Use Of Clinical Decision Support Tools Research Articles

Differences in Use of Clinical Decision Support Tools and Implementation of Aspirin, Blood Pressure Control, Cholesterol Management, and Smoking Cessation Quality Metrics in Small Practices by Race and Sex

Practice-level evidence is needed to clarify the value of population-based clinical decision support (CDS) tools in reducing racial and sex disparities in cardiovascular care. To evaluate the association between CDS tools and racial and sex disparities in the aspirin use, blood pressure control, cholesterol management, and smoking cessation (ABCS) care quality metrics among smaller primary care practices. This cross-sectional study used practice-level data from the Agency for Healthcare Research and Quality-funded EvidenceNOW initiative. The national initiative from May 1, 2015, to April 30, 2021, spanned 12 US states and focused on improving cardiovascular preventive care by providing quality improvement support to smaller primary care practices. A total of 576 primary care practices in EvidenceNOW submitted both survey data and electronic health record (EHR)-derived ABCS data stratified by race and sex. Practice-level estimates of disparities between Black and White patients and between male and female patients were calculated as the difference in proportions of eligible patients within each practice meeting ABCS care quality metrics. The association between CDS tools (EHR prompts, standing orders, and clinical registries) and disparities was evaluated by multiply imputed multivariable models for each CDS tool, adjusted for practice rurality, ownership, and size. Across the 576 practices included in the analysis, 219 (38.0%) had patient panels that were more than half White and 327 (56.8%) had panels that were more than half women. The proportion of White compared with Black patients meeting metrics for blood pressure (difference, 5.16% [95% CI, 4.29%-6.02%]; P < .001) and cholesterol management (difference, 1.49% [95% CI, 0.04%-2.93%] P = .04) was higher; the proportion of men meeting metrics for aspirin use (difference, 4.36% [95% CI, 3.34%-5.38%]; P < .001) and cholesterol management (difference, 3.88% [95% CI, 3.14%-4.63%]; P < .001) was higher compared with women. Conversely, the proportion of women meeting practice blood pressure control (difference, -1.80% [95% CI, -2.32% to -1.28%]; P < .001) and smoking cessation counseling (difference, -1.67% [95% CI, -2.38% to -0.95%]; P < .001) metrics was higher compared with men. Use of CDS tools was not associated with differences in race or sex disparities except for the smoking metric. Practices using CDS tools showed a higher proportion of men meeting the smoking counseling metric than women (coefficient, 3.82 [95% CI, 0.95-6.68]; P = .009). The findings of this cross-sectional study suggest that practices using CDS tools had small disparities that were not statistically significant, but CDS tools were not associated with reductions in disparities. More research is needed on effective practice-level interventions to mitigate disparities.

National Needs Assessment of Utilization of Common Newborn Clinical Decision Support Tools.

Clinical decision support tools (CDSTs) are common in neonatology, but utilization is rarely examined. We examined the utilization of four CDSTs in newborn care. A 72-field needs assessment was developed. It was distributed to listservs encompassing trainees, nurse practitioners, hospitalists, and attendings. At the conclusion of data collection, responses were downloaded and analyzed. We received 339 fully completed questionnaires. BiliTool and the Early-Onset Sepsis (EOS) tool were used by > 90% of respondents, the Bronchopulmonary Dysplasia tool by 39%, and the Extremely Preterm Birth tool by 72%. Common reasons CDSTs did not impact clinical care included lack of electronic health record integration, lack of confidence in prediction accuracy, and unhelpful predictions. From a national sample of neonatal care providers, there is frequent but variable use of four CDSTs. Understanding the factors that contribute to tool utility is vital prior to development and implementation. · Clinical decision support tools are common in medicine.. · There is a varied use of neonatal CDST.. · Understanding the use of CDST is vital for future development..

Assessing the implementation of a clinical decision support tool in primary care for diabetes prevention: a qualitative interview study using the Consolidated Framework for Implementation Science

BackgroundIn this paper we describe the use of the Consolidated Framework for Implementation Research (CFIR) to study implementation of a web-based, point-of-care, EHR-linked clinical decision support (CDS) tool designed to identify and provide care recommendations for adults with prediabetes (Pre-D CDS).MethodsAs part of a large NIH-funded clinic-randomized trial, we identified a convenience sample of interview participants from 22 primary care clinics in Minnesota, North Dakota, and Wisconsin that were randomly allocated to receive or not receive a web-based EHR-integrated prediabetes CDS intervention. Participants included 11 clinicians, 6 rooming staff, and 7 nurse or clinic managers recruited by study staff to participate in telephone interviews conducted by an expert in qualitative methods. Interviews were recorded and transcribed, and data analysis was conducted using a constructivist version of grounded theory.ResultsImplementing a prediabetes CDS tool into primary care clinics was useful and well received. The intervention was integrated with clinic workflows, supported primary care clinicians in clearly communicating prediabetes risk and management options with patients, and in identifying actionable care opportunities. The main barriers to CDS use were time and competing priorities. Finally, while the implementation process worked well, opportunities remain in engaging the care team more broadly in CDS use.ConclusionsThe use of CDS tools for engaging patients and providers in care improvement opportunities for prediabetes is a promising and potentially effective strategy in primary care settings. A workflow that incorporates the whole care team in the use of such tools may optimize the implementation of CDS tools like these in primary care settings.Trial registration Name of the registry: Clinicaltrial.gov. Trial registration number: NCT02759055. Date of registration: 05/03/2016. URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT02759055 Prospectively registered.

Implementation of Electronic Clinical Decision Support Tools for Antibiotic Stewardship in Pediatric Appendicitis.

The efficacy of clinical decision support (CDS) tools to promote antibiotic stewardship in pediatric appendicitis remains poorly understood. Here, we developed an electronic order panel (OP) to assist with decreased utilization of extended spectrum antibiotics. Retrospective review of patients (≤18years) at a single institution from May 2018 to October 2019 treated with ≥1 dose of preferred (narrow) or nonpreferred (broad-spectrum) antibiotics was performed, and they were categorized as pre- (PIC) or postimplementation cohorts (PISC). Of 234 encounters, 170 (73%) and 107 (46%) received preferred and nonpreferred antibiotics, respectively. Postimplementation cohort encounters had a sustained 50% increase in preferred antibiotic use compared to PIC (92% vs 42%, P = .014). Order panel utilization accounted for 31% of overall encounters and 44% of PISC encounters. Despite sustained improvement in antibiotic stewardship, OP utilization remains low. The use of CDS tools may not be a good process measure for quality improvement.

A Systematic Review of Clinical Decision Support Systems for Clinical Oncology Practice.

Electronic health records are central to cancer care delivery. Electronic clinical decision support (CDS) systems can potentially improve cancer care quality and safety. However, little is known regarding the use of CDS systems in clinical oncology and their impact on patient outcomes. A systematic review of peer-reviewed studies was performed to evaluate clinically relevant outcomes related to the use of CDS tools for the diagnosis, treatment, and supportive care of patients with cancer. Peer-reviewed studies published from 1995 through 2016 were included if they assessed clinical outcomes, patient-reported outcomes (PROs), costs, or care delivery process measures. Electronic database searches yielded 2,439 potentially eligible papers, with 24 studies included after final review. Most studies used an uncontrolled, pre-post intervention design. A total of 23 studies reported improvement in key study outcomes with use of oncology CDS systems, and 12 studies assessing the systems for computerized chemotherapy order entry demonstrated reductions in prescribing error rates, medication-related safety events, and workflow interruptions. The remaining studies examined oncology clinical pathways, guideline adherence, systems for collection and communication of PROs, and prescriber alerts. There is a paucity of data evaluating clinically relevant outcomes of CDS system implementation in oncology care. Currently available data suggest that these systems can have a positive impact on the quality of cancer care delivery. However, there is a critical need to rigorously evaluate CDS systems in oncology to better understand how they can be implemented to improve patient outcomes.

Attitudes toward evidence-based clinical decision support tools to reduce exposure to ionizing radiation: The Canadian CT Head Rule.

A large degree of variation in clinical practice exists among clinicians evaluating and treating individuals with minor head injuries. Noncontrast head computerized tomography (CT) scans are commonly used to assess for intracranial damage in patients presenting with head injury. This practice is not supported by the evidence and poses harm to patients by increasing exposure to ionizing radiation. This form of radiation exposure increases the risk of developing cancers over the course of the individual's life, and further strains the limited resources of the healthcare system. This article describes the findings of an evidence-based practice project assessing the attitudes of clinicians toward an evidence-based clinical decision support tool (Canadian CT Head Rule [CCHR]). The CCHR has 100% sensitivity in detecting all clinically important brain injuries and any injury requiring neurosurgical intervention. This clinical decision support (CDS) tool is designed to help guide clinicians in the prudent use of head CT scans in people ages 16-64 that have sustained minor head injuries. The Evidence-Based Attitude Scale was also used to identify which domains were most influential on willingness to adopt into clinical practice. The results revealed an 84% increase in clinician knowledge of the use of the CCHR. A majority (83%) of participants reported moderate likelihood of adoption of the CDS tool into clinical practice if they found the tool appealing, and it was required by a governing authority. The use of CDS tools can help healthcare providers mitigate the risk associated with caring for complex patients. CDS tools provide a systematic method to evaluate patients with minor head injuries while assuring consistency of care and quality outcomes. This practice of assuring consistency and good patient outcomes is foundational to the concept of standard of care, which serves to improve clinical practice.

Improving antibiotic adherence in treatment of acute upper respiratory infections: a quality improvement process

IntroductionApproximately 25 million people in the United States visit their primary care physician each year for acute respiratory infections (ARI). They are a common cause of unnecessary prescription of antibiotics; despite well-validated national treatment guidelines, around 73% of adults with ARI are prescribed antibiotics in the United States. Inappropriate use of antibiotics has profound implications.MethodsOur aim was to increase adherence to antibiotic guidelines for treatment of ARI in an internal medicine outpatient practice. We used a package of active and passive interventions to improve physician awareness of treatment guidelines; these included short sessions of didactic teaching, antibiotic guidelines posters in patient examination rooms and staff areas, clinical decision support (CDS) tools integrated into the electronic medical record system, guideline adherence report cards for providers, and reiteration of CDS tool use and guideline adherence at monthly group meetings. Process measures were the rate of use of CDS tools for the management of ARI and patient callbacks within 72 h for the same issue. Outcome measures were compliance with antibiotic prescribing guidelines.ResultsOur low-cost interventions led to a significant improvement in ARI treatment guideline adherence. There was improvement in compliance with treatment guidelines for sinusitis (90.90% vs. 57.58%, p<0.001), pharyngitis (64.28% vs. 25.00%, p = 0.003), upper respiratory infection (96.18% vs. 73.68%, p = 0.008), and the aggregated measure of ARI (91.25% vs. 78.6%, p<0.001). Rate of CDS tool usage was 40.5% with a 72-h callback rate of 0.05%.ConclusionSimple, low-cost interventions can improve appropriate antibiotic use for ARI and change the prescribing habits of providers in an outpatient setting. Provider and patient education is a vital component of antibiotic stewardship. Simple interventions for common outpatient conditions can have a positive impact on patient outcomes and reduce unnecessary healthcare costs.

Attitudes and perceptions of pediatric residents on transitioning to CPOE.

Many resident physicians have experienced transitioning from traditional paper documentation and ordering to an electronic process during their training. We sought to investigate the attitudes and perceptions of residents related to implementation of computer provider order entry (CPOE) and clinical decision support (CDS). Pediatric residents completed web-based surveys prior to CPOE implementation and at 6 months and 12 months after implementation. The survey assessed resident attitudes and perceptions related to CPOE and the use of CDS tools. Additionally, at 6 and 12 months, residents were asked how electronic medical record (EMR) resources might impact future career decisions. Prior to CPOE implementation, 70% of residents were looking forward to CPOE, but 28% did not want to transition from paper ordering. At 12 months post-implementation, 80% of residents favored CPOE over paper ordering and only 3.33% wished to revert to paper ordering. Residents reported an increase in time needed to enter admission orders 6-months after CPOE implementation. By 12 months post-implementation, there was no significant difference in perceived time to complete admission orders when compared to pre-CPOE responses. Most residents (91.67%) identified that overall EMR resources were an important factor when considering future employment opportunities. The most important factors included the degree of EMR implementation, technology resources and the amount of support staff. The least important factors included patient portal access and which EMR product is used. Overall, residents demonstrated a preference for CPOE compared to traditional paper order entry. Many residents remained unaware of CDS tools embedded within CPOE at the 12 month follow-up, but a majority of residents did find them helpful and felt more knowledgeable about current guidelines. EMR resources, including degree of EMR implementation, technology resources and support staff are likely to be important factors as residents take future employment opportunities into consideration.

The Use of Clinical Decision‐Support Tools to Facilitate Geriatric Education

Innovative methods are needed to incorporate effective geriatric education into internal medicine residency programs. The purpose of this report is to describe the development and use of clinical decision-support (CDS) tools to facilitate geriatric education and improve the care delivered to older adults in an academic internal medicine residency ambulatory care clinic. Starting in 2009, CDS tools were implemented as a major strategy of an initiative to improve resident physician clinical competencies in geriatrics and improve the quality of care and quality of life of older adults. These tools, designed to improve resident assessment and action for each of three educational modules (falls, vision, and dementia) were embedded within the ambulatory electronic medical record (EMR) and provided a method of point-of-care training to residents caring for older adults. One hundred internal medicine residents supervised by 17 general internal medicine faculty members participated. Data regarding CDS use and associated outcomes were recorded and extracted from the ambulatory clinic EMR. Residents screened between 67% and 88% of eligible patients using CDS algorithms; rates of additional assessment and referral or further examination reflected the prevalence of the condition in the patient population. Although further development may be necessary, CDS tools are a promising modality to supplement geriatric postgraduate education while simultaneously improving patient care.

Principles of the patient-centered medical home and preventive services delivery.

Limited research exists examining the principles of the patient-centered medical home (PCMH) and improved outcomes. We examined whether PCMH principles (personal physician, physician-directed team, whole-person orientation, coordination of care, quality and safety, and enhanced access) are associated with receipt of preventive services. We undertook cross-sectional analyses using baseline patient and practice member surveys and chart audits from a quality improvement trial in 24 primary care offices. Association of PCMH principles with preventive services (receipt of cancer screening, lipid screening, influenza vaccination, and behavioral counseling) was examined using hierarchical linear modeling. Higher global PCMH scores were associated with receipt of preventive services (beta = 2.3; P <.001). Positive associations were found with principles of personal physician (beta = 3.7; P <.001), in particular, continuity with the same physician (beta = 4.4; P = .002) and number of visits within 2 years (15% higher for patients with 13 or more visits; P <.001); and whole-person orientation (beta = 5.6; P <.001), particularly, having a well-visit within 5 years (beta = 12.3; P <.001) and being treated for chronic diseases (6% higher if more than 3 chronic diseases; P = .002). Having referral systems to link patients to community programs for preventive counseling (beta = 8.0; P <.001) and use of clinical decision-support tools (beta = 5.0; P = .04) were also associated with receipt of preventive services. Relationship-centered aspects of PCMH are more highly correlated with preventive services delivery in community primary care practices than are information technology capabilities. Demonstration projects and tools that measure PCMH principles should have greater emphasis on these key primary care attributes.