with GDMT use as a primary or secondary outcome. References from related review articles were also included for screening. Quality of studies and bias assessment were graded based on the Cochrane Risk of Bias tool and Oxford Centre for Evidence-Based Medicine. Findings Twenty-eight randomized clinical trials were included with an aggregate sample size of 19 840 patients. Studies were broadly categorized as interdisciplinary interventions (n = 15), clinician education (n = 5), electronic health record initiatives (n = 6), or patient education (n = 2). Overall, interdisciplinary titration clinics were associated with significant increases in the proportion of patients on target doses of GDMT with a 10% to 60% and 2% to 53% greater proportion of patients on target doses of β-blockers and renin-angiotensin-aldosterone system inhibitors, respectively, in intervention groups compared with usual care. Other interventions, such as audits, clinician and patient education, or electronic health record alerts, were also associated with some improvements in GDMT utilization, though these findings were inconsistent across studies. Conclusions and Relevance This review summarizes interventions aimed at optimization of GDMT in clinical practice. Initiatives that used interdisciplinary teams, largely comprised of nurses and pharmacists, most consistently led to improvements in GDMT. Additional large, randomized studies are necessary to better understand other types of interventions, as well as their long-term efficacy and sustainability.
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Affiliation(s)
- Amber B Tang
- Department of Medicine, University of California Los Angeles
| | - Nicholas K Brownell
- Department of Medicine, Division of Cardiology, University of California Los Angeles
| | - Jacob S Roberts
- Department of Medicine, University of California Los Angeles
| | - Amier Haidar
- Department of Medicine, University of California Los Angeles
| | - Antonia Osuna-Garcia
- Louise M. Darling Biomedical Library, UCLA Library, University of California Los Angeles
| | - David J Cho
- Department of Medicine, Division of Cardiology, University of California Los Angeles
| | - Pooya Bokhoor
- Department of Medicine, Division of Cardiology, University of California Los Angeles
| | - Gregg C Fonarow
- Department of Medicine, Division of Cardiology, University of California Los Angeles
- Associate Section Editor, JAMA Cardiology
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2
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Musser RC, Senior R, Havrilesky LJ, Buuck J, Casarett DJ, Ibrahim S, Davidson BA. Randomized Comparison of Electronic Health Record Alert Types in Eliciting Responses about Prognosis in Gynecologic Oncology Patients. Appl Clin Inform 2024; 15:204-211. [PMID: 38232748 PMCID: PMC10937092 DOI: 10.1055/a-2247-9355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 01/16/2024] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVES To compare the ability of different electronic health record alert types to elicit responses from users caring for cancer patients benefiting from goals of care (GOC) conversations. METHODS A validated question asking if the user would be surprised by the patient's 6-month mortality was built as an Epic BestPractice Advisory (BPA) alert in three versions-(1) Required on Open chart (pop-up BPA), (2) Required on Close chart (navigator BPA), and (3) Optional Persistent (Storyboard BPA)-randomized using patient medical record number. Meaningful responses were defined as "Yes" or "No," rather than deferral. Data were extracted over 6 months. RESULTS Alerts appeared for 685 patients during 1,786 outpatient encounters. Measuring encounters where a meaningful response was elicited, rates were highest for Required on Open (94.8% of encounters), compared with Required on Close (90.1%) and Optional Persistent (19.7%) (p < 0.001). Measuring individual alerts to which responses were given, they were most likely meaningful with Optional Persistent (98.3% of responses) and least likely with Required on Open (68.0%) (p < 0.001). Responses of "No," suggesting poor prognosis and prompting GOC, were more likely with Optional Persistent (13.6%) and Required on Open (10.3%) than with Required on Close (7.0%) (p = 0.028). CONCLUSION Required alerts had response rates almost five times higher than optional alerts. Timing of alerts affects rates of meaningful responses and possibly the response itself. The alert with the most meaningful responses was also associated with the most interruptions and deferral responses. Considering tradeoffs in these metrics is important in designing clinical decision support to maximize success.
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Affiliation(s)
- Robert Clayton Musser
- Department of Medicine, Duke University Health System, Durham, North Carolina, United States
- Duke Health Technology Solutions, Durham, North Carolina, United States
| | - Rashaud Senior
- Duke Health Technology Solutions, Durham, North Carolina, United States
- Duke Primary Care, Duke University Health System, Durham, North Carolina, United States
| | - Laura J. Havrilesky
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Health System, Durham, North Carolina, United States
| | - Jordan Buuck
- Duke Health Technology Solutions, Durham, North Carolina, United States
| | - David J. Casarett
- Section of Palliative Care, Department of Medicine, Duke University Health System, Durham, North Carolina, United States
| | - Salam Ibrahim
- Duke Health Performance Services, Duke University Health System, Durham, North Carolina, United States
| | - Brittany A. Davidson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Health System, Durham, North Carolina, United States
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3
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Godfrey S, Peng Y, Lorusso N, Sulistio M, Mentz RJ, Pandey A, Warraich H. Palliative Care for Patients With Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2023; 16:e010802. [PMID: 37869880 DOI: 10.1161/circheartfailure.123.010802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/31/2023] [Indexed: 10/24/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) has become the leading form of heart failure worldwide, particularly among elderly patient populations. HFpEF is associated with significant morbidity and mortality that may benefit from incorporation of palliative care (PC). Patients with HFpEF have similarly high mortality rates to patients with heart failure with reduced ejection fraction. PC trials for heart failure have shown improvement in quality of life, quality of death, and health care utilization, although most trials defined heart failure clinically without differentiating between HFpEF and heart failure with reduced ejection fraction. As such, the timing and role of PC for HFpEF care remains uncertain, and PC referral rates for HFpEF are very low despite potential improvements in important patient-centered outcomes. Specific barriers to referral include limited data, prognostic uncertainty, provider misconceptions about PC, inadequate specialty PC workforce, complexities of treating multimorbidity, and limited home care options for patients with heart failure. While there are many barriers to integration of PC into HFpEF care, there are multiple potential benefits to patients with HFpEF throughout their disease course. As this population continues to grow, targeted efforts to study and implement PC interventions are needed to improve patient quality of life and death.
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Affiliation(s)
- Sarah Godfrey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.G., M.S., A.P.)
| | | | - Nicholas Lorusso
- Department of Natural Sciences, University of North Texas at Dallas (N.L.)
| | - Melanie Sulistio
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.G., M.S., A.P.)
| | - Robert J Mentz
- Duke University Medical Center, Division of Cardiology, Durham, NC (R.J.M.)
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.G., M.S., A.P.)
| | - Haider Warraich
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA (H.W.)
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4
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Chien SC, Yang HC, Chen CY, Chien CH, Hsu CK, Chien PH, Li YCJ. Using alert dwell time to filter universal clinical alerts: A machine learning approach. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 240:107696. [PMID: 37480643 DOI: 10.1016/j.cmpb.2023.107696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 06/14/2023] [Accepted: 06/24/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Alerts in computerized physician order entry (CPOE) systems can improve patient safety. However, alerts in rule-based systems cannot be customized based on individual patient or user characteristics. This limitation can lead to the presentation of irrelevant alerts and subsequent alert fatigue. OBJECTIVE We used machine learning approaches with alert dwell time to filter out irrelevant alerts for physicians based on contextual factors. METHODS We utilized five machine learning algorithms and a total of 1,120 features grouped into six categories: alert, demographic, environment, diagnosis, prescription, and laboratory results. The output of the models was the alert dwell time within a specified time window to determine the optimal range by the sensitivity analysis. RESULTS We used 813,026 records (19 categories) from the hospital's outpatient clinic data from 2020 to 2021. The sensitivity analysis showed that a time window with a range of 0.3-4.0 s had the best performance, with an area under the receiver operating characteristic (AUROC) curve of 0.73 and an area under the precision-recall curve (AUPRC) of 0.97. The model built with alert and demographic feature groups showed the best performance, with an AUROC of 0.73. The most significant individual feature groups were alert and demographic, with AUROCs of 0.66 and 0.62, respectively. CONCLUSION Our study found that alerts and user and patient demographic features are more crucial than clinical features when constructing universal context-aware alerts. Using alert dwell time in combination with a time window is an effective way to determine the trigger status of an alert. The findings of this study can provide useful insights for researchers working on specific and universal context-aware alerts.
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Affiliation(s)
- Shuo-Chen Chien
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan; Artificial Intelligence Research and Development Center, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan; International Center for Health Information and Technology, College of Medical science and Technology, Taipei Medical University, Taipei 110, Taiwan
| | - Hsuan-Chia Yang
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan; International Center for Health Information and Technology, College of Medical science and Technology, Taipei Medical University, Taipei 110, Taiwan; Research Center of Big Data and Meta-analysis, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan
| | - Chun-You Chen
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan; Artificial Intelligence Research and Development Center, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan; International Center for Health Information and Technology, College of Medical science and Technology, Taipei Medical University, Taipei 110, Taiwan; Department of Radiation Oncology, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan
| | - Chia-Hui Chien
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan; International Center for Health Information and Technology, College of Medical science and Technology, Taipei Medical University, Taipei 110, Taiwan; Office of Public Affairs, Taipei Medical University, Taipei 110, Taiwan
| | - Chun-Kung Hsu
- Office of Information Technology, Taipei Medical University, Taipei 110, Taiwan
| | - Po-Han Chien
- Department of Finance, National Taiwan University, Taipei 110, Taiwan
| | - Yu-Chuan Jack Li
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan; International Center for Health Information and Technology, College of Medical science and Technology, Taipei Medical University, Taipei 110, Taiwan; Department of Dermatology, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan; Research Center for Artificial Intelligence in Medicine, Taipei Medical University, Taipei 110, Taiwan.
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5
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Trinkley KE, Wright G, Allen LA, Bennett TD, Glasgow RE, Hale G, Heckman S, Huebschmann AG, Kahn MG, Kao DP, Lin CT, Malone DC, Matlock DD, Wells L, Wysocki V, Zhang S, Suresh K. Sustained Effect of Clinical Decision Support for Heart Failure: A Natural Experiment Using Implementation Science. Appl Clin Inform 2023; 14:822-832. [PMID: 37852249 PMCID: PMC10584394 DOI: 10.1055/s-0043-1775566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/02/2023] [Indexed: 10/20/2023] Open
Abstract
OBJECTIVES In a randomized controlled trial, we found that applying implementation science (IS) methods and best practices in clinical decision support (CDS) design to create a locally customized, "enhanced" CDS significantly improved evidence-based prescribing of β blockers (BB) for heart failure compared with an unmodified commercially available CDS. At trial conclusion, the enhanced CDS was expanded to all sites. The purpose of this study was to evaluate the real-world sustained effect of the enhanced CDS compared with the commercial CDS. METHODS In this natural experiment of 28 primary care clinics, we compared clinics exposed to the commercial CDS (preperiod) to clinics exposed to the enhanced CDS (both periods). The primary effectiveness outcome was the proportion of alerts resulting in a BB prescription. Secondary outcomes included patient reach and clinician adoption (dismissals). RESULTS There were 367 alerts for 183 unique patients and 171 unique clinicians (pre: March 2019-August 2019; post: October 2019-March 2020). The enhanced CDS increased prescribing by 26.1% compared with the commercial (95% confidence interval [CI]: 17.0-35.1%), which is consistent with the 24% increase in the previous study. The odds of adopting the enhanced CDS was 81% compared with 29% with the commercial (odds ratio: 4.17, 95% CI: 1.96-8.85). The enhanced CDS adoption and effectiveness rates were 62 and 14% in the preperiod and 92 and 10% in the postperiod. CONCLUSION Applying IS methods with CDS best practices was associated with improved and sustained clinician adoption and effectiveness compared with a commercially available CDS tool.
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Affiliation(s)
- Katy E. Trinkley
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States
- UCHealth, Aurora, Colorado, United States
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, United States
| | - Garth Wright
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, United States
| | - Larry A. Allen
- Adult and Child Center for Outcomes Research and Delivery Science, Aurora, Colorado, United States
- Division of Cardiology, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States
| | - Tellen D. Bennett
- Adult and Child Center for Outcomes Research and Delivery Science, Aurora, Colorado, United States
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Russell E. Glasgow
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States
- Adult and Child Center for Outcomes Research and Delivery Science, Aurora, Colorado, United States
- Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado, United States
| | - Gary Hale
- UCHealth, Aurora, Colorado, United States
| | | | - Amy G. Huebschmann
- Adult and Child Center for Outcomes Research and Delivery Science, Aurora, Colorado, United States
- Division of Internal Medicine, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States
- University of Colorado Anschutz Medical Campus Ludeman Family Center for Women's Health Research, Aurora, Colorado, United States
| | - Michael G. Kahn
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - David P. Kao
- UCHealth, Aurora, Colorado, United States
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, United States
| | - Chen-Tan Lin
- UCHealth, Aurora, Colorado, United States
- Division of Internal Medicine, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States
| | - Daniel C. Malone
- Department of Pharmacotherapy, University of Utah Skaggs College of Pharmacy, Salt Lake City, Utah, United States
| | - Daniel D. Matlock
- Adult and Child Center for Outcomes Research and Delivery Science, Aurora, Colorado, United States
- Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado, United States
- Division of Internal Medicine, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States
- Division of Geriatrics, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States
| | - Lauren Wells
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, United States
| | - Vincent Wysocki
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, United States
| | - Shelley Zhang
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States
| | - Krithika Suresh
- Adult and Child Center for Outcomes Research and Delivery Science, Aurora, Colorado, United States
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, United States
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6
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DiDomenico RJ, Vardeny O. Optimizing Heart Failure Therapy Requires All-Hands-on-Deck and a DASH of Technology. Circ Heart Fail 2023; 16:e010886. [PMID: 37477011 DOI: 10.1161/circheartfailure.123.010886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Affiliation(s)
- Robert J DiDomenico
- Department of Pharmacy Practice, Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago College of Pharmacy (R.D.)
| | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, MN (O.V.)
- Department of Medicine, University of Minnesota, Minneapolis (O.V.)
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Fuery MA, Kadhim B, Samsky MD, Freeman JV, Clark K, Desai NR, Wilson FP, Ahmed T, Ahmad T. Electronic Health Record Embedded Strategies for Improving Care of Patients With Heart Failure. Curr Heart Fail Rep 2023; 20:280-286. [PMID: 37552356 DOI: 10.1007/s11897-023-00614-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 08/09/2023]
Abstract
PURPOSE A majority of clinical decisions use the electronic health record (EHR) and there is an unmet need to use its capability to help providers to make evidence-based decisions that improve care for heart failure patients. These electronic nudges are rooted in the human psychology of decision-making and often target specific cognitive biases. This review outlines the development of novel EHR nudges and specific lessons learned from each experience to inform the development of future interventions. RECENT FINDINGS There have been several randomized clinical trials examining the impact of EHR alerts on quality of care for heart failure patients. These interventions have targeted both clinicians and patients. There are features of each trial that inform best practices and future directions for EHR nudges. Recent clinical trials have demonstrated that some EHR alerts can improve care for heart failure patients. These trials utilized default options, involved clinicians in the alert design process, provided actionable recommendations, and aimed to minimize disruptions to typical workflow. Alerts aimed at improving care should be examined in a randomized fashion in order to evaluate their impact on clinician satisfaction and patient care.
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Affiliation(s)
- Michael A Fuery
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Bashar Kadhim
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA
| | - Marc D Samsky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Katherine Clark
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Francis P Wilson
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA
| | - Treeny Ahmed
- Yale Center for Customer Insights, Yale School of Management, New Haven, CT, USA
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA.
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8
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Mukhopadhyay A, Reynolds HR, Phillips LM, Nagler AR, King WC, Szerencsy A, Saxena A, Aminian R, Klapheke N, Horwitz LI, Katz SD, Blecker S. Cluster-Randomized Trial Comparing Ambulatory Decision Support Tools to Improve Heart Failure Care. J Am Coll Cardiol 2023; 81:1303-1316. [PMID: 36882134 PMCID: PMC10807493 DOI: 10.1016/j.jacc.2023.02.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/06/2023] [Accepted: 02/06/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Mineralocorticoid receptor antagonists (MRAs) are underprescribed for patients with heart failure with reduced ejection fraction (HFrEF). OBJECTIVES This study sought to compare effectiveness of 2 automated, electronic health record-embedded tools vs usual care on MRA prescribing in eligible patients with HFrEF. METHODS BETTER CARE-HF (Building Electronic Tools to Enhance and Reinforce Cardiovascular Recommendations for Heart Failure) was a 3-arm, pragmatic, cluster-randomized trial comparing the effectiveness of an alert during individual patient encounters vs a message about multiple patients between encounters vs usual care on MRA prescribing. This study included adult patients with HFrEF, no active MRA prescription, no contraindication to MRAs, and an outpatient cardiologist in a large health system. Patients were cluster-randomized by cardiologist (60 per arm). RESULTS The study included 2,211 patients (alert: 755, message: 812, usual care [control]: 644), with average age 72.2 years, average ejection fraction 33%, who were predominantly male (71.4%) and White (68.9%). New MRA prescribing occurred in 29.6% of patients in the alert arm, 15.6% in the message arm, and 11.7% in the control arm. The alert more than doubled MRA prescribing compared to usual care (relative risk: 2.53; 95% CI: 1.77-3.62; P < 0.0001) and improved MRA prescribing compared to the message (relative risk: 1.67; 95% CI: 1.21-2.29; P = 0.002). The number of patients with alert needed to result in an additional MRA prescription was 5.6. CONCLUSIONS An automated, patient-specific, electronic health record-embedded alert increased MRA prescribing compared to both a message and usual care. These findings highlight the potential for electronic health record-embedded tools to substantially increase prescription of life-saving therapies for HFrEF. (Building Electronic Tools to Enhance and Reinforce Cardiovascular Recommendations-Heart Failure [BETTER CARE-HF]; NCT05275920).
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Affiliation(s)
- Amrita Mukhopadhyay
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Harmony R. Reynolds
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Lawrence M. Phillips
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Arielle R. Nagler
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York, USA
| | - William C. King
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Adam Szerencsy
- Medical Center Information Technology, New York University Langone Health, New York, New York, USA
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Archana Saxena
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- Medical Center Information Technology, New York University Langone Health, New York, New York, USA
| | - Rod Aminian
- Medical Center Information Technology, New York University Langone Health, New York, New York, USA
| | - Nathan Klapheke
- Medical Center Information Technology, New York University Langone Health, New York, New York, USA
| | - Leora I. Horwitz
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Stuart D. Katz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Saul Blecker
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
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9
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Mukhopadhyay A, Reynolds HR, Xia Y, Phillips LM, Aminian R, Diah RA, Nagler AR, Szerencsy A, Saxena A, Horwitz LI, Katz SD, Blecker S. Design and pilot implementation for the BETTER CARE-HF trial: A pragmatic cluster-randomized controlled trial comparing two targeted approaches to ambulatory clinical decision support for cardiologists. Am Heart J 2023; 258:38-48. [PMID: 36640860 PMCID: PMC10023424 DOI: 10.1016/j.ahj.2022.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 12/15/2022] [Accepted: 12/30/2022] [Indexed: 05/11/2023]
Abstract
BACKGROUND Beart failure with reduced ejection fraction (HFrEF) is a leading cause of morbidity and mortality. However, shortfalls in prescribing of proven therapies, particularly mineralocorticoid receptor antagonist (MRA) therapy, account for several thousand preventable deaths per year nationwide. Electronic clinical decision support (CDS) is a potential low-cost and scalable solution to improve prescribing of therapies. However, the optimal timing and format of CDS tools is unknown. METHODS AND RESULTS We developed two targeted CDS tools to inform cardiologists of gaps in MRA therapy for patients with HFrEF and without contraindication to MRA therapy: (1) an alert that notifies cardiologists at the time of patient visit, and (2) an automated electronic message that allows for review between visits. We designed these tools using an established CDS framework and findings from semistructured interviews with cardiologists. We then pilot tested both CDS tools (n = 596 patients) and further enhanced them based on additional semistructured interviews (n = 11 cardiologists). The message was modified to reduce the number of patients listed, include future visits, and list date of next visit. The alert was modified to improve noticeability, reduce extraneous information on guidelines, and include key information on contraindications. CONCLUSIONS The BETTER CARE-HF (Building Electronic Tools to Enhance and Reinforce CArdiovascular REcommendations for Heart Failure) trial aims to compare the effectiveness of the alert vs. the automated message vs. usual care on the primary outcome of MRA prescribing. To our knowledge, no study has directly compared the efficacy of these two different types of electronic CDS interventions. If effective, our findings can be rapidly disseminated to improve morbidity and mortality for patients with HFrEF, and can also inform the development of future CDS interventions for other disease states. (Trial registration: Clinicaltrials.gov NCT05275920).
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Affiliation(s)
- Amrita Mukhopadhyay
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY.
| | - Harmony R Reynolds
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Yuhe Xia
- Division of Biostatistics, Department of Population Health, New York, NY
| | - Lawrence M Phillips
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Rod Aminian
- Medical Center Information Technology, New York University Langone Health, New York, NY
| | - Ruth-Ann Diah
- Medical Center Information Technology, New York University Langone Health, New York, NY
| | - Arielle R Nagler
- Ronald O. Perelman Department of Dermatology, New York University School Grossman of Medicine, New York, NY
| | - Adam Szerencsy
- Medical Center Information Technology, New York University Langone Health, New York, NY; Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Archana Saxena
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY; Medical Center Information Technology, New York University Langone Health, New York, NY
| | - Leora I Horwitz
- Department of Medicine, New York University Grossman School of Medicine, New York, NY; Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | - Stuart D Katz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Saul Blecker
- Department of Medicine, New York University Grossman School of Medicine, New York, NY; Department of Population Health, New York University Grossman School of Medicine, New York, NY.
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10
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Ho VT, Aikens RC, Tso G, Heidenreich PA, Sharp C, Asch SM, Chen JH, Shah NK. Interruptive Electronic Alerts for Choosing Wisely Recommendations: A Cluster Randomized Controlled Trial. J Am Med Inform Assoc 2022; 29:1941-1948. [PMID: 36018731 PMCID: PMC10161518 DOI: 10.1093/jamia/ocac139] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/13/2022] [Accepted: 08/17/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess the efficacy of interruptive electronic alerts in improving adherence to the American Board of Internal Medicine's Choosing Wisely recommendations to reduce unnecessary laboratory testing. MATERIALS AND METHODS We administered 5 cluster randomized controlled trials simultaneously, using electronic medical record alerts regarding prostate-specific antigen (PSA) testing, acute sinusitis treatment, vitamin D testing, carotid artery ultrasound screening, and human papillomavirus testing. For each alert, we assigned 5 outpatient clinics to an interruptive alert and 5 were observed as a control. Primary and secondary outcomes were the number of postalert orders per 100 patients at each clinic and number of triggered alerts divided by orders, respectively. Post hoc analysis evaluated whether physicians experiencing interruptive alerts reduced their alert-triggering behaviors. RESULTS Median postalert orders per 100 patients did not differ significantly between treatment and control groups; absolute median differences ranging from 0.04 to 0.40 for PSA testing. Median alerts per 100 orders did not differ significantly between treatment and control groups; absolute median differences ranged from 0.004 to 0.03. In post hoc analysis, providers receiving alerts regarding PSA testing in men were significantly less likely to trigger additional PSA alerts than those in the control sites (Incidence Rate Ratio 0.12, 95% CI [0.03-0.52]). DISCUSSION Interruptive point-of-care alerts did not yield detectable changes in the overall rate of undesired orders or the order-to-alert ratio between active and silent sites. Complementary behavioral or educational interventions are likely needed to improve efforts to curb medical overuse. CONCLUSION Implementation of interruptive alerts at the time of ordering was not associated with improved adherence to 5 Choosing Wisely guidelines. TRIAL REGISTRATION NCT02709772.
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Affiliation(s)
- Vy T Ho
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Rachael C Aikens
- Department of Biomedical Informatics, Stanford University School of Medicine, Stanford, California, USA
| | - Geoffrey Tso
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, California, USA
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California, USA
| | - Christopher Sharp
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Steven M Asch
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, California, USA
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California, USA
| | - Jonathan H Chen
- Stanford Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California, USA
| | - Neil K Shah
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
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11
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Reese TJ, Liu S, Steitz B, McCoy A, Russo E, Koh B, Ancker J, Wright A. Conceptualizing clinical decision support as complex interventions: a meta-analysis of comparative effectiveness trials. J Am Med Inform Assoc 2022; 29:1744-1756. [PMID: 35652167 PMCID: PMC9471719 DOI: 10.1093/jamia/ocac089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/26/2022] [Accepted: 05/23/2022] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES Complex interventions with multiple components and behavior change strategies are increasingly implemented as a form of clinical decision support (CDS) using native electronic health record functionality. Objectives of this study were, therefore, to (1) identify the proportion of randomized controlled trials with CDS interventions that were complex, (2) describe common gaps in the reporting of complexity in CDS research, and (3) determine the impact of increased complexity on CDS effectiveness. MATERIALS AND METHODS To assess CDS complexity and identify reporting gaps for characterizing CDS interventions, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting tool for complex interventions. We evaluated the effect of increased complexity using random-effects meta-analysis. RESULTS Most included studies evaluated a complex CDS intervention (76%). No studies described use of analytical frameworks or causal pathways. Two studies discussed use of theory but only one fully described the rationale and put it in context of a behavior change. A small but positive effect (standardized mean difference, 0.147; 95% CI, 0.039-0.255; P < .01) in favor of increasing intervention complexity was observed. DISCUSSION While most CDS studies should classify interventions as complex, opportunities persist for documenting and providing resources in a manner that would enable CDS interventions to be replicated and adapted. Unless reporting of the design, implementation, and evaluation of CDS interventions improves, only slight benefits can be expected. CONCLUSION Conceptualizing CDS as complex interventions may help convey the careful attention that is needed to ensure these interventions are contextually and theoretically informed.
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Affiliation(s)
- Thomas J Reese
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Siru Liu
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bryan Steitz
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Allison McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elise Russo
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Brian Koh
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jessica Ancker
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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12
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Ronan CE, Crable EL, Drainoni ML, Walkey AJ. The impact of clinical decision support systems on provider behavior in the inpatient setting: A systematic review and meta-analysis. J Hosp Med 2022; 17:368-383. [PMID: 35514024 DOI: 10.1002/jhm.12825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/08/2022] [Accepted: 03/22/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Clinical decision support systems (CDSS) are used to improve processes of care. CDSS proliferation may have unintended consequences impacting effectiveness. OBJECTIVE To evaluate the effectiveness of CDSS in altering clinician behavior. DESIGN Electronic searches were performed in EMBASE, PubMed, and Cochrane Central Register of Control Trials for randomized controlled trials testing the impacted of CDSS on clinician behavior from 2000-2021. Extracted data included study design, CDSS attributed and outcomes, user characteristics, settings, and risk of bias. Eligible studies were analyzed qualitatively to describe CDSS types. Studies with sufficient outcome data were included in the meta-analysis. SETTING AND PARTICIPANTS Adult inpatients in the United States. INTERVENTION Clinical decision support system versus non-clinical decision support system. MAIN OUTCOME AND MEASURE A random-effects model measured the pooled risk difference (RD) and odds ratio of clinicians' adherence to CDSS; subgroup analyses tested differences in CDSS effectiveness over time and by CDSS type. RESULTS Qualitative synthesis included 22 studies. Eleven studies reported sufficient outcome data for inclusion in the meta-analysis. CDSS did not result in a statistically significant increase in clinician adoption of desired practicies (RD = 0.04 [95% confidence interval {CI} 0.00, 0.07]). CDSS from 2010-2015 (n = 5) did not increase clinician adoption of desired practice [RD -0.01, (95% CI -0.04, 0.02)].CDSS from 2016-2021 (n = 6) were associated with an increase in targeted practices [RD 0.07 (95% CI0.03, 0.12)], pInteraction = 0.004. EHR [RD 0.04 (95% CI 0.00, 0.08)] vs. non-EHR [RD 0.01 (95% CI -0.01, 0.04)] based CDSS interventions did not result in different adoption of desired practices (pInteraction = 0.27). The meta-analysis did not find an overall positive impact of CDSS on clinician behavior in the inpatient setting.
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Affiliation(s)
- Clare E Ronan
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Erika L Crable
- Department of Psychiatry, Child and Adolescent Services Research Center, University of California, San Diego, La Jolla, California, USA
- ACTRI UCSD Dissemination and Implementation Science Center, University of California San Diego, La Jolla, California, USA
| | - Mari-Lynn Drainoni
- Department of Medicine, Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Allan J Walkey
- Department of Medicine, Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Medicine, The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts, USA
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13
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Knighton AJ, Kuttler KG, Ranade-Kharkar P, Allen L, Throne T, Jacobs JR, Carpenter L, Winberg C, Johnson K, Shrestha N, Ferraro JP, Wolfe D, Peltan ID, Srivastava R, Grissom CK. An alert tool to promote lung protective ventilation for possible acute respiratory distress syndrome. JAMIA Open 2022; 5:ooac050. [PMID: 35815095 PMCID: PMC9263532 DOI: 10.1093/jamiaopen/ooac050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/26/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Computer-aided decision tools may speed recognition of acute respiratory distress syndrome (ARDS) and promote consistent, timely treatment using lung-protective ventilation (LPV). This study evaluated implementation and service (process) outcomes with deployment and use of a clinical decision support (CDS) synchronous alert tool associated with existing computerized ventilator protocols and targeted patients with possible ARDS not receiving LPV. Materials and Methods We performed an explanatory mixed methods study from December 2019 to November 2020 to evaluate CDS alert implementation outcomes across 13 intensive care units (ICU) in an integrated healthcare system with >4000 mechanically ventilated patients annually. We utilized quantitative methods to measure service outcomes including CDS alert tool utilization, accuracy, and implementation effectiveness. Attitudes regarding the appropriateness and acceptability of the CDS tool were assessed via an electronic field survey of physicians and advanced practice providers. Results Thirty-eight percent of study encounters had at least one episode of LPV nonadherence. Addition of LPV treatment detection logic prevented an estimated 1812 alert messages (41%) over use of disease detection logic alone. Forty-eight percent of alert recommendations were implemented within 2 h. Alert accuracy was estimated at 63% when compared to gold standard ARDS adjudication, with sensitivity of 85% and positive predictive value of 62%. Fifty-seven percent of survey respondents observed one or more benefits associated with the alert. Conclusion Introduction of a CDS alert tool based upon ARDS risk factors and integrated with computerized ventilator protocol instructions increased visibility to gaps in LPV use and promoted increased adherence to LPV.
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Affiliation(s)
- Andrew J Knighton
- Healthcare Delivery Institute, Intermountain Healthcare , Murray, Utah, USA
| | - Kathryn G Kuttler
- Digital Technology Services, Intermountain Healthcare , Salt Lake City, Utah, USA
| | | | - Lauren Allen
- Healthcare Delivery Institute, Intermountain Healthcare , Murray, Utah, USA
| | - Taylor Throne
- Healthcare Delivery Institute, Intermountain Healthcare , Murray, Utah, USA
| | - Jason R Jacobs
- Division of Pulmonary and Critical Care Medicine Department of Medicine, Intermountain Medical Center , Murray, Utah, USA
| | - Lori Carpenter
- Division of Pulmonary and Critical Care Medicine Department of Medicine, Intermountain Medical Center , Murray, Utah, USA
| | - Carrie Winberg
- Division of Pulmonary and Critical Care Medicine Department of Medicine, Intermountain Medical Center , Murray, Utah, USA
| | - Kyle Johnson
- Digital Technology Services, Intermountain Healthcare , Salt Lake City, Utah, USA
| | - Neer Shrestha
- Digital Technology Services, Intermountain Healthcare , Salt Lake City, Utah, USA
| | - Jeffrey P Ferraro
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine , Salt Lake City, Utah, USA
| | - Doug Wolfe
- Healthcare Delivery Institute, Intermountain Healthcare , Murray, Utah, USA
| | - Ithan D Peltan
- Division of Pulmonary and Critical Care Medicine Department of Medicine, Intermountain Medical Center , Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine , Salt Lake City, Utah, USA
| | - Rajendu Srivastava
- Healthcare Delivery Institute, Intermountain Healthcare , Murray, Utah, USA
- Department of Pediatrics, University of Utah School of Medicine , Salt Lake City, Utah, USA
| | - Colin K Grissom
- Division of Pulmonary and Critical Care Medicine Department of Medicine, Intermountain Medical Center , Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine , Salt Lake City, Utah, USA
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14
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Kao DP. Electronic Health Records and Heart Failure. Heart Fail Clin 2022; 18:201-211. [PMID: 35341535 PMCID: PMC9167063 DOI: 10.1016/j.hfc.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Increasing the global adoption of electronic health records (EHRs) is transforming the delivery of clinical care. EHRs offer tools that are useful in the care of heart failure ranging from individualized risk stratification and decision support to population management. EHR tools can be combined to target specific areas of need such as the standardization of care, improved quality of care, and resource management. Leveraging EHR functionality has been shown to improve select outcomes including guideline-based therapies, reduction in adverse clinical outcomes, and improved cost-efficiency. Central to success is participation by clinicians and patients in the design and feedback of EHR tools.
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Affiliation(s)
- David P Kao
- University of Colorado School of Medicine, 12700 East 19th Avenue Box B-139, Research Center 2 Room 8005, Aurora, CO 80045, USA.
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15
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Chien SC, Chen YL, Chien CH, Chin YP, Yoon CH, Chen CY, Yang HC, Li YC(J. Alerts in Clinical Decision Support Systems (CDSS): A Bibliometric Review and Content Analysis. Healthcare (Basel) 2022; 10:healthcare10040601. [PMID: 35455779 PMCID: PMC9028311 DOI: 10.3390/healthcare10040601] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/16/2022] [Accepted: 03/18/2022] [Indexed: 12/10/2022] Open
Abstract
A clinical decision support system (CDSS) informs or generates medical recommendations for healthcare practitioners. An alert is the most common way for a CDSS to interact with practitioners. Research about alerts in CDSS has proliferated over the past ten years. The research trend is ongoing with new emerging terms and focus. Bibliometric analysis is ideal for researchers to understand the research trend and future directions. Influential articles, institutes, countries, authors, and commonly used keywords were analyzed to grasp a comprehensive view on our topic, alerts in CDSS. Articles published between 2011 and 2021 were extracted from the Web of Science database. There were 728 articles included for bibliometric analysis, among which 24 papers were selected for content analysis. Our analysis shows that the research direction has shifted from patient safety to system utility, implying the importance of alert usability to be clinically impactful. Finally, we conclude with future research directions such as the optimization of alert mechanisms and comprehensiveness to enhance alert appropriateness and to reduce alert fatigue.
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Affiliation(s)
- Shuo-Chen Chien
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan; (S.-C.C.); (Y.-L.C.); (C.-H.C.); (Y.-P.C.); (C.-Y.C.); (H.-C.Y.)
- International Center for Health Information and Technology, College of Medical science and Technology, Taipei Medical University, Taipei 110, Taiwan
| | - Ya-Lin Chen
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan; (S.-C.C.); (Y.-L.C.); (C.-H.C.); (Y.-P.C.); (C.-Y.C.); (H.-C.Y.)
- International Center for Health Information and Technology, College of Medical science and Technology, Taipei Medical University, Taipei 110, Taiwan
| | - Chia-Hui Chien
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan; (S.-C.C.); (Y.-L.C.); (C.-H.C.); (Y.-P.C.); (C.-Y.C.); (H.-C.Y.)
- International Center for Health Information and Technology, College of Medical science and Technology, Taipei Medical University, Taipei 110, Taiwan
- Office of Public Affairs, Taipei Medical University, Taipei 110, Taiwan
| | - Yen-Po Chin
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan; (S.-C.C.); (Y.-L.C.); (C.-H.C.); (Y.-P.C.); (C.-Y.C.); (H.-C.Y.)
- International Center for Health Information and Technology, College of Medical science and Technology, Taipei Medical University, Taipei 110, Taiwan
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Chang Ho Yoon
- Big Data Institute, University of Oxford, Oxford OX3 7LF, UK;
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Chun-You Chen
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan; (S.-C.C.); (Y.-L.C.); (C.-H.C.); (Y.-P.C.); (C.-Y.C.); (H.-C.Y.)
- International Center for Health Information and Technology, College of Medical science and Technology, Taipei Medical University, Taipei 110, Taiwan
- Department of Radiation Oncology, Taipei Municipal Wan Fang Hospital, Taipei 110, Taiwan
- Information Technology Office in Taipei Municipal Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan
| | - Hsuan-Chia Yang
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan; (S.-C.C.); (Y.-L.C.); (C.-H.C.); (Y.-P.C.); (C.-Y.C.); (H.-C.Y.)
- International Center for Health Information and Technology, College of Medical science and Technology, Taipei Medical University, Taipei 110, Taiwan
| | - Yu-Chuan (Jack) Li
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 110, Taiwan; (S.-C.C.); (Y.-L.C.); (C.-H.C.); (Y.-P.C.); (C.-Y.C.); (H.-C.Y.)
- International Center for Health Information and Technology, College of Medical science and Technology, Taipei Medical University, Taipei 110, Taiwan
- Department of Dermatology, Taipei Municipal Wan Fang Hospital, Taipei 110, Taiwan
- Correspondence: ; Tel.: +886-2-27361661 (ext. 7600)
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16
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Kouri A, Yamada J, Lam Shin Cheung J, Van de Velde S, Gupta S. Do providers use computerized clinical decision support systems? A systematic review and meta-regression of clinical decision support uptake. Implement Sci 2022; 17:21. [PMID: 35272667 PMCID: PMC8908582 DOI: 10.1186/s13012-022-01199-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/28/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Computerized clinical decision support systems (CDSSs) are a promising knowledge translation tool, but often fail to meaningfully influence the outcomes they target. Low CDSS provider uptake is a potential contributor to this problem but has not been systematically studied. The objective of this systematic review and meta-regression was to determine reported CDSS uptake and identify which CDSS features may influence uptake. METHODS Medline, Embase, CINAHL, and the Cochrane Database of Controlled Trials were searched from January 2000 to August 2020. Randomized, non-randomized, and quasi-experimental trials reporting CDSS uptake in any patient population or setting were included. The main outcome extracted was CDSS uptake, reported as a raw proportion, and representing the number of times the CDSS was used or accessed over the total number of times it could have been interacted with. We also extracted context, content, system, and implementation features that might influence uptake, for each CDSS. Overall weighted uptake was calculated using random-effects meta-analysis and determinants of uptake were investigated using multivariable meta-regression. RESULTS Among 7995 citations screened, 55 studies involving 373,608 patients and 3607 providers met full inclusion criteria. Meta-analysis revealed that overall CDSS uptake was 34.2% (95% CI 23.2 to 47.1%). Uptake was only reported in 12.4% of studies that otherwise met inclusion criteria. Multivariable meta-regression revealed the following factors significantly associated with uptake: (1) formally evaluating the availability and quality of the patient data needed to inform CDSS advice; and (2) identifying and addressing other barriers to the behaviour change targeted by the CDSS. CONCLUSIONS AND RELEVANCE System uptake was seldom reported in CDSS trials. When reported, uptake was low. This represents a major and potentially modifiable barrier to overall CDSS effectiveness. We found that features relating to CDSS context and implementation strategy best predicted uptake. Future studies should measure the impact of addressing these features as part of the CDSS implementation strategy. Uptake reporting must also become standard in future studies reporting CDSS intervention effects. REGISTRATION Pre-registered on PROSPERO, CRD42018092337.
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Affiliation(s)
- Andrew Kouri
- Division of Respirology, Department of Medicine, St. Michael's Hospital, Unity Health Toronto, 6 PGT, 30 Bond St, Toronto, ON, Canada
| | - Janet Yamada
- Daphne Cockwell School of Nursing, Faculty of Community Services, Ryerson University, Toronto, ON, Canada
| | - Jeffrey Lam Shin Cheung
- Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Stijn Van de Velde
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | - Samir Gupta
- Division of Respirology, Department of Medicine, St. Michael's Hospital, Unity Health Toronto, 6 PGT, 30 Bond St, Toronto, ON, Canada. .,Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. .,Department of Medicine, University of Toronto, Toronto, ON, Canada.
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17
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Kennedy EE, Bowles KH. Human Factors Considerations in Transitions in Care Clinical Decision Support System Implementation Studies. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2022; 2021:621-630. [PMID: 35308926 PMCID: PMC8861703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Objective: Review transitions in care clinical decision support system (CDSS) implementation studies and describe human factors considerations in users, design, alert types, intervention timing, and implementation outcomes. Methods: Literature review in PubMed guided by subject matter experts. Results: Twelve articles were included. Targeted users included physicians, nurses, pharmacists, or interdisciplinary teams. Alerts were deployed via email, cloud-based software, or the EHR in inpatient and/or outpatient settings. Outcome measures varied across articles, with mixed performance. There were six readmissions-focused, two prescribing, one laboratory, two prescribing and laboratory, and one discharge disposition CDSS. Few articles reported statistically significant differences in outcomes, and many reported alert fatigue. Discussion and Conclusion: Despite the increasing prevalence of CDSS for transitions in care, few articles describe implementation processes and outcomes, and evidence of clinical practice improvement is mixed. Future studies should utilize implementation science frameworks and incorporate appropriate implementation outcomes in addition to traditional clinical outcomes like readmission rates.
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Affiliation(s)
- Erin E Kennedy
- University of Pennsylvania School of Nursing, NewCourtland Center for Transitions and Health Philadelphia, PA
| | - Kathryn H Bowles
- University of Pennsylvania School of Nursing, NewCourtland Center for Transitions and Health Philadelphia, PA
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18
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Chen Y, Harris S, Rogers Y, Ahmad T, Asselbergs FW. OUP accepted manuscript. Eur Heart J 2022; 43:1296-1306. [PMID: 35139182 PMCID: PMC8971005 DOI: 10.1093/eurheartj/ehac030] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 01/11/2022] [Accepted: 01/17/2022] [Indexed: 12/15/2022] Open
Abstract
The increasing volume and richness of healthcare data collected during routine clinical
practice have not yet translated into significant numbers of actionable insights that have
systematically improved patient outcomes. An evidence-practice gap continues to exist in
healthcare. We contest that this gap can be reduced by assessing the use of nudge theory
as part of clinical decision support systems (CDSS). Deploying nudges to modify clinician
behaviour and improve adherence to guideline-directed therapy represents an underused tool
in bridging the evidence-practice gap. In conjunction with electronic health records
(EHRs) and newer devices including artificial intelligence algorithms that are
increasingly integrated within learning health systems, nudges such as CDSS alerts should
be iteratively tested for all stakeholders involved in health decision-making: clinicians,
researchers, and patients alike. Not only could they improve the implementation of known
evidence, but the true value of nudging could lie in areas where traditional randomized
controlled trials are lacking, and where clinical equipoise and variation dominate. The
opportunity to test CDSS nudge alerts and their ability to standardize behaviour in the
face of uncertainty may generate novel insights and improve patient outcomes in areas of
clinical practice currently without a robust evidence base.
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Affiliation(s)
- Yang Chen
- Institute of Health Informatics, University College London,
222 Euston Road, London NW1 2DA, UK
- Clinical Research Informatics Unit, University College London Hospitals NHS
Healthcare Trust, London, UK
- Barts Heart Centre, St Bartholomew’s Hospital, London,
UK
| | - Steve Harris
- Institute of Health Informatics, University College London,
222 Euston Road, London NW1 2DA, UK
| | - Yvonne Rogers
- UCL Interaction Centre, University College London, London,
UK
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, School of Medicine, Yale
University, New Haven, CT, USA
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19
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Maten N, Kroehl ME, Loeb DF, Bhat S, Ota T, Billups SJ, Schilling LM, Heckman S, Reingardt C, Trinkley KE. An evaluation of clinical decision support tools for Patient Health Questionnaire-9 administration. Ment Health Clin 2021; 11:267-273. [PMID: 34621601 PMCID: PMC8463004 DOI: 10.9740/mhc.2021.09.267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/11/2021] [Indexed: 01/03/2023] Open
Abstract
Introduction Many health care institutions are working to improve depression screening and management with the use of the Patient Health Questionnaire 9 (PHQ-9). Clinical decision support (CDS) within the EHR is one strategy, but little is known about effective approaches to design or implement such CDS. The purpose of this study is to compare implementation outcomes of two versions of a CDS tool to improve PHQ-9 administration for patients with depression. Methods This was a retrospective, observational study comparing two versions of a CDS. Version 1 interrupted clinician workflow, and version 2 did not interrupt workflow. Outcomes of interest included reach, adoption, and effectiveness. PHQ-9 administration was determined by chart review. Chi-square tests were used to evaluate associations between PHQ-9 administration with versions 1 and 2. Results Version 1 resulted in PHQ-9 administration 77 times (15.3% of 504 unique encounters) compared with 49 times (9.8% of 502 unique encounters) with version 2 (P = .011). Discussion An interruptive CDS tool may be more effective at increasing PHQ-9 administration, but a noninterruptive CDS tool may be preferred to minimize alert fatigue despite a decrease in effectiveness.
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Affiliation(s)
- Naweid Maten
- Student, Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Miranda E Kroehl
- Statistician, Charter Communications Corporation, Greenwood Village, Colorado
| | - Danielle F Loeb
- Associate Professor, University of Colorado School of Medicine, Aurora, Colorado
| | - Shubha Bhat
- Clinical Pharmacy Specialist, Cleveland Clinic, Cleveland, Ohio
| | - Taylor Ota
- Student, Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Sarah J Billups
- Associate Professor, Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Lisa M Schilling
- Professor, University of Colorado School of Medicine, Aurora, Colorado; Medical Director, Office of Value Based Performance, University of Colorado Medicine, Aurora, Colorado
| | - Simeon Heckman
- Information Technology Supervisor, Department of Clinical Informatics, University of Colorado Health, Aurora, Colorado
| | - Crystal Reingardt
- Professional Research Assistant, University of Colorado School of Medicine, Aurora, Colorado; Project Manager, Office of Value Based Performance, University of Colorado Medicine, Aurora, Colorado
| | - Katy E Trinkley
- Student, Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado.,Statistician, Charter Communications Corporation, Greenwood Village, Colorado.,Associate Professor, University of Colorado School of Medicine, Aurora, Colorado.,Clinical Pharmacy Specialist, Cleveland Clinic, Cleveland, Ohio.,Student, Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado.,Associate Professor, Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado.,Professor, University of Colorado School of Medicine, Aurora, Colorado; Medical Director, Office of Value Based Performance, University of Colorado Medicine, Aurora, Colorado.,Information Technology Supervisor, Department of Clinical Informatics, University of Colorado Health, Aurora, Colorado.,Professional Research Assistant, University of Colorado School of Medicine, Aurora, Colorado; Project Manager, Office of Value Based Performance, University of Colorado Medicine, Aurora, Colorado
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20
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A Comprehensive Review on Seismocardiogram: Current Advancements on Acquisition, Annotation, and Applications. MATHEMATICS 2021. [DOI: 10.3390/math9182243] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In recent years, cardiovascular diseases are on the rise, and they entail enormous health burdens on global economies. Cardiac vibrations yield a wide and rich spectrum of essential information regarding the functioning of the heart, and thus it is necessary to take advantage of this data to better monitor cardiac health by way of prevention in early stages. Specifically, seismocardiography (SCG) is a noninvasive technique that can record cardiac vibrations by using new cutting-edge devices as accelerometers. Therefore, providing new and reliable data regarding advancements in the field of SCG, i.e., new devices and tools, is necessary to outperform the current understanding of the State-of-the-Art (SoTA). This paper reviews the SoTA on SCG and concentrates on three critical aspects of the SCG approach, i.e., on the acquisition, annotation, and its current applications. Moreover, this comprehensive overview also presents a detailed summary of recent advancements in SCG, such as the adoption of new techniques based on the artificial intelligence field, e.g., machine learning, deep learning, artificial neural networks, and fuzzy logic. Finally, a discussion on the open issues and future investigations regarding the topic is included.
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21
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Chien SC, Chin YP(H, Yoon CH, Islam MM, Jian WS, Hsu CK, Chen CY, Chien PH, Li YC(J. A novel method to retrieve alerts from a homegrown Computerized Physician Order Entry (CPOE) system of an academic medical center: Comprehensive alert characteristic analysis. PLoS One 2021; 16:e0246597. [PMID: 33561178 PMCID: PMC7872273 DOI: 10.1371/journal.pone.0246597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 01/21/2021] [Indexed: 11/19/2022] Open
Abstract
Background The collection and analysis of alert logs are necessary for hospital administrators to understand the types and distribution of alert categories within the organization and reduce alert fatigue. However, this is not readily available in most homegrown Computerized Physician Order Entry (CPOE) systems. Objective To present a novel method that can collect alert information from a homegrown CPOE system (at an academic medical center in Taiwan) and conduct a comprehensive analysis of the number of alerts triggered and alert characteristics. Methods An alert log collector was developed using the Golang programming language and was implemented to collect all triggered interruptive alerts from a homegrown CPOE system of a 726-bed academic medical center from November 2017 to June 2018. Two physicians categorized the alerts from the log collector as either clinical or non-clinical (administrative). Results Overall, 1,625,341 interruptive alerts were collected and classified into 1,474 different categories based on message content. The sum of the top 20, 50, and 100 categories of most frequently triggered alerts accounted for approximately 80, 90 and 97 percent of the total triggered alerts, respectively. Among alerts from the 100 most frequently triggered categories, 1,266,818 (80.2%) were administrative and 312,593 (19.8%) were clinical alerts. Conclusion We have successfully developed an alert log collector that can serve as an extended function to retrieve alerts from a homegrown CPOE system. The insight generated from the present study could also potentially bring value to hospital system designers and hospital administrators when redesigning their CPOE system.
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Affiliation(s)
- Shuo-Chen Chien
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- International Center for Health Information and Technology, College of Medical science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Yen-Po (Harvey) Chin
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Chang Ho Yoon
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Md. Mohaimenul Islam
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- International Center for Health Information and Technology, College of Medical science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Wen-Shan Jian
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
| | - Chun-Kung Hsu
- Information Technology Office, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chun-You Chen
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- International Center for Health Information and Technology, College of Medical science and Technology, Taipei Medical University, Taipei, Taiwan
- Information Technology Office, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Radiation Oncology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Po-Han Chien
- Department of Business Administration, National Taiwan University, Taipei, Taiwan
| | - Yu-Chuan (Jack) Li
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- International Center for Health Information and Technology, College of Medical science and Technology, Taipei Medical University, Taipei, Taiwan
- Department of Dermatology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- * E-mail:
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22
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Allen LA, Venechuk G, McIlvennan CK, Page RL, Knoepke CE, Helmkamp LJ, Khazanie P, Peterson PN, Pierce K, Harger G, Thompson JS, Dow TJ, Richards L, Huang J, Strader JR, Trinkley KE, Kao DP, Magid DJ, Buttrick PM, Matlock DD. An Electronically Delivered Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure With Reduced Ejection Fraction: The EPIC-HF Trial. Circulation 2020; 143:427-437. [PMID: 33201741 DOI: 10.1161/circulationaha.120.051863] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Major gaps exist in the routine initiation and dose up-titration of guideline-directed medical therapies (GDMT) for patients with heart failure with reduced ejection fraction. Without novel approaches to improve prescribing, the cumulative benefits of heart failure with reduced ejection fraction treatment will be largely unrealized. Direct-to-consumer marketing and shared decision making reflect a culture where patients are increasingly involved in treatment choices, creating opportunities for prescribing interventions that engage patients. METHODS The EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction) trial randomized patients with heart failure with reduced ejection fraction from a diverse health system to usual care versus patient activation tools-a 3-minute video and 1-page checklist-delivered electronically 1 week before, 3 days before, and 24 hours before a cardiology clinic visit. The tools encouraged patients to work collaboratively with their clinicians to "make one positive change" in heart failure with reduced ejection fraction prescribing. The primary endpoint was the percentage of patients with GDMT medication initiations and dose intensifications from immediately preceding the cardiology clinic visit to 30 days after, compared with usual care during the same period. RESULTS EPIC-HF enrolled 306 patients, 290 of whom attended a clinic visit during the study period: 145 were sent the patient activation tools and 145 were controls. The median age of patients was 65 years; 29% were female, 11% were Black, 7% were Hispanic, and the median ejection fraction was 32%. Preclinic data revealed significant GDMT opportunities, with no patients on target doses of β-blocker, sacubitril/valsartan, and mineralocorticoid receptor antagonists. From immediately preceding the cardiology clinic visit to 30 days after, 49.0% in the intervention and 29.7% in the control experienced an initiation or intensification of their GDMT (P=0.001). The majority of these changes were made at the clinician encounter itself and involved dose uptitrations. There were no deaths and no significant differences in hospitalization or emergency department visits at 30 days between groups. CONCLUSIONS A patient activation tool delivered electronically before a cardiology clinic visit improved clinician intensification of GDMT. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03334188.
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Affiliation(s)
- Larry A Allen
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Grace Venechuk
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Colleen K McIlvennan
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Robert L Page
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora (R.L.P., K.E.T.)
| | | | - Laura J Helmkamp
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Prateeti Khazanie
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Pamela N Peterson
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.).,Denver Health Medical Center, CO (P.N.P.)
| | - Kenneth Pierce
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Geoffrey Harger
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Jocelyn S Thompson
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Tristan J Dow
- University of Colorado Health Poudre Valley Hospital, Loveland (T.J.D., L.R.)
| | - Lance Richards
- University of Colorado Health Poudre Valley Hospital, Loveland (T.J.D., L.R.)
| | - Janice Huang
- University of Colorado Health Memorial Hospital, Colorado Springs (J.H., J.R.S.)
| | - James R Strader
- University of Colorado Health Memorial Hospital, Colorado Springs (J.H., J.R.S.)
| | - Katy E Trinkley
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.).,University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora (R.L.P., K.E.T.)
| | - David P Kao
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - David J Magid
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Peter M Buttrick
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
| | - Daniel D Matlock
- University of Colorado School of Medicine, Aurora (L.A.A., G.V., C.K.M., C.E.K., L.J.H., P.K., P.N.P., K.P., G.H., J.S.T., K.E.T., D.P.K., D.J.M., P.M.B., D.D.M.)
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