Impact of electronic reminders on venous thromboprophylaxis after admissions and transfers

The effects of clinical decision support system for prescribing medication on patient outcomes and physician practice performance: a systematic review and meta-analysis

Background

Clinical Decision Support Systems (CDSSs) for Prescribing are one of the innovations designed to improve physician practice performance and patient outcomes by reducing prescription errors. This study was therefore conducted to examine the effects of various CDSSs on physician practice performance and patient outcomes.

Methods

This systematic review was carried out by searching PubMed, Embase, Web of Science, Scopus, and Cochrane Library from 2005 to 2019. The studies were independently reviewed by two researchers. Any discrepancies in the eligibility of the studies between the two researchers were then resolved by consulting the third researcher. In the next step, we performed a meta-analysis based on medication subgroups, CDSS-type subgroups, and outcome categories. Also, we provided the narrative style of the findings. In the meantime, we used a random-effects model to estimate the effects of CDSS on patient outcomes and physician practice performance with a 95% confidence interval. Q statistics and I² were then used to calculate heterogeneity.

Results

On the basis of the inclusion criteria, 45 studies were qualified for analysis in this study. CDSS for prescription drugs/COPE has been used for various diseases such as cardiovascular diseases, hypertension, diabetes, gastrointestinal and respiratory diseases, AIDS, appendicitis, kidney disease, malaria, high blood potassium, and mental diseases. In the meantime, other cases such as concurrent prescribing of multiple medications for patients and their effects on the above-mentioned results have been analyzed. The study shows that in some cases the use of CDSS has beneficial effects on patient outcomes and physician practice performance (std diff in means = 0.084, 95% CI 0.067 to 0.102). It was also statistically significant for outcome categories such as those demonstrating better results for physician practice performance and patient outcomes or both. However, there was no significant difference between some other cases and traditional approaches. We assume that this may be due to the disease type, the quantity, and the type of CDSS criteria that affected the comparison. Overall, the results of this study show positive effects on performance for all forms of CDSSs.

Conclusions

Our results indicate that the positive effects of the CDSS can be due to factors such as user-friendliness, compliance with clinical guidelines, patient and physician cooperation, integration of electronic health records, CDSS, and pharmaceutical systems, consideration of the views of physicians in assessing the importance of CDSS alerts, and the real-time alerts in the prescription.

Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials

OBJECTIVE

To report the improvements achieved with clinical decision support systems and examine the heterogeneity from pooling effects across diverse clinical settings and intervention targets.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline up to August 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES AND METHODS

Randomised or quasi-randomised controlled trials reporting absolute improvements in the percentage of patients receiving care recommended by clinical decision support systems. Multilevel meta-analysis accounted for within study clustering. Meta-regression was used to assess the degree to which the features of clinical decision support systems and study characteristics reduced heterogeneity in effect sizes. Where reported, clinical endpoints were also captured.

RESULTS

In 108 studies (94 randomised, 14 quasi-randomised), reporting 122 trials that provided analysable data from 1 203 053 patients and 10 790 providers, clinical decision support systems increased the proportion of patients receiving desired care by 5.8% (95% confidence interval 4.0% to 7.6%). This pooled effect exhibited substantial heterogeneity (I²=76%), with the top quartile of reported improvements ranging from 10% to 62%. In 30 trials reporting clinical endpoints, clinical decision support systems increased the proportion of patients achieving guideline based targets (eg, blood pressure or lipid control) by a median of 0.3% (interquartile range -0.7% to 1.9%). Two study characteristics (low baseline adherence and paediatric settings) were associated with significantly larger effects. Inclusion of these covariates in the multivariable meta-regression, however, did not reduce heterogeneity.

CONCLUSIONS

Most interventions with clinical decision support systems appear to achieve small to moderate improvements in targeted processes of care, a finding confirmed by the small changes in clinical endpoints found in studies that reported them. A minority of studies achieved substantial increases in the delivery of recommended care, but predictors of these more meaningful improvements remain undefined.

Extended Venous Thromboembolism Prophylaxis in Medically Ill Patients: An NATF Anticoagulation Action Initiative

Hospitalized patients with acute medical illnesses are at risk for venous thromboembolism (VTE) during and after a hospital stay. Risk factors include physical immobilization and underlying pathophysiologic processes that activate the coagulation pathway and are still present after discharge. Strategies for optimal pharmacologic VTE thromboprophylaxis are evolving, and recommendations for VTE prophylaxis can be further refined to protect high-risk patients after hospital discharge. An early study of extended VTE prophylaxis with a parenteral agent in medically ill patients yielded inconclusive results with regard to efficacy and bleeding. In the Acute Medically Ill VTE Prevention with Extended Duration Betrixaban (APEX) trial, extended use of betrixaban halved symptomatic VTE, decreased hospital readmission, and reduced stroke and major adverse cardiovascular events compared with standard enoxaparin prophylaxis. Based on findings from APEX, the Food and Drug Administration approved betrixaban in 2017 for extended VTE prophylaxis in acute medically ill patients. In the Reducing Post-Discharge Venous Thrombo-Embolism Risk (MARINER) study, extended use of rivaroxaban halved symptomatic VTE in high-risk medical patients compared with placebo. In 2019, rivaroxaban was approved for extended thromboprophylaxis in high-risk medical patients, thus making available a new strategy for in-hospital and post-discharge VTE prevention. To address the critical unmet need for VTE prophylaxis in medically ill patients at the time of hospital discharge, the North American Thrombosis Forum (NATF) is launching the Anticoagulation Action Initiative, a comprehensive consensus document that provides practical guidance and straightforward, patient-centered recommendations for VTE prevention during hospitalization and after discharge.

Venous thromboembolism prophylaxis in patients hospitalized in medical wards: A real life experience

Venous thromboembolism (VTE) is a preventable cause of morbidity and mortality in acutely ill patients hospitalized in medical departments. Thromboprophylaxis with anticoagulants was shown to be safe and effective in medical patients with high risk to develop VTE. Despite guidelines recommendations, the rate of thromboprophylaxis in those patients is low. The objective of the study was to evaluate the rate of VTE risk assessment in routine medical department practice, the rate of eligible patients for thromboprophylaxis, the rate of patients who received thromboprophylaxis, and their outcome.Medical records of consecutive patients (3000 at 2013, 1000 at 2018) hospitalized in medical department were reviewed, retrospectively, for demographic, clinical characteristics, thromboprophylaxis treatment with enoxaparin and outcome (up to 90 days following discharge). Padua score was used for VTE risk assessment. VTE diagnosis was based on clinical suspicion.The mean patient's age (52.6% females) was 67.95 ± 21.56 years. 21% were eligible for thromboprophylaxis. Routine VTE risk assessment rate increased significantly following its incorporation into quality parameters, but the rate of treated patients was low (22% at 2013; 46% at 2018). The patients who received thromophylaxis were sicker compared to eligible patients without thromboprophylaxis. The rate of symptomatic VTE was low (0.24%; 0.12% and 0.55% for low and high VTE risk, respectively). Thromboprophylaxis did not have significant effect on the low number of VTE events. No major bleeding was observed.Major efforts are still needed to increase the rate of thromboprophylaxis in all eligible medical patients according to the guidelines recommendations.

Electronic alerts, comparative practitioner metrics, and education improve thromboprophylaxis and reduce venous thrombosis in community hospitals

BACKGROUND

Venous thromboembolism prophylaxis remains underutilized in hospitalized medical patients at high risk for venous thromboembolism. We previously reported that a multifaceted intervention was associated with a sustained increase in appropriate thromboprophylaxis and reduced symptomatic venous thromboembolism among medical patients hospitalized in two urban teaching hospitals. The effectiveness of this intervention in community hospitals is unknown.

METHODS

We performed a prospective multicenter cohort study in three community hospitals. All medical patients admitted from February 1, 2011 to January 31, 2014 were eligible. Consecutive eligible patients were enrolled into the 12-month "control," 12-month "intervention," or 12-month "maintenance" group. We provided electronic alerts, physician performance feedback, and targeted medical education for the intervention group. Only the alert component of the intervention continued in the maintenance group. The primary outcome was the rate of appropriate thromboprophylaxis among patients at high risk for venous thromboembolism defined as the prescription of guideline recommended chemoprophylaxis, or identification of a chemoprophylaxis contraindication. Secondary outcomes included rates of symptomatic venous thromboembolism, major bleeding, all-cause mortality, heparin-induced thrombocytopenia, physician satisfaction, and alert fatigue.

RESULTS

Appropriate thromboprophylaxis when compared to the control group rate of 67% was higher for the intervention group (85%) and for the maintenance group (77%; P < .001 for each comparison). A reduction of 90-day symptomatic venous thromboembolism accompanied the intervention (control 4.5%, intervention 3.4%, maintenance 3.0%, P = .04).

CONCLUSIONS

This multifaceted intervention was associated with an overall increase in appropriate thromboprophylaxis of medical patients compared with the control period. Hospital-associated venous thrombosis rates decreased.

Effects of computerized decision support system implementations on patient outcomes in inpatient care: a systematic review

Objectives

To systematically classify the clinical impact of computerized clinical decision support systems (CDSSs) in inpatient care.

Materials and Methods

Medline, Cochrane Trials, and Cochrane Reviews were searched for CDSS studies that assessed patient outcomes in inpatient settings. For each study, 2 physicians independently mapped patient outcome effects to a predefined medical effect score to assess the clinical impact of reported outcome effects. Disagreements were measured by using weighted kappa and solved by consensus. An example set of promising disease entities was generated based on medical effect scores and risk of bias assessment. To summarize technical characteristics of the systems, reported input variables and algorithm types were extracted as well.

Results

Seventy studies were included. Five (7%) reported reduced mortality, 16 (23%) reduced life-threatening events, and 28 (40%) reduced non-life-threatening events, 20 (29%) had no significant impact on patient outcomes, and 1 showed a negative effect (weighted κ: 0.72, P < .001). Six of 24 disease entity settings showed high effect scores with medium or low risk of bias: blood glucose management, blood transfusion management, physiologic deterioration prevention, pressure ulcer prevention, acute kidney injury prevention, and venous thromboembolism prophylaxis. Most of the implemented algorithms (72%) were rule-based. Reported input variables are shared as standardized models on a metadata repository.

Discussion and Conclusion

Most of the included CDSS studies were associated with positive patient outcomes effects but with substantial differences regarding the clinical impact. A subset of 6 disease entities could be filtered in which CDSS should be given special consideration at sites where computer-assisted decision-making is deemed to be underutilized. Registration number on PROSPERO: CRD42016049946.

Computer-generated reminders delivered on paper to healthcare professionals: effects on professional practice and healthcare outcomes

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 them 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. This is an update of a previously published review.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system (computer-generated) and delivered on paper to healthcare professionals on quality of care (outcomes related to healthcare professionals' practice) and patient outcomes (outcomes related to patients' health condition).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers up to 21 September 2016 together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included individual- or cluster-randomized and non-randomized trials that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals, alone (single-component intervention) or in addition to one or more co-interventions (multi-component intervention), compared with usual care or the co-intervention(s) without the reminder component.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. 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 improvement and interquartile range (IQR) across included studies using the primary outcome or median outcome as representative outcome. We assessed the certainty of the evidence according to the GRADE approach.

MAIN RESULTS

We identified 35 studies (30 randomized trials and five non-randomized trials) and analyzed 34 studies (40 comparisons). Twenty-nine studies took place in the USA and six studies took place in Canada, France, Israel, and Kenya. All studies except two took place in outpatient care. Reminders were aimed at enhancing compliance with preventive guidelines (e.g. cancer screening tests, vaccination) in half the studies and at enhancing compliance with disease management guidelines for acute or chronic conditions (e.g. annual follow-ups, laboratory tests, medication adjustment, counseling) in the other half.Computer-generated reminders delivered on paper to healthcare professionals, alone or in addition to co-intervention(s), probably improves quality of care slightly compared with usual care or the co-intervention(s) without the reminder component (median improvement 6.8% (IQR: 3.8% to 17.5%); 34 studies (40 comparisons); moderate-certainty evidence).Computer-generated reminders delivered on paper to healthcare professionals alone (single-component intervention) probably improves quality of care compared with usual care (median improvement 11.0% (IQR 5.4% to 20.0%); 27 studies (27 comparisons); moderate-certainty evidence). Adding computer-generated reminders delivered on paper to healthcare professionals to one or more co-interventions (multi-component intervention) probably improves quality of care slightly compared with the co-intervention(s) without the reminder component (median improvement 4.0% (IQR 3.0% to 6.0%); 11 studies (13 comparisons); moderate-certainty evidence).We are uncertain whether reminders, alone or in addition to co-intervention(s), improve patient outcomes as the certainty of the evidence is very low (n = 6 studies (seven comparisons)). None of the included studies reported outcomes related to harms or adverse effects of the intervention.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that computer-generated reminders delivered on paper to healthcare professionals probably slightly improves quality of care, in terms of compliance with preventive guidelines and compliance with disease management guidelines. It is uncertain whether reminders improve patient outcomes because the certainty of the evidence is very low. The heterogeneity of the reminder interventions included in this review also suggests that reminders can probably improve quality of care in various settings under various conditions.

Electronic Alerts, Comparative Practitioner Metrics, and Education Improves Thromboprophylaxis and Reduces Thrombosis

BACKGROUND

Venous thromboembolism chemoprophylaxis remains underutilized in hospitalized medical patients at high risk for venous thromboembolism. We assessed the effect of a health care quality-improvement initiative comprised of a targeted electronic alert, comparative practitioner metrics, and practitioner-specific continuing medical education on the rate of appropriate venous thromboembolism chemoprophylaxis provided to medical inpatients at high risk for venous thromboembolism.

METHODS

We performed a multicenter prospective observational cohort study in an urban Utah hospital system. All medical patients admitted to 1 of 2 participating hospitals from April 1, 2010 to December 31, 2012 were eligible. Patients were members of the "control" (April 1, 2010 to December 31, 2010), "intervention" (January 1, 2011 to December 31, 2011), or "subsequent year" (January 1, 2012 to December 31, 2012) group. The primary outcome was the rate of appropriate chemoprophylaxis among patients at high risk for venous thromboembolism. Secondary outcomes included rates of symptomatic venous thromboembolism, major bleeding, all-cause mortality, heparin-induced thrombocytopenia, physician satisfaction, and alert fatigue.

RESULTS

The rate of appropriate chemoprophylaxis among patients at high risk for venous thromboembolism increased (66.1% control period vs 81.0% intervention period vs 88.1% subsequent year; P <.001 for each comparison). A significant reduction of 90-day symptomatic venous thromboembolism accompanied the quality initiative (9.3% control period, 9.7% intervention period, 6.7% subsequent year; P = .009); 30-day venous thromboembolism rates also significantly decreased.

CONCLUSIONS

A multifaceted intervention was associated with increased appropriate venous thromboembolism chemoprophylaxis among medical inpatients at high risk for venous thromboembolism and reduced symptomatic venous thromboembolism. The effect of the intervention was sustained.

Exploring sub-optimal use of an electronic risk assessment tool for venous thromboembolism

International guidelines and consensus groups recommend using a risk assessment tool (RAT) to assess Venous Thromboembolism (VTE) risk prior to the prescription of prophylaxis. We set out to examine how an electronic RAT was being used (i.e. if by the right clinician, at the right time, for the right purpose) and to identify factors influencing utilization of the RAT. A sample of 112 risk assessments was audited and 12 prescribers were interviewed. The RAT was used as intended in only 40 (35.7%) cases (i.e. completed by a doctor within 24 h of admission, prior to the prescription of prophylaxis). We identified several reasons for sub-optimal use of the RAT, including beliefs about the need for a RAT, poor awareness of the tool, and poor RAT design. If a user-centred approach had been adopted, it is likely that a RAT would not have been implemented or that problematic design issues would have been identified.

The effects of on-screen, point of care computer reminders on processes and outcomes of care

BACKGROUND

The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering 'computer reminders'.

OBJECTIVES

To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care.

SEARCH STRATEGY

We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles.

SELECTION CRITERIA

Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care.

DATA COLLECTION AND ANALYSIS

Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome.

MAIN RESULTS

Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering. In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase).

AUTHORS' CONCLUSIONS

Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.