Effect of computerised, knowledge-based, clinical decision support systems on patient-reported and clinical outcomes of patients with chronic disease managed in primary care settings: a systematic review

Effectiveness of interactive dashboards to optimise prescribing in primary care: a protocol for a systematic review

Introduction

Advances in therapeutics and healthcare have led to a growing population of individuals living with multimorbidity and polypharmacy making prescribing more challenging. Most prescribing occurs in primary care and General Practitioners (GPs) have expressed interest in comparative feedback on their prescribing performance. Clinical decision support systems (CDSS) and audit and feedback interventions have shown some impact, but changes are often short-lived. Interactive dashboards, a novel approach integrating CDSS and audit and feedback elements, offer longitudinal updated data outside clinical encounters. This systematic review aims to explore the effectiveness of interactive dashboards on prescribing-related outcomes in primary care and examine the characteristics of these dashboards.

Methods

This protocol was prospectively registered on PROSPERO (CRD42023481475) and reported in line with PRISMA-P guidelines. Searches of PubMed, EMBASE, Medline, PsychINFO, CINAHL, Scopus, the Cochrane Library, and grey literature, including trial registries were performed to identify interventional studies (randomised and non-randomised) that assess the effectiveness of interactive dashboards on prescribing related outcomes. The search will be supplemented by searching references of retrieved articles with the use of an automated citation chaser. Identified records will be screened independently by two reviewers and data from eligible studies extracted using a purposely developed data extraction tool. We will narratively summarise the intervention types and those associated with improvements in prescribing outcomes. A quantitative synthesis will be carried out if a sufficient number of homogenous studies are identified. Methodological quality will be assessed by two reviewers using the Cochrane Effective Practice and Organisation of Care risk assessment tool.

Discussion

This systematic review will explore the effect of interactive dashboards on prescribing related outcome measures in primary care and describe the characteristics of interactive dashboards. This research may inform future intervention development and shape policymaking particularly in the context of ongoing and planned developments in e-prescribing infrastructure.

Testing an HPV Vaccine Decision Aid for 27- to 45-Year-Old Adults in the United States: A Randomized Trial

BACKGROUND

In the United States, human papillomavirus (HPV) vaccination among 27- to 45-y-olds (mid-adults) is recommended based on shared clinical decision making with a health care provider. We developed a patient decision aid tool to support the implementation of this mid-adult HPV vaccination guideline. The purpose of this study was to evaluate the effect of a patient decision aid tool for HPV vaccination, HPV DECIDE, compared with an information fact sheet among mid-adults who have not received the HPV vaccine.

METHOD

Participants were recruited between December 2023 and January 2024. We used a randomized Solomon, 4-group, pretest/posttest design with mid-adults aged 27 to 45 y who were unvaccinated for HPV and balanced based on sex (n = 612). The primary outcome was decisional conflict. Intermediate outcomes included knowledge, behavioral expectancies, self-efficacy, and perceived risk. Variables were measured using validated scales. Pretest sensitization was not present; intervention and control groups were compared. Fixed-effects inverse-variance weighting was used to pool effect estimates and determine meta-analytic statistical significance across tests with and without pretest controls.

RESULTS

Participants in the intervention group had significantly lower total decisional conflict scores (B = -3.58, P = 0.007) compared with the control group. Compared with the control group, participants in the intervention group showed higher knowledge (B = 0.48, P = 0.020), greater intention to receive (B = 0.196, P = 0.049) and discuss the HPV vaccine (B = 0.324, P ≤ 0.001), and greater self-efficacy about HPV vaccine decision making (B = 3.28, P = 0.043). There were no statistically significant results for perceived risks of HPV infection.

CONCLUSIONS

The HPV DECIDE tool for mid-adult HPV vaccination shows promise for immediate reductions in decisional conflict and improvement in knowledge, intentions, and self-efficacy about the HPV vaccine. Future studies are warranted to evaluate the effectiveness of this patient decision aid tool in real-world settings.

HIGHLIGHTS

Shared clinical decision making is recommended for HPV vaccination with mid-adults.A patient decision aid for HPV vaccination reduced decisional conflict for mid-adults.The HPV vaccine patient decision aid was acceptable to mid-adults.

Association of Patients' Knowledge on the Disease and Its Management with Indicators of Disease Severity and Individual Characteristics in Patients with Chronic Obstructive Pulmonary Disease (COPD): Results from COSYCONET 2

Background

In patients with chronic diseases, including those with chronic obstructive pulmonary disease (COPD), knowledge on the disease and its self-management is considered as relevant for improving disease control and long-term outcome. We studied to which extent components of knowledge depended on potential predictors, such as participation in educational programs and disease severity. For example, the perception of exacerbations or GOLD grade might modulate the content and reliability of COPD understanding.

Methods

Data from the German COSYCONET 2 COPD cohort was used, and 13 questions addressing knowledge and self-management were analyzed.

Results

Overall, 310 patients with the diagnosis of COPD of GOLD grades 1/2/3/4 as well as the former grade 0 were included (39.7% female, median age 66.0 years). The answers to 3 questions (knowledge of term exacerbation, pursed lip breathing technique, criteria for contacting a doctor) were improved (p < 0.05 each) when patients had had moderate-to-severe exacerbations, and to one question (breathing exercise) when having COPD grade 3/4 versus 0/1/2. The other 9 responses did not depend on disease severity, but most of the knowledge was improved when having participated in an educational COPD program. This was particularly true for knowledge that also depended on exacerbations, or if the treating physician was a pulmonary specialist. In some responses, the proportion of correct answers was significantly reduced in males compared to females. The dependence on education level, existence of a treatment plan, self-reported level of risk aversion and low depression score was weak and heterogeneous.

Conclusion

These findings suggest that part of the disease-related knowledge in patients with COPD was reinforced by the experience of exacerbations, especially knowledge regarding criteria on contacting a physician. These observations might help in focusing education on those parts of knowledge that are considered as important by patients based on their own experience.

The feasibility of integrating an alcohol screening clinical decision support tool into primary care clinical software: a review and Australian key stakeholder study

BACKGROUND

This study explored the feasibility of integrating a clinical decision support tool into general practice clinical management software in Australia to prompt for alcohol screening among patients who are pregnant or planning a pregnancy. The study aimed to increase understanding of what is an appropriate and acceptable clinical decision support tool, the circumstances when a prompt to use such a screening tool should occur, and the barriers and enablers of successful implementation.

METHODS

This feasibility study employed a mixed methods approach and purposive sampling to identify key stakeholders to interview. Participants included vendors of clinical software used in Australian general practice, clinicians in general practice, and relevant others. Data from a literature review and 23 interviews were analysed leading to recommendations which were 'sense-tested' by an additional 22 stakeholders.

RESULTS

Although there are at least 18 clinical software packages used in Australian general practice, it is feasible to integrate an alcohol screening tool for pregnancy into software for the majority of general practices in Australia. The AUDIT-C alcohol screening tool for pregnancy was widely accepted as suitable for such a purpose. Clinicians suggested the greatest barriers to screening were lack of time within antenatal consultations and insufficient remuneration for longer consultations. Many clinicians saw opportunity for introducing a multifunctional antenatal tool that could incorporate screening and clinical decision support for alcohol, tobacco and other substance use, mental health, domestic and family violence and potentially other areas informing healthy pregnancy. It could also be used opportunistically for preconception screening and counselling. Deployment of the tool could be supported by an education campaign from professional associations.

CONCLUSION

The integration of a tool for screening for alcohol use among women who are pregnant or planning pregnancy into general practice clinical software is feasible; however, a multifunctional antenatal screening tool, incorporating other psychosocial elements, was considered more useful than a stand-alone alcohol screening tool. Codesign is needed with vendors and end-users to develop an acceptable tool that can be widely implemented. Issues with GP renumeration need also to be addressed to encourage alcohol screening pre-pregnancy and in the early months of pregnancy.

Benefits of Clinical Decision Support Systems for the Management of Noncommunicable Chronic Diseases: Targeted Literature Review

BACKGROUND

Clinical decision support systems (CDSSs) are designed to assist in health care delivery by supporting medical practice with clinical knowledge, patient information, and other relevant types of health information. CDSSs are integral parts of health care technologies assisting in disease management, including diagnosis, treatment, and monitoring. While electronic medical records (EMRs) serve as data repositories, CDSSs are used to assist clinicians in providing personalized, context-specific recommendations derived by comparing individual patient data to evidence-based guidelines.

OBJECTIVE

This targeted literature review (TLR) aimed to identify characteristics and features of both stand-alone and EMR-integrated CDSSs that influence their outcomes and benefits based on published scientific literature.

METHODS

A TLR was conducted using the Embase, MEDLINE, and Cochrane databases to identify data on CDSSs published in a 10-year frame (2012-2022). Studies on computerized, guideline-based CDSSs used by health care practitioners with a focus on chronic disease areas and reporting outcomes for CDSS utilization were eligible for inclusion.

RESULTS

A total of 49 publications were included in the TLR. Studies predominantly reported on EMR-integrated CDSSs (ie, connected to an EMR database; n=32, 65%). The implementation of CDSSs varied globally, with substantial utilization in the United States and within the domain of cardio-renal-metabolic diseases. CDSSs were found to positively impact "quality assurance" (n=35, 69%) and provide "clinical benefits" (n=20, 41%), compared to usual care. Among CDSS features, treatment guidance and flagging were consistently reported as the most frequent elements for enhancing health care, followed by risk level estimation, diagnosis, education, and data export. The effectiveness of a CDSS was evaluated most frequently in primary care settings (n=34, 69%) across cardio-renal-metabolic disease areas (n=32, 65%), especially in diabetes (n=13, 26%). Studies reported CDSSs to be commonly used by a mixed group (n=27, 55%) of users including physicians, specialists, nurses or nurse practitioners, and allied health care professionals.

CONCLUSIONS

Overall, both EMR-integrated and stand-alone CDSSs showed positive results, suggesting their benefits to health care providers and potential for successful adoption. Flagging and treatment recommendation features were commonly used in CDSSs to improve patient care; other features such as risk level estimation, diagnosis, education, and data export were tailored to specific requirements and collectively contributed to the effectiveness of health care delivery. While this TLR demonstrated that both stand-alone and EMR-integrated CDSSs were successful in achieving clinical outcomes, the heterogeneity of included studies reflects the evolving nature of this research area, underscoring the need for further longitudinal studies to elucidate aspects that may impact their adoption in real-world scenarios.

Provision of Digital Primary Health Care Services: Overview of Reviews

BACKGROUND

Digital health is a growing field, and many digital interventions have been implemented on a large scale since the COVID-19 pandemic, mainly in primary health care (PHC). The development of digital health interventions and their application in PHC are encouraged by the World Health Organization. The increased number of published scientific papers on this topic has resulted in an overwhelming amount of information, but there is no overview of reviews to summarize this evidence.

OBJECTIVE

This study aims to provide policy makers, health managers, and researchers with a summary of evidence on digital interventions used in PHC.

METHODS

This overview of reviews searched the Web of Science and MEDLINE databases for systematic and scoping reviews on assessments of digital technologies implemented in PHC published from January 2007 to March 2023. Only reviews that addressed digital interventions whose targets were real patients or health care providers (HCPs) were included.

RESULTS

A total of 236 records were identified from the search strategy, of which 42 (17.8%) full-text papers were selected for analysis, and 18 (7.6%) reviews met the eligibility criteria. In total, 61% (11/18) of the reviews focused their analysis on specific digital health interventions (client-to-provider telemedicine, provider-to-provider telemedicine, health worker decision support systems, systems for tracking patients' health status, client participation and self-care platforms, and provision of education and training to health workers), and 39% (7/18) of the reviews focused on specific topics related to PHC (preventive care, chronic disease management, behavioral health disorders, the COVID-19 pandemic, multicomponent PHC interventions, and care coordination). Most studies in the included reviews agreed on barriers to implementation, such as software and apps developed without involving end users, the lack of training of HCPs and patients in digital technology use, and the lack of reimbursement and billing strategies for remote consultations. However, they showed several mixed results related to health service quality and patients' clinical conditions and behavior changes.

CONCLUSIONS

Research in digital health applied to PHC is still concentrated in high-income countries, mainly in North America and Europe. The mixed results related to health service quality and patients' clinical conditions or behavior changes may have been caused by deficiencies in the process of implementing digital interventions. It is necessary to examine the entire impact pathway and the causal relationship among implementation, health service quality, and clinical condition outcomes to support the spread of digital health in PHC settings.

[Supporting medical and nursing activities with AI: recommendations for responsible design and use]

Clinical decision support systems (CDSS) based on artificial intelligence (AI) are complex socio-technical innovations and are increasingly being used in medicine and nursing to improve the overall quality and efficiency of care, while also addressing limited financial and human resources. However, in addition to such intended clinical and organisational effects, far-reaching ethical, social and legal implications of AI-based CDSS on patient care and nursing are to be expected. To date, these normative-social implications have not been sufficiently investigated. The BMBF-funded project DESIREE (DEcision Support In Routine and Emergency HEalth Care: Ethical and Social Implications) has developed recommendations for the responsible design and use of clinical decision support systems. This article focuses primarily on ethical and social aspects of AI-based CDSS that could have a negative impact on patient health. Our recommendations are intended as additions to existing recommendations and are divided into the following action fields with relevance across all stakeholder groups: development, clinical use, information and consent, education and training, and (accompanying) research.

Technology-supported shared decision-making in chronic conditions: A systematic review of randomized controlled trials

OBJECTIVES

To describe the role of patients with a chronic disease, healthcare professionals (HCPs) and technology in shared decision making (SDM) and the use of clinical decision support systems (CDSSs), and to evaluate the effectiveness of SDM and CDSSs interventions.

METHODS

Randomized controlled studies published between 2011 and 2021 were identified and screened independently by two reviewers, followed by data extraction and analysis. SDM elements and interactive styles were identified to shape the roles of patients, HCPs and technology.

RESULTS

Forty-three articles were identified and reported on 21 SDM-studies, 15 CDSS-studies, 2 studies containing both an SDM-tool and a CDSS, and 5 studies with other decision support components. SDM elements were mostly identified in SDM-tools and interactions styles were least common in the other decision support components.

CONCLUSIONS

Patients within the included RCTs mainly received information from SDM-tools and occasionally CDSSs when it concerns treatment strategies. HCPs provide and clarify information using SDM-tools and CDSSs. Technology provides interactions, which can support more active SDM. SDM-tools mostly showed evidence for positive effects on SDM outcomes, while CDSSs mostly demonstrated positive effects on clinical outcomes.

PRACTICE IMPLICATIONS

Technology-supported SDM has potential to optimize SDM when patients, HCPs and technology collaborate well together.

Acceptance and use of a clinical decision support system in musculoskeletal pain disorders - the SupportPrim project

BACKGROUND

We have developed a clinical decision support system (CDSS) based on methods from artificial intelligence to support physiotherapists and patients in the decision-making process of managing musculoskeletal (MSK) pain disorders in primary care. The CDSS finds the most similar successful patients from the past to give treatment recommendations for a new patient. Using previous similar patients with successful outcomes to advise treatment moves management of MSK pain patients from one-size fits all recommendations to more individually tailored treatment. This study aimed to summarise the development and explore the acceptance and use of the CDSS for MSK pain patients.

METHODS

This qualitative study was carried out in the Norwegian physiotherapy primary healthcare sector between October and November 2020, ahead of a randomised controlled trial. We included four physiotherapists and three of their patients, in total 12 patients, with musculoskeletal pain in the neck, shoulder, back, hip, knee or complex pain. We conducted semi-structured telephone interviews with all participants. The interviews were analysed using the Framework Method.

RESULTS

Overall, both the physiotherapists and patients found the system acceptable and usable. Important findings from the analysis of the interviews were that the CDSS was valued as a preparatory and exploratory tool, facilitating the therapeutic relationship. However, the physiotherapists used the system mainly to support their previous and current practice rather than involving patients to a greater extent in decisions and learning from previous successful patients.

CONCLUSIONS

The CDSS was acceptable and usable to both the patients and physiotherapists. However, the system appeared not to considerably influence the physiotherapists' clinical reasoning and choice of treatment based on information from most similar successful patients. This could be due to a smaller than optimal number of previous patients in the CDSS or insufficient clinical implementation. Extensive training of physiotherapists should not be underestimated to build understanding and trust in CDSSs.

Universal health coverage in China part 2: addressing challenges and recommendations

This report analyses the underlying causes of China's achievements and gaps in universal health coverage over the past 2 decades and proposes policy recommendations for advancing universal health coverage by 2030. Although strong political commitment and targeted financial investment have produced positive outcomes in reproductive, maternal, newborn, and child health and infectious diseases, a fragmented and hospital-centric delivery system, rising health-care costs, shallow benefit coverage of health insurance schemes, and little integration of health in all policies have restricted China's ability to effectively prevent and control chronic disease and provide adequate financial risk protection, especially for lower-income households. Here, we used a health system conceptual framework and we propose a set of feasible policy recommendations that draw from international experiences and first-hand knowledge of China's unique institutional landscape. Our six recommendations are: instituting a primary care-focused integrated delivery system that restructures provider incentives and accountability mechanisms to prioritise prevention; leveraging digital tools to support health behaviour change; modernising information campaigns; improving financial protection through insurance reforms; promoting a health in all policy; and developing a domestic monitoring framework with refined tracer indicators that reflects China's disease burden.

Clinical decision support systems to improve drug prescription and therapy optimisation in clinical practice: a scoping review

OBJECTIVE

Clinical decision support systems (CDSSs) can reduce medical errors increasing drug prescription appropriateness. Deepening knowledge of existing CDSSs could increase their use by healthcare professionals in different settings (ie, hospitals, pharmacies, health research centres) of clinical practice. This review aims to identify the characteristics common to effective studies conducted with CDSSs.

MATERIALS AND METHODS

The article sources were Scopus, PubMed, Ovid MEDLINE and Web of Science, queried between January 2017 and January 2022. Inclusion criteria were prospective and retrospective studies that reported original research on CDSSs for clinical practice support; studies should describe a measurable comparison of the intervention or observation conducted with and without the CDSS; article language Italian or English. Reviews and studies with CDSSs used exclusively by patients were excluded. A Microsoft Excel spreadsheet was prepared to extract and summarise data from the included articles.

RESULTS

The search resulted in the identification of 2424 articles. After title and abstract screening, 136 studies remained, 42 of which were included for final evaluation. Most of the studies included rule-based CDSSs that are integrated into existing databases with the main purpose of managing disease-related problems. The majority of the selected studies (25 studies; 59.5%) were successful in supporting clinical practice, with most being pre-post intervention studies and involving the presence of a pharmacist.

DISCUSSION AND CONCLUSION

A number of characteristics have been identified that may help the design of studies feasible to demonstrate the effectiveness of CDSSs. Further studies are needed to encourage CDSS use.

[Implementation of an electronic clinical decision aid to support quality of care for COPD in family medicine]

BACKGROUND

Electronic clinical decision aids (eCDAs) have the potential to improve the quality of chronic disease management (CDM) and; therefore, patient relevant outcomes. However, eCDAs are only sparsely implemented in primary care for chronic obstructive pulmonary disease (COPD). The aim of this pilot study was to develop and implement of an eCDA for COPD primary care in two Swiss primary care practices.

METHOD

Two primary care practices, each with five primary care physicians and their assistants participated in the study. The eCDA was developed in collaboration with one of the two GP practices (Practice 1) following a development cycle encompassing alpha- and beta-testing stages. Long-term testing for one year was conducted in both practices. The implementation of the eCDA was evaluated according to the RE-AIM framework counting occurrences as follows: Reach: the number of patients included in the CDM using the eCDA.

EFFECTIVENESS

the number of treatment processes initiated per patient. Adoption: practice utilization of the diverse functions featured in the eCDA. Implementation and Maintenance: health care professionals' attitudes towards the impact of the eCDA on the quality of care and their willingness to continue using the eCDA after long-term testing. Data were collected by the eCDA itself, which was programmed to track user data, and from practice staff using questionnaires.

RESULTS

Reach: After the long-term test, the number of patients recorded in the eCDA was 28 in practice 1, and 12 in practice 2.

EFFECTIVENESS

The number of evidence-based treatment processes per patient was 14 (IQR 6 to 22) in Practice 1 and 6 (IQR 5 to 8) in Practice 2. Adoption: The utilization profiles of the eCDA differed greatly between practices. Implementation and Maintenance: After the long-term test, respondents were more critical of the quality of the CDM for patients with COPD, and attitudes consistent with interprofessional care were more prevalent compared to baseline. Respondents were optimistic regarding both the potential of the eCDA to improve the quality of CDM and their motivation to continue using the eCDA after long-term testing.

CONCLUSION

This pilot study is a roadmap for future projects aiming to develop and implement eCDAs for the CDM of COPD in primary care. Future larger implementation studies in this domain should place greater emphasis on the measurement of structural practice characteristics as potential determinants of patient-relevant outcomes. The modifiable determinants should then be tested for their effects on patient-relevant outcomes in a randomized controlled design.

Patient-Facing Clinical Decision Support for High Blood Pressure Control: Patient Survey

BACKGROUND

High blood pressure (HBP) affects nearly half of adults in the United States and is a major factor in heart attacks, strokes, kidney disease, and other morbidities. To reduce risk, guidelines for HBP contain more than 70 recommendations, including many related to patient behaviors, such as home monitoring and lifestyle changes. Thus, the patient's role in controlling HBP is crucial. Patient-facing clinical decision support (CDS) tools may help patients adhere to evidence-based care, but customization is required.

OBJECTIVE

Our objective was to understand how to adapt CDS to best engage patients in controlling HBP.

METHODS

We conducted a mixed methods study with two phases: (1) survey-guided interviews with a limited cohort and (2) a nationwide web-based survey. Participation in each phase was limited to adults aged between 18 and 85 years who had been diagnosed with hypertension. The survey included general questions that assessed goal setting, treatment priorities, medication load, comorbid conditions, satisfaction with blood pressure (BP) management, and attitudes toward CDS, and also a series of questions regarding A/B preferences using paired information displays to assess perceived trustworthiness of potential CDS user interface options.

RESULTS

We conducted 17 survey-guided interviews to gather patient needs from CDS, then analyzed results and created a second survey of 519 adults with clinically diagnosed HBP. A large majority of participants reported that BP control was a high priority (83%), had monitored BP at home (82%), and felt comfortable using technology (88%). Survey respondents found displays with more detailed recommendations more trustworthy (56%-77% of them preferred simpler displays), especially when incorporating social trust and priorities from providers and patients like them, but had no differences in action taken.

CONCLUSIONS

Respondents to the survey felt that CDS capabilities could help them with HBP control. The more detailed design options for BP display and recommendations messaging were considered the most trustworthy yet did not differentiate perceived actions.

Increasing Societal Benefit From Cardiovascular Drugs

During the past few years, several innovative treatments for noncommunicable chronic disease have become available, including SGLT2i (sodium-glucose cotransporter-2 inhibitors), GLP-1a (glucagon-like-peptide 1 agonists), ARNI (angiotensin receptor-neprilysin inhibitors), and finerenone, a selective nonsteroidal mineralocorticoid receptor antagonist. Each of these medications improves clinically relevant outcomes when added to existing therapies, and the indications for their use are rapidly expanding. Because existing drug regimens are already complex and costly, ensuring that society derives the maximal benefit from these new agents represents a major challenge. This Primer discusses how society can meet this challenge, which we address in terms of 5 principles: maximizing benefit, minimizing harm, optimizing uptake, increasing value for money, and ensuring equitable access. The Primer is most relevant for stakeholders in high-income countries, but the principles are broadly applicable to stakeholders in other settings, including low- and middle-income countries. We have focused the discussion on SGLT-2i, but the 5 principles herein could be used with reference to ARNI, finerenone, or any other health product.

Patient activation is a treatable trait in patients with chronic airway diseases: An observational study

Background

Self-management is key for reducing the burden of disease in chronical illness. However, applying self-management presupposes behavioral change. Sufficient knowledge, skills, confidence and motivation to make the needed behavior changes are important prerequisites. During the past years the Integral Diagnostic Trajectory was developed for patients with asthma or COPD which aims to identify treatable traits and activating patients for self-management.

Objective

In the present study the effects of the Integral Diagnostic Trajectory on the Patient Activation Measure (PAM®) were examined. In addition, predictive variables for PAM baseline scores and change scores were sought.

Materials and methods

A total of 241 patients with asthma or COPD referred to the pulmonologist at the Radboud university medical center, location Dekkerswald, Nijmegen were included. Patient activation was measured before the first visit and after the intervention with the 13-item PAM®. Additional, patient characteristics and health status were measured with the Nijmegen Clinical Screening Instrument (NCSI), modified Medical Research Council (mMRC), Asthma Control Questionnaire (ACQ), and COPD Clinical Questionnaire (CCQ).

Results

Fifty percent of the patients with asthma and seventy percent of the patients with COPD had low levels of activation at baseline (PAM level 1-2). Baseline PAM scores could be explained in patients with asthma for 7% by number of severe problems in health status. And for 18% in patients with COPD by number of severe problems, age and employment status. After the intervention both groups significantly improved on the PAM (T0: 56.0 ± 13.1 vs. T1:63.3 ± 14.0 in asthma, and T0: 50.0 ± 8.8 vs. 58.4 ± 11.1 in COPD). Multivariate stepwise regression analysis showed that only 24% of the change in score could be explained by baseline PAM score and being employed in patients with asthma, and 18% of the variance in change score could be predicted by baseline PAM score in COPD.

Conclusion

The present study showed that low level of activation is a common feature in patients with asthma and COPD. With a relatively short and seemingly simple intervention patients can reach higher levels of patient activation, which is a prerequisite for adopting self-management techniques in daily life.

Design, effectiveness, and economic outcomes of contemporary chronic disease clinical decision support systems: a systematic review and meta-analysis

Objectives

Electronic health record-based clinical decision support (CDS) has the potential to improve health outcomes. This systematic review investigates the design, effectiveness, and economic outcomes of CDS targeting several common chronic diseases.

Material and Methods

We conducted a search in PubMed (Medline), EBSCOHOST (CINAHL, APA PsychInfo, EconLit), and Web of Science. We limited the search to studies from 2011 to 2021. Studies were included if the CDS was electronic health record-based and targeted one or more of the following chronic diseases: cardiovascular disease, diabetes, chronic kidney disease, hypertension, and hypercholesterolemia. Studies with effectiveness or economic outcomes were considered for inclusion, and a meta-analysis was conducted.

Results

The review included 76 studies with effectiveness outcomes and 9 with economic outcomes. Of the effectiveness studies, 63% described a positive outcome that favored the CDS intervention group. However, meta-analysis demonstrated that effect sizes were heterogenous and small, with limited clinical and statistical significance. Of the economic studies, most full economic evaluations (n = 5) used a modeled analysis approach. Cost-effectiveness of CDS varied widely between studies, with an estimated incremental cost-effectiveness ratio ranging between USD$2192 to USD$151 955 per QALY.

Conclusion

We summarize contemporary chronic disease CDS designs and evaluation results. The effectiveness and cost-effectiveness results for CDS interventions are highly heterogeneous, likely due to differences in implementation context and evaluation methodology. Improved quality of reporting, particularly from modeled economic evaluations, would assist decision makers to better interpret and utilize results from these primary research studies.

Registration

PROSPERO (CRD42020203716)

Use of an Electronic Medication Management Support System in Patients with Polypharmacy in General Practice: A Quantitative Process Evaluation of the AdAM Trial

Polypharmacy is associated with a risk of negative health outcomes. Potentially inappropriate medications, interactions resulting from contradicting medical guidelines, and inappropriate monitoring, all increase the risk. This process evaluation (PE) of the AdAM study investigates implementation and use of a computerized decision-support system (CDSS). The CDSS analyzes medication appropriateness by including claims data, and hence provides general practitioners (GPs) with full access to patients’ medical treatments. We based our PE on pseudonymized logbook entries into the CDSS and used the four dimensions of the Medical Research Council PE framework. Reach, which examines the extent to which the intended study population was included, and Dose, Fidelity, and Tailoring, which examine how the software was actually used by GPs. The PE was explorative and descriptive. Study participants were representative of the target population, except for patients receiving a high level of nursing care, as they were treated less frequently. GPs identified and corrected inappropriate prescriptions flagged by the CDSS. The frequency and intensity of interventions documented in the form of logbook entries lagged behind expectations, raising questions about implementation barriers to the intervention and the limitations of the PE. Impossibility to connect the CDSS to GPs’ electronic medical records (EMR) of GPs due to technical conditions in the German healthcare system may have hindered the implementation of the intervention. Data logged in the CDSS may underestimate medication changes in patients, as documentation was voluntary and already included in EMR.