Annemie Heselmans

Effectiveness of electronic guideline-based implementation systems in ambulatory care settings - a systematic review

BackgroundElectronic guideline-based decision support systems have been suggested to successfully deliver the knowledge embedded in clinical practice guidelines. A number of studies have already shown positive findings for decision support systems such as drug-dosing systems and computer-generated reminder systems for preventive care services.MethodsA systematic literature search (1990 to December 2008) of the English literature indexed in the Medline database, Embase, the Cochrane Central Register of Controlled Trials, and CRD (DARE, HTA and NHS EED databases) was conducted to identify evaluation studies of electronic multi-step guideline implementation systems in ambulatory care settings. Important inclusion criterions were the multidimensionality of the guideline (the guideline needed to consist of several aspects or steps) and real-time interaction with the system during consultation. Clinical decision support systems such as one-time reminders for preventive care for which positive findings were shown in earlier reviews were excluded. Two comparisons were considered: electronic multidimensional guidelines versus usual care (comparison one) and electronic multidimensional guidelines versus other guideline implementation methods (comparison two).ResultsTwenty-seven publications were selected for analysis in this systematic review. Most designs were cluster randomized controlled trials investigating process outcomes more than patient outcomes. With success defined as at least 50% of the outcome variables being significant, none of the studies were successful in improving patient outcomes. Only seven of seventeen studies that investigated process outcomes showed improvements in process of care variables compared with the usual care group (comparison one). No incremental effect of the electronic implementation over the distribution of paper versions of the guideline was found, neither for the patient outcomes nor for the process outcomes (comparison two).ConclusionsThere is little evidence at the moment for the effectiveness of an increasingly used and commercialised instrument such as electronic multidimensional guidelines. After more than a decade of development of numerous electronic systems, research on the most effective implementation strategy for this kind of guideline-based decision support systems is still lacking. This conclusion implies a considerable risk towards inappropriate investments in ineffective implementation interventions and in suboptimal care.

Effectiveness of Nonresuscitative First Aid Training in Laypersons: A Systematic Review

STUDY OBJECTIVE This study reviewed evidence on the effects of nonresuscitative first aid training on competence and helping behavior in laypersons. METHODS We identified randomized and nonrandomized controlled trials and interrupted time series on nonresuscitative first aid training for laypersons by using 12 databases (including MEDLINE, EMBASE, and PsycINFO), hand searching, reference checking, and author communication. Two reviewers independently evaluated selected studies with the Cochrane Effective Practice and Organisation of Care Review Group quality criteria. One reviewer extracted data with a standard form and another checked them. In anticipation of substantial heterogeneity across studies, we elected a descriptive summary of the included studies. RESULTS We included 4 studies, 3 of which were randomized trials. We excluded 11 studies on quality issues. Two studies revealed that participants trained in first aid demonstrated higher written test scores than controls (poisoning first aid: relative risk 2.11, 95% confidence interval [CI] 1.64 to 2.72; various first aid cases: mean difference 4.75, 95% CI 3.02 to 6.48). Two studies evaluated helping responses during unannounced simulations. First aid training improved the quality of help for a bleeding emergency (relative risk 25.94; 95% CI 3.60 to 186.93), not the rate of helping (relative risk 1.13; 95% CI 0.88 to 1.45). Training in first aid and helping behavior increased the helping rates in a chest pain emergency compared with training in first aid only (relative risk 2.80; 95% CI 1.05 to 7.50) or controls (relative risk 3.81; 95% CI 0.98 to 14.89). Participants trained in first aid only did not help more than controls (relative risk 1.36; 95% CI 0.28 to 6.61). CONCLUSION First aid programs that also train participants to overcome inhibitors of emergency helping behavior could lead to better help and higher helping rates.

Evidence-based Prehospital Management of Severe Traumatic Brain Injury: A Comparative Analysis of Current Clinical Practice Guidelines

Abstract Objective. This study appraised the completeness and level of evidence behind prehospital recommendations in clinical practice guidelines (CPGs) for management of severe traumatic brain injury (TBI). Differences and similarities in key recommendations for prehospital emergency care were assessed between current CPGs. Methods. A systematic search identified current evidence-based CPGs for the management of severe TBI. The identified CPGs were screened for prehospital recommendations. Finally, an evaluation of the completeness and level of evidence for each of the identified recommendations was carried out. A review of the literature identified additional evidence. Designs of the retrieved publications were considered and classified according to the GRADE levels of evidence. Results. This study identified 12 current CPGs for the management of patients after traumatic brain injury. Of these, twenty-one prehospital recommendations were selected. Only a few CPGs made recommendations on temperature management and ventilation patterns. Statements on prehospital transport and advanced airway management were common to all of the guidelines. Statements on initial treatment demonstrated the greatest variability. The literature review identified several relevant publications not included in the CPGs even after we controlled for the indicated time-intervals of their literature search. In addition, evidence from more recent trials published outside the search-interval of the clinical practice guidelines was found. Conclusions. The use of current guidelines on traumatic brain injury will not always facilitate decisions about best or most appropriate practice for prehospital practitioners. The amount of recommended prehospital interventions varied considerably, and there was large content variation in prehospital recommendations in these guidelines. Not all evidence was taken into account and not all CPGs were up-to-date.

The attitude of Flemish occupational health physicians toward evidence-based occupational health and clinical practice guidelines

PurposeTo identify the attitude of occupational health physicians toward evidence-based occupational health (EBOH) and clinical practice guidelines (CPGs); to determine their ability to access, retrieve and appraise the health evidence and the barriers to applying evidence to practice.MethodsA cross-sectional survey study was carried out among all Dutch-speaking occupational health physicians in Belgium (584 physicians could be reached).ResultsA response rate of 25.5% was achieved. The majority of respondents were positive toward EBOH and CPGs. Most respondents were less confident in basic skills of EBM, except for their searching skills. Perceived barriers to applying evidence to practice were mainly time and lack of EBM skills.ConclusionsBelgian occupational health physicians are interested in the implementation of EBOH in their daily occupational practice and have a general knowledge of EBM. However, there are barriers in the legislative framework, the education and the information infrastructure, which first have to be removed. The time has come for the responsible authorities to take educational initiatives and to take a huge leap forward in the integration of EBOH into occupational practice.

The Effects of Computerized Clinical Decision Support Systems on Laboratory Test Ordering: A Systematic Review

CONTEXT - Inappropriate laboratory test ordering has been shown to be as high as 30%. This can have an important impact on quality of care and costs because of downstream consequences such as additional diagnostics, repeat testing, imaging, prescriptions, surgeries, or hospital stays. OBJECTIVE - To evaluate the effect of computerized clinical decision support systems on appropriateness of laboratory test ordering. DATA SOURCES - We used MEDLINE, Embase, CINAHL, MEDLINE In-Process and Other Non-Indexed Citations, Clinicaltrials.gov, Cochrane Library, and Inspec through December 2015. Investigators independently screened articles to identify randomized trials that assessed a computerized clinical decision support system aimed at improving laboratory test ordering by providing patient-specific information, delivered in the form of an on-screen management option, reminder, or suggestion through a computerized physician order entry using a rule-based or algorithm-based system relying on an evidence-based knowledge resource. Investigators extracted data from 30 papers about study design, various study characteristics, study setting, various intervention characteristics, involvement of the software developers in the evaluation of the computerized clinical decision support system, outcome types, and various outcome characteristics. CONCLUSIONS - Because of heterogeneity of systems and settings, pooled estimates of effect could not be made. Data showed that computerized clinical decision support systems had little or no effect on clinical outcomes but some effect on compliance. Computerized clinical decision support systems targeted at laboratory test ordering for multiple conditions appear to be more effective than those targeted at a single condition.

Can training improve laypersons helping behaviour in first aid? A randomised controlled deception trial

Background There is limited evidence indicating that laypersons trained in first aid provide better help, but do not help more often than untrained laypersons. This study investigated the effect of conventional first aid training versus conventional training plus supplementary training aimed at decreasing barriers to helping. Methods The authors conducted a randomised controlled trial. After 24 h of conventional first aid training, the participants either attended an experimental lesson to reduce barriers to helping or followed a control lesson. The authors used a deception test to measure the time between the start of the unannounced simulated emergency and seeking help behaviour and the number of particular helping actions. Results The authors randomised 72 participants to both groups. 22 participants were included in the analysis for the experimental group and 36 in the control group. The authors found no statistically or clinically significant differences for any of the outcome measures. The time until seeking help (geometrical mean and 95% CI) was 55.5 s (42.9 to 72.0) in the experimental group and 56.5 s (43.0 to 74.3) in the control group. 57% of the participants asked a bystander to seek help, 40% left the victim to seek help themselves and 3% did not seek any help. Conclusion Supplementary training on dealing with barriers to helping did not alter the helping behaviour. The timing and appropriateness of the aid provided can be improved. Trial registration The authors registered this trial at ClinicalTrials.gov as NCT00954161.

Human Computation as a New Method for Evidence-Based Knowledge Transfer in Web-Based Guideline Development Groups: Proof of Concept Randomized Controlled Trial

Background Guideline developers use different consensus methods to develop evidence-based clinical practice guidelines. Previous research suggests that existing guideline development techniques are subject to methodological problems and are logistically demanding. Guideline developers welcome new methods that facilitate a methodologically sound decision-making process. Systems that aggregate knowledge while participants play a game are one class of human computation applications. Researchers have already proven that these games with a purpose are effective in building common sense knowledge databases. Objective We aimed to evaluate the feasibility of a new consensus method based on human computation techniques compared to an informal face-to-face consensus method. Methods We set up a randomized design to study 2 different methods for guideline development within a group of advanced students completing a master of nursing and obstetrics. Students who participated in the trial were enrolled in an evidence-based health care course. We compared the Web-based method of human-based computation (HC) with an informal face-to-face consensus method (IC). We used 4 clinical scenarios of lower back pain as the subject of the consensus process. These scenarios concerned the following topics: (1) medical imaging, (2) therapeutic options, (3) drugs use, and (4) sick leave. Outcomes were expressed as the amount of group (dis)agreement and the concordance of answers with clinical evidence. We estimated within-group and between-group effect sizes by calculating Cohen’s d. We calculated within-group effect sizes as the absolute difference between the outcome value at round 3 and the baseline outcome value, divided by the pooled standard deviation. We calculated between-group effect sizes as the absolute difference between the mean change in outcome value across rounds in HC and the mean change in outcome value across rounds in IC, divided by the pooled standard deviation. We analyzed statistical significance of within-group changes between round 1 and round 3 using the Wilcoxon signed rank test. We assessed the differences between the HC and IC groups using Mann-Whitney U tests. We used a Bonferroni adjusted alpha level of .025 in all statistical tests. We performed a thematic analysis to explore participants’ arguments during group discussion. Participants completed a satisfaction survey at the end of the consensus process. Results Of the 135 students completing a master of nursing and obstetrics, 120 participated in the experiment. We formed 8 HC groups (n=64) and 7 IC groups (n=56). The between-group comparison demonstrated that the human computation groups obtained a greater improvement in evidence scores compared to the IC groups, although the difference was not statistically significant. The between-group effect size was 0.56 (P=.30) for the medical imaging scenario, 0.07 (P=.97) for the therapeutic options scenario, and 0.89 (P=.11) for the drug use scenario. We found no significant differences in improvement in the degree of agreement between HC and IC groups. Between-group comparisons revealed that the HC groups showed greater improvement in degree of agreement for the medical imaging scenario (d=0.46, P=.37) and the drug use scenario (d=0.31, P=.59). Very few evidence arguments (6%) were quoted during informal group discussions. Conclusions Overall, the use of the IC method was appropriate as long as the evidence supported participants’ beliefs or usual practice, or when the availability of the evidence was sparse. However, when some controversy about the evidence existed, the HC method outperformed the IC method. The findings of our study illustrate the importance of the choice of the consensus method in guideline development. Human computation could be an acceptable methodology for guideline development specifically for scenarios in which the evidence shows no resonance with participants’ beliefs. Future research is needed to confirm the results of this study and to establish practical significance in a controlled setting of multidisciplinary guideline panels during real-life guideline development.

Medication review by a clinical pharmacist at the transfer point from ICU to ward: a randomized controlled trial

Drug‐related problems (DRPs) occur frequently in hospitalized patients. Patient discharge from the intensive care unit (ICU) to a non‐ICU ward is one of the most challenging and high‐risk transitions of care due to the number of medications, and the complexity and acuity of the medical conditions that characterize this patient group. Pharmacists could play an important role in preventing DRPs. This study was undertaken to evaluate the impact on the number and severity of drug‐related problems by assigning a clinical pharmacist to the transfer process from ICU to wards.

A systematic review of trials evaluating success factors of interventions with computerised clinical decision support

BackgroundComputerised clinical decision support (CDS) can potentially better inform decisions, and it can help with the management of information overload. It is perceived to be a key component of a learning health care system. Despite its increasing implementation worldwide, it remains uncertain why the effect of CDS varies and which factors make CDS more effective.ObjectiveTo examine which factors make CDS strategies more effective on a number of outcomes, including adherence to recommended practice, patient outcome measures, economic measures, provider or patient satisfaction, and medical decision quality.MethodsWe identified randomised controlled trials, non-randomised trials, and controlled before-and-after studies that directly compared CDS implementation with a given factor to CDS without that factor by searching CENTRAL, MEDLINE, EMBASE, and CINAHL and checking reference lists of relevant studies. We considered CDS with any objective for any condition in any healthcare setting. We included CDS interventions that were either displayed on screen or provided on paper and that were directed at healthcare professionals or targeted at both professionals and patients. The reviewers screened the potentially relevant studies in duplicate. They extracted data and assessed risk of bias in independent pairs or individually followed by a double check by another reviewer. We summarised results using medians and interquartile ranges and rated our certainty in the evidence using the GRADE system.ResultsWe identified 66 head-to-head trials that we synthesised across 14 comparisons of CDS intervention factors. Providing CDS automatically versus on demand led to large improvements in adherence. Displaying CDS on-screen versus on paper led to moderate improvements and making CDS more versus less patient-specific improved adherence modestly. When CDS interventions were combined with professional-oriented strategies, combined with patient-oriented strategies, or combined with staff-oriented strategies, then adherence improved slightly. Providing CDS to patients slightly increased adherence versus CDS aimed at the healthcare provider only. Making CDS advice more explicit and requiring users to respond to the advice made little or no difference. The CDS intervention factors made little or no difference to patient outcomes. The results for economic outcomes and satisfaction outcomes were sparse.ConclusionMultiple factors may affect the success of CDS interventions. CDS may be more effective when the advice is provided automatically and displayed on-screen and when the suggestions are more patient-specific. CDS interventions combined with other strategies probably also improves adherence. Providing CDS directly to patients may also positively affect adherence. The certainty of the evidence was low to moderate for all factors.Trial registrationPROSPERO, CRD42016033738