Difference between revisions of "Evaluation of Effectiveness and Cost‐Effectiveness of a Clinical Decision Support System in Managing Hypertension in Resource Constrained Primary Health Care Settings: Results From a Cluster Randomized Trial"

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(Created page with "This is a review for a study done by Zahra Niazkhani, MD, MS,Hab ibollah Pirnejad, MD, MS, PhD, Marc Berg, MD, MA, PhD, and Jos Aarts, PhD which helps summarize CPOE workflow ...")
 
 
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This is a review for a study done by Zahra Niazkhani, MD, MS,Hab ibollah Pirnejad, MD, MS, PhD, Marc Berg, MD, MA, PhD, and Jos Aarts, PhD which helps summarize CPOE workflow advantage and disadvantages in published literature between 1990 and 2007. <ref name="Zahra 2009">. Creating The Impact of Computerized Provider Order Entry Systems on Inpatient Clinical Workflow:A Literature Review.  Journal of American Medical Informatics Association. 2009 July; 16(4): 539-549; 38(1): 51-60. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2705258/</ref>
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This is a review for a study done by Raghupathy Anchala, MD, PhD; Stephen Kaptoge, PhD; Hira Pant, MA; Emanuele Di Angelantonio, MD, PhD; Oscar H. Franco, MD, PhD; and D. Prabhakaran, MD, DM, MSc to assess through randomized control trials from the developed world report whether clinical decision support systems ([[CDS]]) could provide an effective means to improve the management of hypertension (HTN).
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<ref name="Anchala 2014">. Evaluation of Effectiveness and Cost‐Effectiveness of a Clinical Decision Support System in Managing Hypertension in Resource Constrained Primary Health Care Settings: Results From a Cluster Randomized Trial.  J Am Heart Assoc.
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2015; 4: e001213. http://jaha.ahajournals.org/content/4/1/e001213.full</ref>
  
 
== Research question ==
 
== Research question ==
  
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What are some advantages and disadvantages in inpatient clinical workflow which have been documented through [[CPOE]] integrated in [[EMR|electronic health records (EMR)]]?
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Can clinical decision support systems ([[CDS]]) provide an effective means to improve the management of hypertension (HTN) in third world countries?
  
 
== Methods ==
 
== Methods ==
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=== Design ===
 
=== Design ===
  
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A literature review was conducted in the PubMed and Cochrane library(see [[Searching for Evidence]]) for journal articles, conference proceedings, and summaries.  MeSH terms (see [[Unified Medical Language System (UMLS)]] and keywords were used to identify CPOE evaluations published in the English language between Jan 1990 and Jun 2007.
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The authors performed a cluster randomized trial to test the effectiveness and cost‐effectiveness of a [[CDS]] among Indian adult hypertensive patients (between 35 and 64 years of age), wherein 16 PHC clusters from a district of Telangana state, India, were randomized to receive either a DSS or a chart‐based support (CBS) system.
  
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The following criteria were used to narrow the searches:
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Each intervention arm had 8 PHC clusters, with a mean of 102 hypertensive patients per cluster (n=845 in DSS and 783 in CBS groups). Mean change in systolic blood pressure (SBP) from baseline to 12 months was the primary endpoint.
  
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# Evaluated the effects of CPOE on realistic or simulated workflow of care providers
 
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# Study must be carried out in inpatient settings
 
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# Reported on either quantitative or qualitative studies
 
  
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Once the potential studies had been identified, they were analyzed based on a conceptual model and one which  met the following criteria:
 
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# Workflow of individual providers versus co-working providers
 
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# Workflow with homegrown versus commercial systems
 
  
 
== Results ==
 
== Results ==
  
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Findings from both studies raised issues with the amount and organization of information in the display, interference with workflow patterns of primary care physicians, and the availability of visual cues and feedback. These findings were then used to recommend user interface design changes.
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Findings from the studies have determined an improvement in clinical outcomes as a measure of blood pressure control and cost reduction in care.
  
 
=== Main results ===
 
=== Main results ===
  
  
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The review identified 51 publications: 31 journal articles, 32–62 16 proceedings papers, 63–78 and four proceedings abstracts.
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The mean difference in SBP change from baseline between the DSS and CBS at the 12th month of follow‐up,and were adjusted for the following parameters as they were identified factors in the study which had significance:
  
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A compilation of the benefits of CPOE include the following:
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# Age
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# Sex
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# Height
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# Waist
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# Body mass index (BMI)
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# Alcohol consumption
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# Vegetable intake
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# Pickle intake
  
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# Remote access to enter orders or view their status
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The results were the following--using [[CDS]], baseline differences in blood pressure, was −6.59 mm Hg (95% confidence interval: −12.18 to −1.42; P=0.021). The cost‐effective ratio for CBS and [[CDS]] groups was $96.01 and $36.57 per mm of SBP reduction, respectively.
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# Access to knowledge sources, decision support, order sets, graphical display of data
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# Clerks, nurses, and pharmacists spent less time per day on the medication process after the implementation
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# Physicians had more time to talk with patients after the implementation
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# Substantial decrease in the drug turnaround time, varying from 23 to 92%
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A compilation of the negative effects included the following:
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*1. More time was spent on ordering after the implementation
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*2. [[Usability]] limitations and their effects on workflow
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*3. Ineffective interface between different departmental information systems can cause interruptions for providers working in different departments
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*4. Pattern of responsibilities for providers also changes after CPOE implementation
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== Conclusion ==
 
== Conclusion ==
  
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Clinical workflow is highly contingent and collaborative. Many in situ contextual factors such as the kind of specialties, the time through a day and so forth may have an influence on it. Based on the contextual factors, providers may decide to rearrange the order of activities or redelegate certain responsibilities among themselves. 83 When put in practice, the formal, predefined, stepwise, and role-based models of workflow underlying CPOE systems may show a fragile compatibility with the contingent, pragmatic, and co-constructive nature of workflow. This in turn can cause an interruption in workflow and challenge the integration of these systems into daily practice.
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[[CDS]] embedded with standardized, best-practice clinical practice guidelines aid in the management of HTN even in resource‐limited settings. [[CDS]] result in better management of HTN, provided patients adhere to the suggested dietary and lifestyle modifications, and medications and providers adhere to the suggested DSS recommendations. Key features of the DSS include the following:
  
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In conclusion, more multi-method research is needed to explore CPOE's multidimensional and collective impact on especially collaborative workflow. This review may inform designers, implementers, and evaluators how to pay closer attention to the collective, multidimensional, and contextual impact of CPOE systems on clinical workflow.
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# Patient-specific, tailor-made and guideline-specific recommendations for the management of HTN
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# Counseling on lifestyle modification (both of when aid the clinicians and physicians in deciding the appropriate line of management for the patient.
  
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== Commentary ==
 
  
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Healthcare is a complex activity system of specialized and non-specialized workers, their tools, and their environment. Healthcare work involves continuous interaction among different elements and trade-offs between multiple goals, preferences, values, incentives, and motivations in the course of care processes.
 
  
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The [[CDS]] was not only effective, but also cost‐effective in management of HTN which would be appropriate in a resource-limited area of the world.
  
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A conceptual model for CPOE was created and had the following elements.  The aspects of clinical workflow therefore can be categorized into four elements:
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== Commentary ==
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# Structuring of clinical tasks
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# Coordinating of task performance
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# Enabling of the flow of information to support task performance
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# Monitoring
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The resulting model enabled the reviewers to examine the interplay between the social context of healthcare work and CPOE systems.  This research study which was a cohort of multiple studies helped create these elements and can create a structure to evaluate CPOE systems.
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Healthcare is a complex system where technology is becoming more prominent.  However, most studies have been done in first world countries where resources are much more plentiful.  This study is significant in that it demonstrates even in third-world country settings where resources are much more limited, there can be a significant impact on patient care, and demonstrate a significant savings in the financial health of the system.  This proves that [[CDS]], when well-implemented in a very thoughtful manner can be of benefit in a variety of settings.  Future studies on [[CDS]] should be of a longer duration and look at assessing (1) the effectiveness of the intervention in reducing the number of MI and stroke cases (where even more cost savings can be identified) and (2) cost utility of the [[CDS]], which, when answered, would aid in deciding the scalability and replicability of [[CDS]] in other settings and assessing whether other tools such as [[CPOE]] have a role in cost savings or patient safety in those settings.
  
 
== References ==
 
== References ==
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[[Category:Reviews]]
 
[[Category:Reviews]]
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[[Category:CDS]]
 
[[Category:CPOE]]
 
[[Category:CPOE]]
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[[Category:Interface, Usability and Accessibility]]
 

Latest revision as of 19:16, 31 March 2015

This is a review for a study done by Raghupathy Anchala, MD, PhD; Stephen Kaptoge, PhD; Hira Pant, MA; Emanuele Di Angelantonio, MD, PhD; Oscar H. Franco, MD, PhD; and D. Prabhakaran, MD, DM, MSc to assess through randomized control trials from the developed world report whether clinical decision support systems (CDS) could provide an effective means to improve the management of hypertension (HTN). [1]

Research question

Can clinical decision support systems (CDS) provide an effective means to improve the management of hypertension (HTN) in third world countries?

Methods

Design

The authors performed a cluster randomized trial to test the effectiveness and cost‐effectiveness of a CDS among Indian adult hypertensive patients (between 35 and 64 years of age), wherein 16 PHC clusters from a district of Telangana state, India, were randomized to receive either a DSS or a chart‐based support (CBS) system.

Each intervention arm had 8 PHC clusters, with a mean of 102 hypertensive patients per cluster (n=845 in DSS and 783 in CBS groups). Mean change in systolic blood pressure (SBP) from baseline to 12 months was the primary endpoint.


Results

Findings from the studies have determined an improvement in clinical outcomes as a measure of blood pressure control and cost reduction in care.

Main results

The mean difference in SBP change from baseline between the DSS and CBS at the 12th month of follow‐up,and were adjusted for the following parameters as they were identified factors in the study which had significance:

  1. Age
  2. Sex
  3. Height
  4. Waist
  5. Body mass index (BMI)
  6. Alcohol consumption
  7. Vegetable intake
  8. Pickle intake

The results were the following--using CDS, baseline differences in blood pressure, was −6.59 mm Hg (95% confidence interval: −12.18 to −1.42; P=0.021). The cost‐effective ratio for CBS and CDS groups was $96.01 and $36.57 per mm of SBP reduction, respectively.


Conclusion

CDS embedded with standardized, best-practice clinical practice guidelines aid in the management of HTN even in resource‐limited settings. CDS result in better management of HTN, provided patients adhere to the suggested dietary and lifestyle modifications, and medications and providers adhere to the suggested DSS recommendations. Key features of the DSS include the following:

  1. Patient-specific, tailor-made and guideline-specific recommendations for the management of HTN
  2. Counseling on lifestyle modification (both of when aid the clinicians and physicians in deciding the appropriate line of management for the patient.


The CDS was not only effective, but also cost‐effective in management of HTN which would be appropriate in a resource-limited area of the world.

Commentary

Healthcare is a complex system where technology is becoming more prominent. However, most studies have been done in first world countries where resources are much more plentiful. This study is significant in that it demonstrates even in third-world country settings where resources are much more limited, there can be a significant impact on patient care, and demonstrate a significant savings in the financial health of the system. This proves that CDS, when well-implemented in a very thoughtful manner can be of benefit in a variety of settings. Future studies on CDS should be of a longer duration and look at assessing (1) the effectiveness of the intervention in reducing the number of MI and stroke cases (where even more cost savings can be identified) and (2) cost utility of the CDS, which, when answered, would aid in deciding the scalability and replicability of CDS in other settings and assessing whether other tools such as CPOE have a role in cost savings or patient safety in those settings.

References

  1. ↑ . Evaluation of Effectiveness and Cost‐Effectiveness of a Clinical Decision Support System in Managing Hypertension in Resource Constrained Primary Health Care Settings: Results From a Cluster Randomized Trial. J Am Heart Assoc. 2015; 4: e001213. http://jaha.ahajournals.org/content/4/1/e001213.full
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