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The effect of computerized decision support systems on cardiovascular risk factors: a systematic review and meta-analysis.

ABSTRACT:

Background

Cardiovascular risk management (CVRM) is notoriously difficult because of multi-morbidity and the different phenotypes and severities of cardiovascular disease. Computerized decision support systems (CDSS) enable the clinician to integrate the latest scientific evidence and patient information into tailored strategies. The effect on cardiovascular risk factor management is yet to be confirmed.

Methods

We performed a systematic review and meta-analysis evaluating the effects of CDSS on CVRM, defined as the change in absolute values and attainment of treatment goals of systolic blood pressure (SBP), low density lipoprotein cholesterol (LDL-c) and HbA1c. Also, CDSS characteristics related to more effective CVRM were identified. Eligible articles were methodologically appraised using the Cochrane risk of bias tool. We calculated mean differences, relative risks, and if appropriate (I² ResultsOf the 14,335 studies identified, 22 were included. Four studies reported on SBP, 3 on LDL-c, 10 on CVRM in patients with type II diabetes and 5 on guideline adherence. The CDSSs varied considerably in technical performance and content. Heterogeneity of results was such that quantitative pooling was often not appropriate. Among CVRM patients, the results tended towards a beneficial effect of CDSS, but only LDL-c target attainment in diabetes patients reached statistical significance. Prompting, integration into the electronical health record, patient empowerment, and medication support were related to more effective CVRM.

Conclusion

We did not find a clear clinical benefit from CDSS in cardiovascular risk factor levels and target attainment. Some features of CDSS seem more promising than others. However, the variability in CDSS characteristics and heterogeneity of the results - emphasizing the immaturity of this research area - limit stronger conclusions. Clinical relevance of CDSS in CVRM might additionally be sought in the improvement of shared decision making and patient empowerment.

SUBMITTER: Groenhof TKJ

PROVIDER: S-EPMC6558725 | biostudies-literature | 2019 Jun

REPOSITORIES: biostudies-literature

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The effect of computerized decision support systems on cardiovascular risk factors: a systematic review and meta-analysis.

Groenhof T Katrien J TKJ Asselbergs Folkert W FW Groenwold Rolf H H RHH Grobbee Diederick E DE Visseren Frank L J FLJ Bots Michiel L ML

BMC medical informatics and decision making 20190610 1

<h4>Background</h4>Cardiovascular risk management (CVRM) is notoriously difficult because of multi-morbidity and the different phenotypes and severities of cardiovascular disease. Computerized decision support systems (CDSS) enable the clinician to integrate the latest scientific evidence and patient information into tailored strategies. The effect on cardiovascular risk factor management is yet to be confirmed.<h4>Methods</h4>We performed a systematic review and meta-analysis evaluating the eff ...[more]

PMID: 31182084

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Project description:BackgroundThe use of computerized clinical decision support systems (CCDSSs) may improve chronic disease management, which requires recurrent visits to multiple health professionals, ongoing disease and treatment monitoring, and patient behavior modification. The objective of this review was to determine if CCDSSs improve the processes of chronic care (such as diagnosis, treatment, and monitoring of disease) and associated patient outcomes (such as effects on biomarkers and clinical exacerbations).MethodsWe conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid's EBM Reviews database, Inspec, and reference lists for potentially eligible articles published up to January 2010. We included randomized controlled trials that compared the use of CCDSSs to usual practice or non-CCDSS controls. Trials were eligible if at least one component of the CCDSS was designed to support chronic disease management. We considered studies 'positive' if they showed a statistically significant improvement in at least 50% of relevant outcomes.ResultsOf 55 included trials, 87% (n = 48) measured system impact on the process of care and 52% (n = 25) of those demonstrated statistically significant improvements. Sixty-five percent (36/55) of trials measured impact on, typically, non-major (surrogate) patient outcomes, and 31% (n = 11) of those demonstrated benefits. Factors of interest to decision makers, such as cost, user satisfaction, system interface and feature sets, unique design and deployment characteristics, and effects on user workflow were rarely investigated or reported.ConclusionsA small majority (just over half) of CCDSSs improved care processes in chronic disease management and some improved patient health. Policy makers, healthcare administrators, and practitioners should be aware that the evidence of CCDSS effectiveness is limited, especially with respect to the small number and size of studies measuring patient outcomes.

Project description:BACKGROUND:Computerized decision support systems (CDSSs) are software programs that support the decision making of practitioners and other staff. Other reviews have analyzed the relationship between CDSSs, practitioner performance, and patient outcomes. These reviews reported positive practitioner performance in over half the articles analyzed, but very little information was found for patient outcomes. OBJECTIVE:The purpose of this review was to analyze the relationship between CDSSs, practitioner performance, and patient medical outcomes. PubMed, CINAHL, Embase, Web of Science, and Cochrane databases were queried. METHODS:Articles were chosen based on year published (last 10 years), high quality, peer-reviewed sources, and discussion of the relationship between the use of CDSS as an intervention and links to practitioner performance or patient outcomes. Reviewers used an Excel spreadsheet (Microsoft Corporation) to collect information on the relationship between CDSSs and practitioner performance or patient outcomes. Reviewers also collected observations of participants, intervention, comparison with control group, outcomes, and study design (PICOS) along with those showing implicit bias. Articles were analyzed by multiple reviewers following the Kruse protocol for systematic reviews. Data were organized into multiple tables for analysis and reporting. RESULTS:Themes were identified for both practitioner performance (n=38) and medical outcomes (n=36). A total of 66% (25/38) of articles had occurrences of positive practitioner performance, 13% (5/38) found no difference in practitioner performance, and 21% (8/38) did not report or discuss practitioner performance. Zero articles reported negative practitioner performance. A total of 61% (22/36) of articles had occurrences of positive patient medical outcomes, 8% (3/36) found no statistically significant difference in medical outcomes between intervention and control groups, and 31% (11/36) did not report or discuss medical outcomes. Zero articles found negative patient medical outcomes attributed to using CDSSs. CONCLUSIONS:Results of this review are commensurate with previous reviews with similar objectives, but unlike these reviews we found a high level of reporting of positive effects on patient medical outcomes.

Project description:Some drugs have a narrow therapeutic range and require monitoring and dose adjustments to optimize their efficacy and safety. Computerized clinical decision support systems (CCDSSs) may improve the net benefit of these drugs. The objective of this review was to determine if CCDSSs improve processes of care or patient outcomes for therapeutic drug monitoring and dosing.We conducted a decision-maker-researcher partnership systematic review. Studies from our previous review were included, and new studies were sought until January 2010 in MEDLINE, EMBASE, Evidence-Based Medicine Reviews, and Inspec databases. Randomized controlled trials assessing the effect of a CCDSS on process of care or patient outcomes were selected by pairs of independent reviewers. A study was considered to have a positive effect (i.e., CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive.Thirty-three randomized controlled trials were identified, assessing the effect of a CCDSS on management of vitamin K antagonists (14), insulin (6), theophylline/aminophylline (4), aminoglycosides (3), digoxin (2), lidocaine (1), or as part of a multifaceted approach (3). Cluster randomization was rarely used (18%) and CCDSSs were usually stand-alone systems (76%) primarily used by physicians (85%). Overall, 18 of 30 studies (60%) showed an improvement in the process of care and 4 of 19 (21%) an improvement in patient outcomes. All evaluable studies assessing insulin dosing for glycaemic control showed an improvement. In meta-analysis, CCDSSs for vitamin K antagonist dosing significantly improved time in therapeutic range.CCDSSs have potential for improving process of care for therapeutic drug monitoring and dosing, specifically insulin and vitamin K antagonist dosing. However, studies were small and generally of modest quality, and effects on patient outcomes were uncertain, with no convincing benefit in the largest studies. At present, no firm recommendation for specific systems can be given. More potent CCDSSs need to be developed and should be evaluated by independent researchers using cluster randomization and primarily assess patient outcomes related to drug efficacy and safety.

Project description:ImportanceHealth care professionals do not adequately stratify risk or provide prophylaxis for venous thromboembolism (VTE) among surgical patients. Computerized clinical decision support systems (CCDSSs) have been implemented to assist clinicians and improve prophylaxis for VTE.ObjectiveTo evaluate the effect of implementing CCDSSs on the ordering of VTE prophylaxis and the rates of VTE.Data sourcesPubMed, MEDLINE via OVID, EMBASE via OVID, Scopus, Cochrane CENTRAL Register of Controlled Trials, and clinicaltrials.gov were searched in June 2016 for articles published in English from October 15, 1991, to February 16, 2016. A manual search of references from relevant articles was also performed.Study selectionClinical trials and observational studies among surgical patients comparing CCDSSs with VTE risk stratification and assistance in ordering prophylaxis vs routine care without decision support were included. Of the 188 articles screened, 11 (5.9%) were eligible for meta-analysis.Data extraction and synthesisMeta-analysis of Observational Studies in Epidemiology guidelines were followed. Two reviewers extracted data and assessed quality independently.Main outcomes and measuresRates of prophylaxis for VTE and VTE events. Random- and fixed-effects models were used to summarize odds ratios and risk ratios.ResultsEleven articles (9 prospective cohort trials and 2 retrospective cohort trials) comprising 156 366 individuals (104 241 in the intervention group and 52 125 in the control group) were included. The use of CCDSSs was associated with a significant increase in the rate of appropriate ordering of prophylaxis for VTE (odds ratio, 2.35; 95% CI, 1.78-3.10; P < .001) and a significant decrease in the risk of VTE events (risk ratio, 0.78; 95% CI, 0.72-0.85; P < .001).Conclusions and relevanceUse of CCDSSs increases the proportion of surgical patients who were prescribed adequate prophylaxis for VTE and correlates with a reduction in VTE events.

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Dataset Information

The effect of computerized decision support systems on cardiovascular risk factors: a systematic review and meta-analysis.

Background

Methods

Conclusion

Publications

The effect of computerized decision support systems on cardiovascular risk factors: a systematic review and meta-analysis.

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