Computer Decision Support Software Research Articles

American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation.

This Clinical Practice Guideline (CPG) addresses the topic of acute fluid resuscitation during the first 48 hours following a burn injury for adults with burns ≥20% of the total body surface area (%TBSA). The listed authors formed an investigation panel and developed clinically relevant PICO (Population, Intervention, Comparator, Outcome) questions. A systematic literature search returned 5978 titles related to this topic and after 3 levels of screening, 24 studies met criteria to address the PICO questions and were critically reviewed. We recommend that clinicians consider the use of human albumin solution, especially in patients with larger burns, to lower resuscitation volumes and improve urine output. We recommend initiating resuscitation based on providing 2 mL/kg/% TBSA burn in order to reduce resuscitation fluid volumes. We recommend selective monitoring of intra-abdominal and intraocular pressure during burn shock resuscitation. We make a weak recommendation for clinicians to consider the use of computer decision support software to guide fluid titration and lower resuscitation fluid volumes. We do not recommend the use of transpulmonary thermodilution-derived variables to guide burn shock resuscitation. We are unable to make any recommendations on the use of high-dose vitamin C (ascorbic acid), fresh frozen plasma (FFP), early continuous renal replacement therapy, or vasopressors as adjuncts during acute burn shock resuscitation. Mortality is an important outcome in burn shock resuscitation, but it was not formally included as a PICO outcome because the available scientific literature is missing studies of sufficient population size and quality to allow us to confidently make recommendations related to the outcome of survival at this time.

What effects did home working have on 999 clinician practice from one UK ambulance service during the Covid-19 pandemic?

PurposeVirtual care is any interaction between a patient and clinician or clinicians, occurring remotely using information technologies. Like many international services, United Kingdom (UK) ambulance services use paramedics and nurses to undertake telephone assessments of patients calling the 999 emergency service line. Using their clinical knowledge, experience, and, at times, computer decision support software, these clinicians assess patients from a range of clinical acuities to confirm the need for an emergency response or identify and support those patients who can be cared for with remote treatment advice and referral. The Covid-19 pandemic saw UK ambulance services change and adapt their operating models to meet social distancing requirements, increase clinical staff numbers and mitigate staff becoming unavailable for work due to self-isolation. One such strategy was moving clinicians from Emergency Operations Centres (EOCs) to working at home. Staff utilised digital phone systems, remote computer-aided dispatch modules, remote clinical decision support software and video platforms, which allowed close to full functionality compared to inside typical EOCs. There is a dearth of literature exploring the comparative practice of clinicians from home rather than from EOCs. Therefore, this study reports the findings of a qualitative analysis of these effects from the clinician's perspective. The authors hope that the findings from this study will inform the operating, education and leadership practices of those delivering such services.Design/methodology/approachA convenience sample of telephone nurses and paramedics from one UK ambulance service in which home working had been implemented were contacted. 15 clinicians with recent home working experience responded to the invite out of a possible 31 (48%). All participants had previously practised remote assessment from within an EOC. Semi-structured interviews took place via video conferencing software and were recorded, transcribed and thematically analysed. An inductive approach was taken to generating codes and both researchers separately reading the transcripts before re-reading them, assigning initial themes and determining frequency.FindingsFour main themes were identified with further associated sub-themes: (1) performance, (2) support, (3) distractions and interruptions and (4) confidence in decision-making.Originality/valueThere are very few studies exploring the practice of remote clinicians in emergency EOCs. This study identified that home working clinicians felt their productivity had increased, making them more satisfied in their practice. However, there were mixed feelings over the level of support they perceived they now received, despite the mechanisms of support being largely the same. Supervisors found it especially challenging to provide support to practitioners; and employers might need to clarify the support mechanisms they provide to homeworkers. The elimination of distractions and interruptions was seen as a largely positive result of homeworking; however, these interruptions were not seen as inappropriate, thus, identifying a need for role clarity and task coordination rather than interruption elimination. Finally, clinicians felt that they become more confident when working from home, researching more, trusting themselves more and relying less on others to reach safe outcomes. However, there were missed opportunities to learn from listening to others' clinical practice.

Consistency of decision support software-integrated telephone triage and associated factors: a systematic review

BackgroundIn the recent decades, the use of computerized decision support software (CDSS)-integrated telephone triage (TT) has become an important tool for managing rising healthcare demands and overcrowding in the emergency department. Though these services have generally been shown to be effective, large gaps in the literature exist with regards to the overall quality of these systems. In the current systematic review, we aim to document the consistency of decisions that are generated in CDSS-integrated TT. Furthermore, we also seek to map those factors in the literature that have been identified to have an impact on the consistency of generated triage decisions.MethodsAs part of the TRANS-SENIOR international training and research network, a systematic review of the literature was conducted in November 2019. PubMed, Web of Science, CENTRAL, and the CINAHL database were searched. Quantitative articles including a CDSS component and addressing consistency of triage decisions and/or factors associated with triage decisions were eligible for inclusion in the current review. Studies exploring the use of other types of digital support systems for triage (i.e. web chat, video conferencing) were excluded. Quality appraisal of included studies were performed independently by two authors using the Methodological Index for Non-Randomized Studies.ResultsFrom a total of 1551 records that were identified, 39 full-texts were assessed for eligibility and seven studies were included in the review. All of the studies (n = 7) identified as part of our search were observational and were based on nurse-led telephone triage. Scientific efforts investigating our first aim was very limited. In total, two articles were found to investigate the consistency of decisions that are generated in CDSS-integrated TT. Research efforts were targeted largely towards the second aim of our study—all of the included articles reported factors related to the operator- (n = 6), patient- (n = 1), and/or CDSS-integrated (n = 2) characteristics to have an influence on the consistency of CDSS-integrated TT decisions.ConclusionTo date, some efforts have been made to better understand how the use of CDSS-integrated TT systems may vary across settings. In general, however, the evidence-base surrounding this field of literature is largely inconclusive. Further evaluations must be prompted to better understand this area of research.Protocol registration The protocol for this study is registered in the PROSPERO database (registration number: CRD42020146323).

PMD15 - COMPUTER-ASSISTED (TAONET®) AND MANUAL DOSAGE CONTROL OF PATIENTS ON ORAL ANTICOAGULANT THERAPY IN ROUTINE CLINICAL PRACTICE. PRELIMINARY RESULTS OF A MULTICENTER STUDY

Patients under oral anticoagulant therapy (OAT) need frequent monitoring and appropriate dose adjustment. TAONet® is a computerized decision support software for OAT dose management. The study estimates the time in therapeutic range (TTR) of patients whose dose of OAT is calculated automatically by TAONet® or manually by experienced medical staff in routine clinical practice. A multicentre prospective, 6-month follow-up, observational study has been conducted in 6 Spanish healthcare centres (5 primary care, 1 hospital) and it is expected to be completed in 17 centres in Spain and Portugal. It included adult patients with an international normalized ratio (INR) therapeutic range (TR) of 2-3 or 2.5-3.5; whose OAT (warfarin or acenocoumarol) dose was managed by TAONet® (PS cohort) or manually by medical staff (PM cohort). Sociodemographic and clinical variables were collected using an electronic case report form. TTR was calculated using the Rosendaal linear interpolation method. Good control was considered when TTR≥65%. A total of 127 patients (20.8% of the estimated final sample) were included in the study [n: 60PS, 67PM; men: 61.7%PS, 55.2%PM; mean age (years): 72.3PS (SD:12.0), 65.7PM (SD:14.4); INR TR 2-3: 90.0%PS, 70.1%PM; main OAT indication: atrial fibrillation 68.3%PS, (atrial fibrillation 35.8%, valve prostheses 26.9%)PM; ≥3 comorbidities: 60%PS, 31.3%PM; mean time on current treatment (years): 8.5PS (SD:7.3), 8.5PM (SD:8.7); mean follow-up visits: 8.8PS (SD:1.7), 9.3PM (SD:3.1)]. The mean TTR was higher in the PS cohort [69.4% (SD:17.6%) vs 63.1% (SD:23.7%)]. The proportion of patients with TTR≥65% was also higher in the PS cohort (66.7% vs 46.3%). The results of the study suggest that the computer program TAONet® is a reliable instrument to calculate the OAT dosage of patients with an INR TR established on 2-3 or 2.5-3.5. Its use may help optimize OAT control and patient management in routine clinical practice.

Follow-Up Evaluation of the U.S. Army Institute of Surgical Research Burn Flow Sheet for En Route Care Documentation of Burned Combat Casualties.

In 2006, burn clinical practice guidelines were developed to provide recommendations for optimal care of U.S. military and local national burn casualties. As part of that effort, a paper-based Burn Flow Sheet (BFS) was included to document the burn resuscitation of combat casualties with ≥20% total body surface area burns. The purpose of this study was to evaluate the BFS in terms of ongoing utilization, resuscitation management, and outcomes of patients transported. A retrospective review was performed of hard-copy BFSs received from January 2007 to December 2013. En route injury and treatment data from these flowsheets were manually transcribed into the research database. Outcomes and complications of BFS subjects were extracted from the Burn Center Registry and added to the research database. A total of 73 BFSs were collected from the study period. On average, BFSs were 61 ± 30% complete with a total of 14.7 ± 7 hours documented per patient in the first 24-hours postburn. Patients received nearly 7 L more fluid than estimated by traditional formulas. Sixteen patients (26%) received greater than 250 mL/kg of fluid, half of whom had concomitant traumatic injuries. Fifteen patients received a fasciotomy (21%), 4 received a laparotomy (5%), and 8 (11%) received both. No patients developed abdominal compartment syndrome associated with fluid resuscitation. Overall mortality was 21%. Although the majority of providers did initiate a BFS, it was not always used as intended; problems included missing data and miscalculations. Although there was a clear improvement with decline in the incidence of abdominal compartment syndrome, mortality did not change for severely burned patients. Simplification of the recommendations, additional built-in prompts, and automated tools such as computerized decision support software may help standardize practice and improve outcomes.

Exploring demographic and lifestyle associations with patient experience following telephone triage by a primary care doctor or nurse: secondary analyses from a cluster randomised controlled trial

BackgroundThe ESTEEM trial was a cluster randomised controlled trial that compared two telephone triage management systems (general practitioner (GP) or a nurse supported by computer decision support software) with usual...

The impact of using computer decision-support software in primary care nurse-led telephone triage: Interactional dilemmas and conversational consequences

Telephone triage represents one strategy to manage demand for face-to-face GP appointments in primary care. Although computer decision-support software (CDSS) is increasingly used by nurses to triage patients, little is understood about how interaction is organized in this setting. Specifically any interactional dilemmas this computer-mediated setting invokes; and how these may be consequential for communication with patients. Using conversation analytic methods we undertook a multi-modal analysis of 22 audio-recorded telephone triage nurse–caller interactions from one GP practice in England, including 10 video-recordings of nurses' use of CDSS during triage. We draw on Goffman's theoretical notion of participation frameworks to make sense of these interactions, presenting ‘telling cases’ of interactional dilemmas nurses faced in meeting patient's needs and accurately documenting the patient's condition within the CDSS. Our findings highlight troubles in the ‘interactional workability’ of telephone triage exposing difficulties faced in aligning the proximal and wider distal context that structures CDSS-mediated interactions. Patients present with diverse symptoms, understanding of triage consultations, and communication skills which nurses need to negotiate turn-by-turn with CDSS requirements. Nurses therefore need to have sophisticated communication, technological and clinical skills to ensure patients' presenting problems are accurately captured within the CDSS to determine safe triage outcomes. Dilemmas around how nurses manage and record information, and the issues of professional accountability that may ensue, raise questions about the impact of CDSS and its use in supporting nurses to deliver safe and effective patient care.

Question design in nurse-led and GP-led telephone triage for same-day appointment requests: a comparative investigation

ObjectiveTo compare doctors’ and nurses’ communication with patients in primary care telephone triage consultations.DesignQualitative comparative study of content and form of questions in 51 telephone triage encounters between practitioners (general...

Feasible Evidence-Based Strategies to Manage Depression in Primary Care

According to the World Health Organization, major depressive disorder (MDD) is a leading cause of disability-adjusted life years worldwide. However, recent evidence suggests depression remains undertreated in primary care settings. Measurement-based care (MBC) is an evidence-based strategy that can feasibly assist primary care physicians in managing patients with MDD. Utilizing health information technology tools, such as computer decision support software, can improve adherence to evidence-based treatment guidelines and MBC at the point of care.

Computer Decision Support Software Safely Improves Glycemic Control in the Burn Intensive Care Unit: A Randomized Controlled Clinical Study

The optimal method for glycemic control in the critically burned patient is unknown. The purpose of this randomized controlled study was to determine the safety and efficacy of computer decision support software (CDSS) to control serum glucose concentration in a burn intensive care unit. Eighteen adult burn/trauma patients receiving continuous insulin infusion were initially randomized to receive glucose management by a traditional paper protocol or a computer protocol (CP) for 72 hours and then crossed over to the alternate method for an additional 72 hours. Time in target glucose range (range: 80-110 mg/dl) was higher in the CP group (47 ± 17% vs 41 ± 16.6%; P ≤ .05); time over target range was not significantly reduced in the CP group (49 ± 17.8% vs 54 ± 17.1%; P = .08); and no difference was noted in time under target range of 80 mg/dl (CP: 4.5 ± 2.8%, paper protocol: 4.8 ± 3.3%; P = .8), less than 60 mg/dl (P = .7), and less than 40 mg/dl (P = 1.0). Severe hypoglycemic events (<40 mg/dl) did not differ from the CP group compared with historical controls for patients receiving no insulin (P = .6). More glucose measurements were performed in the CP group (P = .0003), and nursing staff compliance with CP recommendations was greater (P < .0001). Glycemic control using CDSS is safe and effective for the critically burned patient. Time in target range improved without increase in hypoglycemic events. CDSS enhanced consistency in practice, providing standardization among nursing staff.

Importance and Impact of Antimicrobial Stewardship

The landscape of health care is rapidly changing. With health care reform on the horizon, institutions are examining many practices to determine the best way to provide optimal care while minimizing economic burden. Antimicrobial stewardship is one method many institutions are implementing to achieve this balance. Antimicrobial stewardship encompasses a wide range of services aimed at improving patient outcomes and minimizing the untoward effects of antimicrobial agents including side effects as well as induction of resistance. These programs have been shown to decrease both the development of resistance as well as expenditures on antimicrobial agents. Recently, computerized decision support software has been implemented at many institutions. This technology has greatly improved the productivity of antimicrobial stewardship programs. Combining available technology with expert knowledge in infectious diseases is necessary to ensure the continued efficacy of current antimicrobial agents.

Using artificial neural networks for transport decisions: Managerial guidelines

One information technology that may be considered by transportation managers, and which is included in the portfolio of technologies that encompass TMS. is artificial neural networks (ANNs). These artificially intelligent computer decision support software provide solutions by finding and recognizing complex patterns in data. ANNs have been used successfully by transportation managers to forecast transportation demand, estimate future transport costs, schedule vehicles and shipments, route vehicles and classify earners for selection. Artificial neural networks excel in transportation decision environments that are dynamic, complex and unstructured. This article introduces ANNs to transport managers by describing ANN technological capabilities, reporting the current status of transportation neural network applications, presenting ANN applications that offer significant potential for future development and offering managerial guidelines for ANN development.

SAFER (Support and Assessment for Fall Emergency Referrals) trial: study design

Many emergency ambulance calls are made for older people who fall. For some, a community-based response may be more appropriate than being taken to hospital. This trial will assess the costs and benefits of paramedics using a hand-held tablet PC with computerised decision support software to help them decide which patients to convey to hospital.The objectives are to …

Randomized Controlled Trial of Supervised Patient Self-Testing of Warfarin Therapy Using An Internet Based Expert System

Improved anticoagulation control results in improved outcomes, with a decrease in the incidence of bleeding and thromboembolic events. The outcomes of oral anticoagulation therapy (OAT) are dependent on the model of care used to manage warfarin therapy, with better outcomes associated with the use of a specialised anticoagulation management service (AMS), computerized decision support and increased testing frequency (facilitated by patient self-testing (PST) of the international normalised ratio (INR)) (Ansell and Hughes 1996). This study uses a novel strategy to combine the advantages of these three approaches to warfarin management. A prospective, randomized controlled cross-over study was carried out at the anticoagulation clinic of Cork University Hospital, Ireland, to test the hypothesis that supervised PST using an internet based expert system could provide comparable anticoagulation control to that provided by traditional outpatient AMS management. This was a cross-over study; patients served in both AMS and supervised PST arms, with random assignment as to the order of management. Both arms were six months in duration. Patients on established long term OAT who had internet access were eligible for enrolment. During the supervised PST arm of the study, patients measured their INR at home using the CoaguChek XS® point of care meter, (Roche Diagnostics, UK) either twice weekly, weekly or every two weeks depending on their anticoagulation control. They entered this result along with other information relating to their warfarin therapy (e.g. signs or symptoms of thrombosis or hemorrhage, missed doses, concurrent illnesses, dietary or medication changes etc) onto the CoagCare® (Zycare Inc, Chapel Hill, NC) web page. Patients with a therapeutic INR and no other issues were automatically provided with algorithm-derived dosing and repeat testing instructions. Patients with non-therapeutic results, or symptoms suggestive of thromboembolic or hemorrhagic complications, were prioritized for caregiver review according to problem severity. During the AMS arm, patients were required to attend the clinic every four to six weeks, or more frequently, if clinically indicated. Dosage adjustments were performed by the anticoagulant clinic staff using the laboratory INR and the APEX® (iSOFT, UK) computer decision support software. The primary outcome variable to assess anticoagulation control was the difference in time in therapeutic range (TTR) during the AMS management and supervised PST management period. In addition, the number of INR measurements indicative of serious under- or over-anticoagulation and the number of serious hemorrhagic or thrombotic adverse events were also compared. One hundred and sixty two patients were enrolled over a nine-month period (July 2006–April 2007). The majority of study patients were male (61.4%) and the mean age of the study population was 59.6 +/−14.3 years. One hundred and thirty two (81.5%) patients completed both arms of the study. The mean TTR during the AMS arm was 60.2% +/−19.5%, which increased to 71.4% +/− 13.6% during the PST period (p<0.001). Eighty-seven patients (65.91%) achieved better anticoagulation control during the supervised PST period. Patients measured their INR almost four times more frequently while home-testing giving a mean frequency of INR testing of 4.5 days compared with 17.4 days for the AMS period. Extreme INR values (< 1.5 and > 5.0) occurred more frequently during the AMS arm of the study (6% vs 2.4%, p<0.001). There was no significant difference in the adverse event rate between the two study periods. Table 1.Table 1. Adverse eventsModel of careHemorrhagicThromboembolicAMSGastric bleed (INR 2.5)TIA (INR 2.2)Supervised PSTNoneDVT (INR 1.6)DVT (1.4)Daily time to manage 70 patients ranged from 10 to 45 minutes (mean 23.19+/−9.48 mins/day). This novel system of supervised PST using an internet based expert system improves the clinical effectiveness of OAT when compared with management by a specialized anticoagulant management service.

The effect of attitude to risk on decisions made by nurses using computerised decision support software in telephone clinical assessment: an observational study

BackgroundThere is variation in the decisions made by telephone assessment nurses using computerised decision support software (CDSS). Variation in nurses' attitudes to risk has been identified as a possible explanatory factor. This study was undertaken to explore the effect of nurses' attitudes to risk on the decisions they make when using CDSS. The setting was NHS 24 which is a nationwide telephone assessment service in Scotland in which nurses assess health problems, mainly on behalf of out-of-hours general practice, and triage calls to self care, a service at a later date, or immediate contact with a service.MethodsAll NHS 24 nurses were asked to complete a questionnaire about their background and attitudes to risk. Routine data on the decisions made by these nurses was obtained for a six month period in 2005. Multilevel modelling was used to measure the effect of nurses' risk attitudes on the proportion of calls they sent to self care rather than to services.ResultsThe response rate to the questionnaire was 57% (265/464). 231,112 calls were matched to 211 of these nurses. 16% (36,342/231,112) of calls were sent to self care, varying three fold between the top and bottom deciles of nurses. Fifteen risk attitude variables were tested, including items on attitudes to risk in clinical decision-making. Attitudes to risk varied greatly between nurses, for example 27% (71/262) of nurses strongly agreed that an NHS 24 nurse "must not take any risks with physical illness" while 17% (45/262) disagreed. After case-mix adjustment, there was some evidence that nurses' attitudes to risk affected decisions but this was inconsistent and unconvincing.ConclusionMuch of the variation in decision-making by nurses using CDSS remained unexplained. There was no convincing evidence that nurses' attitudes to risk affected the decisions made. This may have been due to the limitations of the instrument used to measure risk attitude.

The dilemma of paediatric drug dosing and equipment sizing in the era of patient safety

The dilemma of paediatric drug dosing and equipment sizing in the era of patient safety

Investigating patients' and general practitioners' views of computerised decision support software for the assessment and management of cardiovascular risk

This paper reports an evaluation of the usability and acceptability of a computer-based decision support program (EMPOWER) for cardiovascular risk from the perspectives of both general practitioners (GPs) and consumers. A qualitative research design utilised semi-structured telephone interviews to assess the program from participants' perspectives. Qualitative approaches included the use of purposeful sampling, the collection of open-ended data, and the analysis of text and personal interpretation of findings. The theoretical foundations for the methods chosen are explained. Consumers enjoyed being involved in the study and thought the program had benefits for encouraging confidence in seeking health care. Consumers reported feeling reassured about the processes followed during consultation. GPs found the application of the software program increased demands on their time but admired several features of the program, especially its educational advantages. Participants were of the opinion that the program would be of particular benefit to inexperienced GPs and newly diagnosed patients. Computer decision support programs are becoming more prevalent, but little is known about their usability and acceptability to both health professionals and consumers. The complexities of cardiovascular risk assessment and management can be adequately managed with such programs. As a contemporary report this study contributes to the growing knowledge required for developers of medical software and decision support systems to better understand the needs of end-users.

INRstar: computerised decision support software for anticoagulation management in primary care

Computerised decision support software (CDSS) for anticoagulation management has become established practice in the UK, offering significant advantages for patients and clinicians over traditional methods of dose calculation. The New GMS Contract has been partly responsible for this shift of management from secondary to primary care, in which INRstar has been the market leader for many years. In September 2004, INRstar received the John Perry Prize, awarded by the PHCSG for excellence and innovation in medical applications of information technology.

A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study

To determine the most cost-effective method of screening for atrial fibrillation (AF) in the population aged 65 years and over, as well as its prevalence and incidence in this age group. Also to evaluate the relative cost-effectiveness of different methods of recording and interpreting the electrocardiogram (ECG) within a screening programme. Multicentred randomised controlled trial. Purposefully selected general practices were randomly allocated to 25 intervention practices and 25 control practices. Fifty primary care centres across the West Midlands, UK. Patients aged 65 years and over. GPs and practice nurses in the intervention practices received education on the importance of AF detection and ECG interpretation. Patients in the intervention practices were randomly allocated to systematic (n = 5000) or opportunistic screening (n = 5000). Prospective identification of pre-existing risk factors for AF within the screened population enabled comparison between targeted screening of people at higher risk of AF and total population screening. AF detection rates in systematically screened and opportunistically screened populations in the intervention practices were compared with AF detection rate in 5000 patients in the control practices. The screening period was 12 months. Baseline prevalence of AF was 7.2%, with a higher prevalence in males (7.8%) and patients aged 75 years and over (10.3%). The control population demonstrated higher baseline prevalence (7.9%) than either the systematic (6.9%) or opportunistic (6.9%) intervention population. In the control population 47 new cases were detected (incidence 1.04% per year). In the opportunistic arm 243 patients without a baseline diagnosis of AF were found to have an irregular pulse, with 177 having an ECG, yielding 31 new cases (incidence 0.69% per year). A further 44 cases were detected outside the screening programme (overall incidence 1.64% per year). In the systematic arm 2357 patients had an ECG yielding 52 new cases (incidence 1.1% per year). Of these, 31 were detected by targeted screening and a further 21 by total population screening. A further 22 cases were detected outside the screening programme (overall incidence 1.62% per year). In terms of ECG interpretation, computerised decision support software (CDSS) gave a sensitivity of 87.3%, a specificity of 99.1% and a positive predictive value (PPV) of 89.5% compared with the gold standard (cardiologist reporting). GPs and practice nurses performed less well. The only difference in performance between intervention populations and controls was that practice nurses from the control arm performed less well than with intervention practice nurses on interpretation of limb-lead (PPV 38.8% versus 20.8%) and single-lead (PPV 37.7% versus 24.0%) ECGs. The within-trial economic evaluation results showed the lowest incremental cost to be for the opportunistic arm, with an incremental cost-effectiveness ratio of 337 pounds Sterling for each additional case detected compared to the control arm. Opportunistic screening dominated both more intensive screening strategies. Model-based analyses showed small differences in cost and quality-adjusted life-years for different methods and intensities of screening, but annual opportunistic screening resulted in the lowest number of ischaemic strokes and greatest proportion of cases of AF diagnosed. Probabilistic sensitivity results indicated that there was a probability of approximately 60% that screening from the age of 65 years was cost-effective in both men and women. The results of the study indicated that in terms of a screening programme for atrial fibrillation in patients 65 and over, the only strategy that improved on routine practice was opportunistic screening, model-based analyses indicated that there was a probability of approximately 60% of annual opportunistic screening being cost effective. It is suggested that the following topics are worthy of further investigation: the effect of the implementation of a screening programme for AF on the uptake and maintenance of anticoagulation in patients aged 65 years and over; an evaluation of the role of CDSS in the diagnosis of cardiac arrythmias; the best method for routinely detecting paroxysmal AF; ways of improving healthcare professionals' performance in ECG interpretation; development of a robust economic model to incorporate data on new therapeutic agents for use as thromboprophylactic agents for patients with AF, and an evaluation of the relative risk of stroke for patients with incident as opposed to prevalent AF.

Nurses' views of using computerized decision support software in NHS Direct.

Nurses working in NHS Direct, the 24-hour telephone advice line in England, use computerized decision support software to recommend to callers the most appropriate service to contact, or to advise on self-care. To explore nurses' views of their roles and the computerized decision support software in NHS Direct. Qualitative analysis of semi-structured interviews with 24 NHS Direct nurses in 12 sites. Nurses described both the software and themselves as essential to the clinical decision-making process. The software acted as safety net, provider of consistency, and provider of script, and was relied upon more when nurses did not have clinical knowledge relevant to the call. The nurse handled problems not covered by the software, probed patients for the appropriate information to enter into the software, and interpreted software recommendations in the light of contextual information which the software was unable to use. Nurses described a dual process of decision-making, with the nurse as active decision maker looking for consensus with the software recommendation and ready to override recommendations made by the software if necessary. However, nurses' accounts of the software as a guide, prompt or support did not fully acknowledge the power of the software, which they are required to use, and the recommendation of which they are required to follow under some management policies. Over time, the influence of nurse and software merges as nurses internalize the software script as their own knowledge, and navigate the software to produce recommendations that they feel are most appropriate. The nurse and the software have distinct roles in NHS Direct, although the effect of each on the clinical decision-making process may be difficult to determine in practice.