Rick Goud

Effect of guideline based computerised decision support on decision making of multidisciplinary teams: cluster randomised trial in cardiac rehabilitation

Objective To determine the extent to which computerised decision support can improve concordance of multidisciplinary teams with therapeutic decisions recommended by guidelines. Design Multicentre cluster randomised trial. Participants Multidisciplinary cardiac rehabilitation teams in Dutch centres and their cardiac rehabilitation patients. Interventions Teams received an electronic patient record system with or without additional guideline based decision support. Main outcome measures Concordance with guideline recommendations assessed for two standard rehabilitation treatments—exercise and education therapy—and for two new but evidence based rehabilitation treatments—relaxation and lifestyle change therapy; generalised estimating equations were used to account for intra-cluster correlation and were adjusted for patient’s age, sex, and indication for cardiac rehabilitation and for type and volume of centre. Results Data from 21 centres, including 2787 patients, were analysed. Computerised decision support increased concordance with guideline recommended therapeutic decisions for exercise therapy by 7.9% (control 84.7%; adjusted difference 3.5%, 95% confidence 0.1% to 5.2%), for education therapy by 25.7% (control 63.9%; adjusted difference 23.7%, 15.5% to 29.4%), and for relaxation therapy by 25.5% (control 34.1%; adjusted difference 41.6%, 25.2% to 51.3%). The concordance for lifestyle change therapy increased by 3.2% (control 54.1%; adjusted difference 7.1%, −2.9% to 18.3%). Computerised decision support reduced cases of both overtreatment and undertreatment. Conclusions In a multidisciplinary team motivated to adopt a computerised decision support aid that assists in formulating guideline based care plans, computerised decision support can be effective in improving the team’s concordance with guidelines. Therefore, computerised decision support may also be considered to improve implementation of guidelines in such settings. Trial registration Current Controlled Trials ISRCTN36656997.

A parallel guideline development and formalization strategy to improve the quality of clinical practice guidelines

PURPOSE Clinical practice guidelines often contain ambiguities, inconsistencies, and logical errors that hamper implementation of these guidelines in practice. As guideline formalization is useful to verify the logical structure, consistency, and completeness of guidelines, several authors have argued that the formalization of guidelines concurrent with their development may improve their quality. However, experiences with such a parallel guideline development and formalization approach have not yet been reported. The goal of this study was to develop such a strategy and evaluate its application in practice. METHODS Existing methodologies for guideline development and guideline formalization were analyzed and used as a basis to develop a strategy in which guideline formalization is performed concurrently with guideline development. The developed strategy was applied in the development of a clinical practice guideline for cardiac rehabilitation. RESULTS A parallel guideline development and formalization strategy was developed that intertwines the processes of guideline development and guideline formalization. Central assets are early involvement of guideline formalization specialists and formalization tools, cooperation between guideline authors and guideline formalization specialists in the development of clinical algorithms, access to domain knowledge when formalization identifies inconsistencies or omissions, and formal verification of the guideline model prior to guideline dissemination. This strategy was applied in the development of a guideline for cardiac rehabilitation and helped to identify several vague and inconsistent recommendations and impracticabilities in the narrative guidelines that could be resolved before publication. In addition, the strategy ensured consistency between the narrative and formalized guideline. CONCLUSIONS Based on our experience, formalizing a guideline concurrent with its development is feasible in practice and we recommend applying such a strategy as it can be beneficial to the quality of and consistency between the guidelines narrative and formalized version.

Development of a guideline-based decision support system with explanation facilities for outpatient therapy

For effective guideline implementation it is recommended to develop and apply carefully designed implementation strategies and instruments. Computerized decision support systems (CDSSs) are such instruments as they can improve guideline adherence by providing advice at the point of care. To improve the implementation of the Dutch cardiac rehabilitation guidelines a CDSS, named CARDSS, was developed. CARDSS actively provides care professionals with patient-specific, guideline-based treatment recommendations at the onset of a patients rehabilitation trajectory. To maximize the chances of acceptance, CARDSS also provides explanation facilities and other additional information management services, and takes the working procedures specific to multidisciplinary outpatient care into account. CARDSS is currently used in over 40 Dutch cardiac rehabilitation outpatient clinics. This paper describes the development of the CARDSS system. In particular, technical issues are discussed concerning the delivery of active decision support, and the provision of advice rationales to users while taking account of dynamic clinical contexts and changing guidelines.

Is the MacNew quality of life questionnaire a useful diagnostic and evaluation instrument for cardiac rehabilitation

Purpose The MacNew health-related quality of life questionnaire is internationally used as a standard for psychosocial assessment in many cardiac rehabilitation centres. This study investigates its discriminating capacity between diagnostic disease categories, sex and age at entry (T1) and at the end (T2) of cardiac rehabilitation as well as the responsiveness of the MacNew during this period. Method Data were used from 6749 cardiac rehabilitation patients at T1 and 1654 at T2. Results Results show that the global MacNew as well as the three (physical, emotional, social) subscales have high internal consistencies, and differentiate well and in the expected direction at T1 between diagnostic groups (heart surgery, myocardial infarction with and without percutaneous coronary intervention, stable angina with and without percutaneous coronary intervention, implantable cardioverter defibrillator, and heart failure patients), sex and age. The MacNew also proves to be an adequate evaluation instrument for cardiac rehabilitation, as all scales are responsive enough to capture changes from T1 to T2. At T2, however, the MacNew seems to lose some of its discriminating power, partly because of ceiling effects. Conclusion It is suggested to complement the use of the MacNew both at T1 and T2 with a brief anxiety and depression measure, which is valid and responsive for different groups of cardiac rehabilitation patients.

Improving guideline adherence for cardiac rehabilitation in the Netherlands

BackgroundIn 2004, the Netherlands Society of Cardiology released the current guideline on cardiac rehabilitation. Given its complexity and the involvement of various healthcare disciplines, it was supplemented with a clinical algorithm, serving to facilitate its implementation in daily practice. Although the algorithm was shown to be effective for improving guideline adherence, several shortcomings and deficiencies were revealed. Based on these findings, the clinical algorithm has now been updated. This article describes the process and the changes that were made.MethodsThe revision consisted of three phases. First, the reliability of the measurement instruments included in the 2004 Clinical Algorithm was investigated by evaluating between-centre variations of the baseline assessment data. Second, based on the available evidence, a multidisciplinary expert advisory panel selected items needing revision and provided specific recommendations. Third, a guideline development group decided which revisions were finally included, also taking practical considerations into account.ResultsA total of nine items were revised: three because of new scientific insights and six because of the need for more objective measurement instruments. In all revised items, subjective assessment methods were replaced by more objective assessment tools (e.g. symptom-limited exercise instead of clinical judgement). In addition, four new key items were added: screening for anxiety/depression, stress, cardiovascular risk profile and alcohol consumption.ConclusionBased on previously determined shortcomings, the Clinical Algorithm for Cardiac Rehabilitation was thoroughly revised mainly by incorporating more objective assessment methods and by adding several new key areas.

A computer-based guideline implementation system for cardiac rehabilitation screening

The Netherlands heart foundation recently released a new cardiac rehabilitation guideline. Concurrent with its development, a decision support system (DSS) was built to assist professionals in implementing the guideline in practice. The DSS was evaluated during a 6-week pilot study in four cardiac rehabilitation centers. The number of patients enrolled in the DSS during the pilot study was 134. Adherence to the guidelines on a patient level was 83% for rehabilitation goals, and 68% for rehabilitation therapies. After the pilot study several new functionalities were added to the system while other DSS parts of the system were slightly changed based on user advice. Currently, a large-scale cluster randomized trial is conducted in 38 Dutch hospitals to rigorously assess the effect of the DSS on guideline adherence

Revision of the Dutch clinical algorithm for assessing patient needs in cardiac rehabilitation based on identified implementation problems

Background: Despite all available evidence of its effectiveness, cardiac rehabilitation and secondary prevention (CRSP) is still insufficiently implemented in current clinical practice. Based on an analysis of implementation problems, recently the Dutch clinical algorithm for the assessment of patient’s CRSP needs was revised. The purpose of this paper is to describe the revision process and its results to improve CRSP guideline implementation. Methods: The National Institute for Health and Clinical Excellence (NICE) guidelines manual for conducting guideline revisions was followed. Information on the use of the algorithm in practice was collected from electronic medical records and by conducting semi-structured interviews. Next, an expert advisory group identified the problems for use in daily practice and defined the scope for the revision. A multidisciplinary guideline development group subsequently wrote the revised algorithm. Results: A large variation in assessed patient needs was observed between CRSP clinics. Assessment based on clinical judgement was found to be a source of practice variation and is therefore avoided in the revised algorithm. It was decided to add assessment instruments for anxiety and depression, cardiovascular risk factors, stress, attitude of partner and lifestyle parameters. Conclusion: The Dutch clinical algorithm for assessing patient needs for CRSP was revised using a combination of patient data from routine practice, knowledge from academic experts and experience from field experts. The revised algorithm is a practical tool consisting of assessment instruments to improve CRSP guideline adherence in the Netherlands. This algorithm may also be useful for other Western countries to organize their CRSP needs assessment procedure.

CARDSS: development and evaluation of a guideline based decision support system for cardiac rehabilitation

Cardiac rehabilitation is a multidisciplinary therapy aimed at recovery and secondary prevention after hospitalization for cardiac incidents (such as myocardial infarctions) and cardiac interventions (such as heart surgery). To stimulate implementation of the national guidelines, an electronic patient record system with computerised decision support functionalities called CARDSS (cardiac rehabilitation decision support system) was developed, and made available to Dutch rehabilitation clinics. The system was quantitatively evaluated in a cluster randomised trial at 31 clinics, and qualitatively by interviewing 29 users of the system. Computerised decision support was found to improve guideline concordance by increasing professional knowledge of preferred practice, by reducing inertia to previous practice, and by reducing guideline complexity. It was not effective when organizational or procedural changes were required that users considered to be beyond their responsibilities.