Background
Methods
CCDSS definition
Search strategy
Search terms used | |
---|---|
1.
|
exp Decision Support Systems, Clinical/
|
2.
|
clinical decision support systems.tw.
|
3.
|
clinical decision support tool*.tw.
|
4.
|
clinical decision support system*.tw.
|
5.
|
Decision Support Techniques/
|
6.
|
Medical Order Entry Systems/
|
7.
|
Decision Making, Computer-Assisted/
|
8.
|
Diagnosis, Computer-Assisted/
|
9.
|
clinical decision support aid*.tw.
|
10.
|
clinical decision support guideline*.tw.
|
11.
|
computer assisted therap$.tw.
|
12.
|
Therapy, Computer-Assisted/
|
13.
|
reminder system*.tw.
|
14.
|
Reminder Systems/
|
15.
|
computeri?ed clinical decision support.tw.
|
16.
|
CCDS.tw.
|
17.
|
medical informatic*.tw.
|
18.
|
Medical Informatics/
|
19.
|
1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18
|
20.
|
asthma.mp. or exp Asthma/
|
21.
|
exp Pulmonary Disease, Chronic Obstructive/
|
22.
|
chronic obstructive pulmonary disease.tw.
|
23.
|
COPD.tw.
|
24.
|
20 or 21 or 22 or 23
|
19 and 24
| |
25.
|
19 and 24
|
26.
|
limit 25 to (English language and humans)
|
27.
|
limit 26 to yr = ”2000 -Current”
|
Inclusion criteria
-
Empirical studies published in the English language between 2003 to May 2013;
-
Pediatric or adult CCDSS interventions involving COPD and/or asthma screening, prevention, case detection, and management;
-
Randomized controlled trials comparing CCDSS with explicitly defined clinical or process outcome measures;
-
CCDS system used by any clinicians (physicians, physician assistants, pharmacists, dentists, pulmonary specialists or nurse practitioners) directly involved in patient care;
-
CCDSS targeting patients in improving self-management.
Exclusion criteria
-
Review articles, conference proceedings, meeting abstracts;
-
Paper-based tools (e.g. flow charts and non-electronic clinical pathway tools);
-
CCDSS interventions in people with other conditions (rather than asthma and COPD), including other respiratory diseases;
-
CCDSS for medical education purposes or only providing summaries of information for patients;
-
Group based interventions that did not include individual clinical assessment;
-
Evaluations which focused only on the technical performance of the system as opposed to its effect on clinical practice;
-
In-patient hospital based systems.
Study selection
Data extraction and quality assessment
Citation, year, country | Population: no. of centers/providers/patients (Intervention, I or Control, C) | Study design, setting and duration | Intervention | Comparator | Outcome measures | Key findings and effect size | Comments |
---|---|---|---|---|---|---|---|
1. Carroll et al. [35] USA. | 1/-/2098 (children aged 3-11 years) (I = 1082, C = 1016) | RCT, Community based. Duration: 21 months | Parent survey on the presence of asthma symptoms linked sequentially to physician prompts. Physician prompts mediated by CDSS. | Parents received no screening questions, and physicians received no prompts. |
Primary outcome: Physicians’ diagnosis of childhood asthma based on prompts by the CDSS. | (+) effect. The number of children diagnosed with asthma in the intervention group was significantly more compared to the control group (8.6% vs. 5.8%, P <0.02). Effect size Cohen’s d = 0.24, 95% C.I = (0.04-0.43) | Not clear if physician training was provided. |
2. Hashimoto et al. [36] Netherlands | 6/-/95 (adults with adults diagnosed with severe asthma) (I = 51, C = 38) | Pragmatic Multicentre RCT, Academic and community setting Duration: 6 months | Internet-based management tool involving home monitoring of symptoms (using an electronic diary), treatment decision support for the patients, and monitoring support by a study nurse. | Conventional asthma treatment by pulmonologists |
Primary outcome: Cumulative sparing of oral corticosteroids, asthma control using Asthma control Questionnaire (ACQ), asthma-related quality of life (AQLQ), Secondary outcomes: FEV1 (using Piko-1 device), exacerbations, hospitalizations and satisfaction (Global satisfaction scale) | (+) effect. Median cumulative sparing of prednisone was 205 mg in the internet group compared with 0 mg in the conventional group. (P = 0.02) Asthma control, AQLQ, FEV1, exacerbations, hospitalizations and satisfaction with the strategy were not different between groups. Effect size for CCS sparing effect: Cohen’s d = 0.46. 95% C.I = (0.08- 0.93) | Patients were trained in using the electronic self -management support system, recording symptoms, measuring lung function and fraction of exhaled nitric oxide (FENO) |
3. Van der Meer et al. [37], Netherlands | 37 general practices and 1 academic outpatient department/69/200 (adults with asthma) (I = 101, C = 99) | Multi-centre, RCT, Community and Academic setting. Duration = 12 months | Internet-based asthma self-management program consisting of weekly asthma control monitoring and treatment advice, online support and group education delivered via remote web communications by a specialized asthma nurse | Usual physician-provided asthma care | Process outcomes: (asthma knowledge, inhaler technique and self-reported medication adherence), health care provider contacts for asthma, use of internet based asthma monitoring tool, and medication changes. Clinical outcomes: Primary: Asthma-related quality of life, (32-item Asthma Quality of Life Questionnaire). Secondary: Asthma control (ACQ), symptom-free days, pre-bronchodilator FEV1 (Piko-1), daily inhaled corticosteroid dose, and exacerbations | (+ but modest effect) Improvement in asthma knowledge, inhaler technique and slightly fewer physician visits in the internet group. Treatment changes occurred more often in the internet group. Modest improvement in asthma control and lung function with the Internet intervention, but no reduction in exacerbations. Improvement in asthma-related quality of life was slightly less than clinically significant. (P ≥ 0.5). Effect size for the primary clinical outcome (AQLQ increase by >0.5): Cohen’s d = 0.6. 95% C.I = (0.3-0.9) | Education and training provided to the participants. Non-blinded nature of the study may have affected the results |
4. Van der Meer et al. [38] Netherlands | 37/69/200 (adults with partly controlled or uncontrolled asthma) (I = 101, C = 99) | Prospective RCT, Community and academic. Duration: 1 year | Weekly internet based self-monitoring (using ACQ) and subsequent treatment adjustment (using an online management algorithm) | Usual care by the general practitioner according to the Dutch GP guidelines based on GINA guidelines |
Primary: Asthma control using (ACQ), spirometry and ATAQ (asthma therapy assessment questionnaire). | (+) effect. Significant improvements in ACQ score after 12 months in the internet based self-monitoring group. Daily inhaled corticosteroid dose significantly increased in the Internet group compared to usual care in the first 3 months in patients with uncontrolled asthma, but not in patients with well or partly controlled asthma. After one year there were no differences in daily inhaled corticosteroid use or long-acting β2-agonists between the Internet group and usual care. | Patients were trained to measure (FEV1) daily with a hand-held electronic spirometer (PiKo1). Supervision provided by a nurse specialist. So there is heavy initial investment. Study outcomes were self-reported by the patients which may overestimate effect. The effect size for change in asthma control is quite large, esp. in the uncontrolled group making the intervention promising. |
Secondary: Mean daily dose of inhaled corticosteroid (ICS), and the proportion of participant’s using long-acting β2-agonists (LABA) or leukotriene receptor antagonists (LTRA). |
Effect size primary outcome i.e. change in ACQ in partly controlled asthma group*: Cohen’s d = 0.81 95% C.I = (0.33- 1.35) | ||||||
Effect size for change in ACQ in uncontrolled asthma group*: Cohen’s d = 0.94. 95% C.I = (0.38-1.5). *Assuming t-test was performed. | |||||||
5. Taylor et al. [39] Australia. | 3/50/1 (simulated patient) (I = 27, C = 23 ED doctors) | RCT, Community setting, Duration: 4 months | An integrated and dynamic electronic decision support system for management of acute asthma in the emergency department (ED) by ED physicians. | Acute asthma management using paper -based clinical records, treatment order sheets and discharge documentation. | Work load & efficiency outcomes: Primary: Quality of asthma documentation–measured using 10 documentation variables (clinical parameters and discharge documentation). Secondary: consultation time | (+) effect. Significantly higher rates of documentation in 7 out of 10 variables, including provision of written short-term asthma management plans. No significant difference in consultation times. Effect size for documentation of asthma management plan provision: Cohen’s d = 0.78. 95% C.I = (0.18-1.37) | Relevant to the ED setting. A 2 minute introduction to the system, including basic functions of the program provided to physicians, which may not be enough. One simulated patient case may not reflect a spectrum of scenarios faced in the ED setting |
6. Fiks et al. [40] USA. | 20/-/11919 (children with asthma between 5-19 years of age) (I = 6110, C = 5809) | Cluster-RCT, Academic. Duration: 5 months. | Electronic health record (EHR) based influenza vaccine clinical alerts | Routine care | Health care process outcomes- rates of captured opportunities for influenza vaccination (visit-level analysis) and up-to-date influenza vaccination status among patients with asthma | (+) but modest effect. Standardized influenza vaccination rates improved 3.4% more at intervention sites than at control sites. Effect was not significant, Cohen’s d not calculated) | Primary care sites were linked to a teaching hospital. Information on the comparator was unclear-implied usual practice. Training provided to the physicians was quite thorough. |
7. Bell et al. [41] USA. | 12/-/19450 (children) (I = 6, C = 6) Children with persistent asthma identified by using the pediatric asthma control test (PACT)) | RCT, Academic setting. Duration: 1 year | CDSS embedded in an electronic health record (EHR), where it provides support in the management of children with asthma in accordance with the (National Asthma Education Prevention Program guidelines (NAEPP). | Passive asthma management tools available in the electronic health record (EHR). | Health care process outcomes: Proportion of children with at least 1 prescription for controller medication, an up-to-date asthma care plan, and documentation of performed office-based spirometry. | (+) effect. Significant improvement in adherence to NAEPP guidelines. 6% increase in the number of prescriptions for controller medications, (P = 0.006) and 3% increase for spirometry (P = 0.04) in the intervention urban practices. Filing an up-to date asthma care plan improved 14% (P = 0.03) and spirometry improved 6% (P = 0.003) in the suburban practices with the intervention. The effect size could not be calculated, as data provided was insufficient to calculate d values). | Medical practices within the Children’s Hospital of Philadelphia (CHOP) Pediatric Research Consortium-may not be generalizable. Physicians were trained to use the CDSS. The actual number of providers involved in the study is unclear. |
8. Rasmussen et al. [42] Denmark. | -/-/300 (adults with asthma) | Multi-centre RCT with three parallel groups. Community setting Duration: 6 months | Physician-managed online interactive asthma monitoring tool which comprised of (1) an electronic diary, (2) an action plan for the patients and (3) a decision support system for the physician. Patients with persistent asthma received advice on treatment based on their asthma control. | Two other usual care groups: specialist group, where treatment was provided by an asthma specialist in an outpatient clinic; and a general practitioner (GP) group, where treatment was provided by GPs in primary care. |
Clinical outcomes Asthma symptoms: electronic diary. Asthma quality of life: AQLQ) questionnaire. Lung function: Spirometry Airway responsiveness: Methacholine challenge test. | (+) effect. Significant improvement in the Internet group compared to the other 2 groups regarding asthma symptoms, quality of life, lung function, airway responsiveness. Significant improvement in the use of inhaled corticosteroids in the internet and specialist group. Effect size comparing the Internet vs. Specialist group for asthma symptom reduction was Cohen’s d =0.53. 95% C.I = (0.19-0.87). Cohen’s d comparing the Internet vs. GP group for asthma symptom reduction was 0.64. 95% C.I = (0.29-0.99). | The number of practitioners and the number of centers participating were unclear. No training provided to the participants or the GP’s but the laboratory assistants providing spirometry and methacholine test were trained in the required protocol |
9. Dexheimer et al. [43] USA. | 1/-/704 (Children 2-18 years of age), (I = 358, C = 346) | RCT, Community setting, Duration: 3 months | A fully computerized asthma detection system which printed a paper-based asthma care protocol in the pediatric ED to guide early asthma treatment and reduce time to disposition decision. | Usual care, i.e., no reminders or automatic printout was provided. |
Primary outcome: Time from ED triage to disposition (discharge or hospital admission) decision. | No effect. No difference in time to disposition. Length of ED stay and the rate of hospital admission were similar between the two groups. (Effect was not significant, Cohen’s d not calculated) | The number of physicians, respiratory therapists and nurses involved in the study is unclear. |
Secondary outcomes: Guideline adherence measures including asthma education ordered, protocol found on chart, any asthma scoring performed. | |||||||
10. Smith et al. [44] UK. | 29/-/911 (patients 5+ years of age with severe asthma) (I = 457, C = 454) | Cluster RCT, Community setting. Duration: 2.5 years | Addition of electronic alerts to computerized records to identify at-risk asthma patients experiencing an exacerbation and modify their care. | Control practices continued usual care. |
Primary outcome: number of patients experiencing a moderate-severe exacerbation | No significant difference between groups in number of people experiencing exacerbations. Relative reductions in people experiencing hospitalizations, accident and emergency, out-of hours contacts and increase in prednisolone prescriptions for exacerbations without increasing costs. (Effect was not significant, Cohen’s d not calculated) | Training on using electronic alerts provided to at least one representative from each staff group (GP, nurse, receptionist, manager/administrator, dispenser) of the intervention practices. |
Secondary outcome: outpatient attendances for asthma, primary care contacts, ‘did not attends’ (DNAs) at consultations, asthma medications and cost analyses | |||||||
11. Kattan et al. [45] USA. | -/435/937 (5-11year old with moderate to severe asthma) (I = 471, C = 468) | RCT, Community setting. Duration: 1 year | Computer generated letters based on information collected from the child’s carer through bi-monthly telephone calls conducted by the centralized service for all the study sites. The letter to the physician caring for that child summarized the child’s asthma symptoms, health service use, and medication use with a corresponding recommendation to step up or step down medications in accordance with the NAEPP guidelines. | No letters sent to the providers of the children in the control group | Health care process outcomes: scheduled visits and changes in medications. Patient outcomes: maximum number of symptom days, ED visits and hospitalizations for asthma, and school days missed because of asthma. | (+) effect Significant increase in scheduled visits, (17.1% vs12.3%, P = 0.005). Significant increase in medication step up (46% vs 35.6%, P = 0.03). Significantly fewer ED visits in the intervention group compared with controls (0.87 vs 1.14 per year, p = 0.013). No difference in the maximum number of symptom days and number of school days missed. Effect size for % of scheduled visits resulting in step-up of medication: Cohen’s d = 0.23. 95% C.I = (0.02-0.43) | Intervention practitioners were trained. Effect size was low for medication change related outcomes. Key issues also included the design where not all children whose medication change was warranted visited the physician. |
12. Tierney et al. [46] USA. | 4/266/706 (246 physicians and 20 outpatient pharmacists) | RCT, Academic setting, Duration: 3 years | Computerized care suggestions to improve asthma and COPD management. These focused on: (1) pulmonary function tests, (2) influenza and pneumococcal vaccinations, (3) prescribing inhaled steroid preparations in patients with frequent symptoms of dyspnea, (4) prescribing inhaled anticholinergic agents in patients with COPD, (5) escalating doses of inhaled β-agonists for all patients with persistent symptoms, (6) prescribing theophylline for patients with COPD and continued symptoms despite aggressive use of inhaled anticholinergic agents, b-agonists, and steroids, and (7) encouraging smoking cessation. | Four groups: physician intervention only, pharmacist intervention only, both pharmacist and physician interventions, and no intervention (controls). |
Primary: Adherence to guideline based care suggestions. | No effect. No differences between groups in adherence to the care suggestions, quality of life, patients satisfaction with physicians’ or pharmacists, medication compliance, emergency department visits, or hospitalizations. Physicians receiving the intervention had significantly higher total health care costs. Physician attitudes toward guidelines were mixed. (Effect was not significant, Cohen’s d not calculated) | Hospital based academic practices. Providers included internal medicine physicians, residents and pharmacists. Training was provided to the providers. Questionnaires were administered via telephone. |
Secondary: Quality of life-McMaster Chronic Respiratory Disease Questionnaire (CRQ) for COPD patients or the McMaster Asthma Quality-of-Life. Questionnaire (AQLQ). Patient satisfaction: American Board of Internal Medicine’s patient satisfaction questionnaire. Medication adherence: Inui and Morisky surveys and pharmacy dispensing records | |||||||
13. Martens et al. [47] Netherlands. | -/53/- | Clustered RCT, Community setting Duration: 1 year | A decision support system with reactive computer reminders (CRS) to improve drug prescribing behaviors. 25 GPs received reminders on antibiotics and asthma/COPD prescriptions. | 28 GPs received reactive computer reminders (CRS) to improve prescribing of cholesterol-lowering drugs |
Primary outcome: prescription according to the guidelines as a percentage of total prescriptions of a certain drug. Secondary outcome: user friendliness. | (+) but not significant effect. CRS with reactive reminders improved drug prescribing behavior. Preliminary results also indicate reduction in the number of prescriptions according to the advice of the computerized guidelines not to present certain drugs. It was perceived stable and user friendly. (Effect was not significant, Cohen’s d not calculated) | Preliminary study. Both groups served as control to one another. Not specific to asthma/COPD. |
14. Martens et al. [48] Netherlands. Follow-up of the above study | 14/53/- | Clustered RCT, Community setting. Duration: 1 year | CRS focused on drug-prescribing behavior of GPs. 25 GPs received reminders on antibiotics and asthma/COPD prescriptions | 28 GPs received CRS reminders on cholesterol prescriptions | Guideline appropriate prescriptions as a percentage of total prescriptions (of the drug category involved) for the same diagnosis on the individual GP level. Absolute number of prescriptions for a specific diagnosis per GP per 1000 enlisted patients. | No effect. No favorable effects were found for CRS with the message to prescribe certain drugs. On the other hand, CRS with the message not to prescribe certain drugs sometimes positively influenced the prescribing behavior of GPs. (Effect was not significant, Cohen’s d not calculated) | Not specific to asthma/COPD. Both groups served as a control group to one another. Authors report the study to be underpowered due to high inter doctor variation in prescribing behavior (Cluster effect). Training was provided. |
15. Martens et al. [49] Netherlands. Follow-up of the above study. | 20/48/- | Clustered RCT, Community setting. Duration: 1 year | 25 GPs received reactive computer reminders on antibiotics and asthma/COPD prescriptions | 28 GPs received (reactive) reminders on cholesterol prescriptions | Number of GPs (competent and willing) with CRS still functioning after 1 year. Number of GPs having technical problems or are unwilling. Number of reminders/GP/month/1000 enlisted patients. GP user satisfaction (satisfaction questionnaire). GP experience (content and extensiveness of CRS). Barriers and facilitators to implementation and use of CRS | (+) learning effect from the CRS. 9% of GPs dropped out after 1 year. A significant learning curve was found (P = 0.03) for the reminders on antibiotics, asthma and COPD. GPs were satisfied with the user-friendliness and the content of the different types of reminders, but less satisfied with certain specific technical performance issues of the system. Cohen’s d = N/A (Effect size not calculable due to insufficient data provided in report) | Not specific to asthma/COPD. Both groups served as a control to one another. GP’s were trained. |
16. Kuilboer et al. [50] Netherlands. | 32/40/156,772 (study patients (children and adults) either had chronic bronchitis, emphysema, other chronic pulmonary diseases, asthma or COPD) (I = 20, C = 20 General practitioners) | RCT, Community and academic Duration: 10 months | Asthma Critic used for monitoring and treatment of patients with asthma and COPD by Dutch general practitioners in daily practice. The asthma critic was a computer software support program that presented a patient specific comment to the physician based on the current clinical situation. | Usual care | Average number of contacts, FEV1 (force expiratory volume) and peak flow measurements per asthma/COPD patient per practice, and the average number of antihistamine, cromogylate, deptropine, and oral bronchodilator prescriptions per asthma/COPD patient per practice. | (+) effect. Statistically significant increase in contact frequency with the patient (P = 0.034), peak flow measurement, FEV1 measurements in 12-39 years age group (P = 0.02). Significant decrease in cromogylate prescriptions in the age group of 12-39 years, (P = 0.03). Non-significant decrease in deptropine, antihistamines, oral bronchodilators. (Effect size not calculable due to insufficient data provided in report). | The study focused on change in physicians’ behavior. Training was provided to the general practitioners. |
17. Poels et al. [51] Netherlands | 1 medical centre, several private practices/78/774 paper case descriptions. (10 case descriptions per GP). | Simulated cluster- RCT Community. Duration = 10 months | Expert support system for the interpretation of spirometry tests to help GPs’ in the diagnosis of chronic respiratory diseases. The expert system provided interpretation in the form of flow volume curve, graphical interpretation and textual interpretative notes of spirometry results to intervention GPs. | GPs in the control group simply received the spirometry test results, and the flow–volume and volume–time curves. |
Primary: Difference between the percentage agreement of the cases’ diagnoses between GPs and expert panel judgment before and after interpretation of spirometry | No Effect. There were no differences between the computerized expert support and control groups in the agreement between GPs and expert panel on diagnosis of COPD, asthma and absence of respiratory disease. A higher rate of additional diagnostic tests was observed in the expert support group. (Effect was not significant, Cohen’s d not calculated) | This was a simulated study- no real patients involved. Training was provided. |
Secondary: Impact of the expert system intervention on the GPs decision-making processes through six measures: additional diagnostic test rates; width of differential diagnosis; certainty of diagnosis; estimated severity of disease; referral rate; and medication or non-medication changes. | |||||||
18. Poels et al. [52] The Netherlands | 44/-/2098 (I = 15. C = 15. Chest physician = 14) | Cluster-RCT Duration: not mentioned. | Two interventions: GPs received spirometry interpretation support by either a chest physician (who had standard spirometry software) or expert spirometry support software. | Usual care had standard spirometry software (i.e. no additional interpretation support). |
Primary: A change of diagnosis after spirometry interpretation support. Secondary: referral rate, additional diagnostic tests, and disease management changes. | No effect. Differences in proportion of changed diagnoses were not statistically significant. There were no differences in secondary outcomes. (Effect was not significant, Cohen’s d not calculated) | Training was provided. |
19. Frickton et al. [53], USA. | 15/102/59,147. (Patients with medically complex conditions like xerostomia, diabetes mellitus, COPD, congestive heart failure). | RCT with three arms (provider activation, patient activation and control group), Community setting. Duration = 2 years | Two CDS approaches. In one group, dentists and hygienists received alerts in the EDRs (electronic dental records) when patients scheduled for dental appointments had one of the targeted medical conditions. In second group, in addition to the above, patients with upcoming dental appointments who had one of the targeted medical conditions received a notification from HPDG (health partners dental group) before the visit, encouraging them to discuss it with his or her dental care provider at the appointment. | Patients in the control group received usual care. Neither the patients nor the provider’s, received alerts about a patient’s medical status or personalized care guidelines. |
Primary: Total use-the overall frequency with which providers accessed the guidelines web site via the EDR for any patient. Targeted use—the proportion of providers who accessed the care guidelines in general and for targeted patients at the point of care. Ongoing use—the proportion of providers who continued to access the web-based guidelines through-out the study period. | (+) effect. Participants in the provider and patient activation groups increased their use of the system during the first six months. Provider activation was more effective than was patient activation. (P < 0.05). However, it was not sustainable, and by the end of the study, the rate of use had returned to baseline levels despite participants’ continued receipt of electronic alerts. (Effect expressed as Odds Ratio for web use for provider group in first six months = 4.4 (95% C.I = 1.6-12.1) and 6-12 months after implementation compared to controls = 1.7 (95% C.I = 0.1-2.9). For provider + patient activation group, effect expressed as Odds Ratio for web use in first six months =2.1 (95% CI, 0-9-4.8) and 6-12 months after implementation compared to controls = 1.4 (95% CI 0.5-3.5). | Dental clinic based. Study was not specific to asthma/COPD patients. |
Citation | Random sequence generation | Allocation concealment | Blinding of participants | Blinding of personnel | Blinding of outcome assessment | Incomplete outcome data | Selective reporting | Funding bias | Overall bias |
---|---|---|---|---|---|---|---|---|---|
1. Carroll et al. [35] | Low | Unclear | High | High | High | Low | Low | Low | High |
2. Hashimoto et al. [36] | Low | Low | Unclear | Unclear | Low | Low | Low | Low | Low |
3. Van der Meer et al. [37] | Low | Low | High | High | High | Low | Low | Low | Low |
4. Van der Meer et al. [38] | Low | Low | High | High | High | Low | Low | Low | Low |
5. Taylor et al. [39] | Unclear | Low | Low | Unclear | Low | Low | Low | Low | Low |
6. Fiks et al. [40] | Low | Unclear | High | High | High | Low | Low | Low | High |
7. Bell et al. [41] | Low | Unclear | High | High | High | Low | Low | Low | Moderate |
8. Rassmusen et al. [42] | Low | High | High | High | High | High | High | High | High |
9. Dexheimer et al. [43] | Unclear | High | High | Low | Unclear | Low | Low | Low | Moderate |
10. Smith et al. [44] | Low | Low | Low | Low | Low | Low | Low | Low | Low |
11. Kattan et al. [45] | Low | Low | High | High | Unclear | Low | Low | Low | Low |
12. Tierney et al. [46] | Low | Low | Unclear | Low | High | High | Low | Low | Low |
13. Martens et al. [47] | Low | High | Low | Unclear | Unclear | High | High | High | High |
14. Martens et al. [48] | Low | High | Low | Unclear | Low | Low | Low | High | Unclear |
15. Martens et al. [49] | Low | High | Low | High | Unclear | Low | Low | High | High |
16. Kuilboer et al. [50] | Low | Low | Unclear | Low | Low | Low | Low | Unclear | Low |
17. Poels et al. [51] | Low | Unclear | Low | Low | Low | Low | Low | Low | Low |
18. Poels et al. [52] | Low | Unclear | High | Low | Low | Low | Low | Low | Low |
19. Frickton et al. [53] | Low | Low | Low | High | Low | Low | Low | Low | Low |
Assessment of intervention effects
Type of CCDSS intervention provided
Citation | CCDSS setting and format | CCDSS user | Type of CCDSS | Effect of CCDSS | |||
---|---|---|---|---|---|---|---|
Diagnostic/Drug therapy management only/Multifaceted CCDSS | Health care process outcomes (recommended preventative care, clinical study ordered, treatment ordered) | Clinical outcomes (morbidity, mortality, HRQOL, hospitalization, adverse events) | User workload and Efficiency outcomes (user knowledge, clinician workload, efficiency) | Relationship centered outcomes (patient satisfaction)/Economic outcomes (cost and cost effectiveness)/Use and implementation (health care provider acceptance, satisfaction, use and implementation) | |||
1. Caroll et al. [35], USA. | Community/Integrated with the EMR | Practitioners |
Diagnostic CCDSS: Clinician prompted to make an asthma diagnosis based on the results of a pre-screening questionnaire |
Primary outcome: Significantly more children diagnosed with asthma (+ effect) | |||
2. Hashimoto et al. [36], Netherlands. | Hospital/Stand alone (Internet based) | Patients |
Drug therapy management based CCDSS: Corticosteroid treatment decision support for the patients based on symptoms, lung function and exhaled NO (nitric oxide) |
Primary outcome: Significant decrease in corticosteroid consumption in patients with steroid dependent asthma (+ effect) | No difference in asthma control, quality of life, FEV1, exacerbations, hospitalizations between groups. (+ effect) | No difference in patient satisfaction between groups | |
3. Van der Meer et al. [37], Netherlands. | Community/Stand-alone (Internet based) | Patients |
Multifaceted CCDSS: Weekly asthma monitoring and advice, online and group education and remote web communications | Patients’ asthma knowledge, inhaler technique improved. Medication changes occurred more often. Health care provider contacts were fewer. (+ but modest effect) |
Primary outcome: Asthma related quality of life improved. Secondary: Asthma control, lung function improved, symptom-free days increased, exacerbations did not differ between groups. (+ but modest effect) | ||
4. Van der Meer et al. [38], Netherlands. | Community/Stand-alone (Internet based) | Patients |
Multifaceted CCDSS: Weekly asthma monitoring and self-management advice. |
Secondary: Significant increase in the corticosteroid dose in patients with uncontrolled asthma, but not in patients with well or partly controlled asthma. (+ effect). Adherence to ACQ monitoring gradually declined in the first month to the seventh month and then remained stable. No difference in dose of corticosteroids or LABA or LRTA after 12 months |
Primary outcome: Significant improvement in asthma control in patients with partly and uncontrolled asthma. (+ effect) | ||
5. Taylor et al. [39], Australia. | Hospital/Integrated | Practitioners (ED doctors) |
Multifaceted CDSS: The system integrated asthma management pathways based on current guidelines into clinical and discharge documentation. Including triage and registration, clinical documentation, treatment orders, order entry and discharge documentation. |
Primary outcome: Significantly higher rate of asthma documentation. Secondary outcome: No significant difference in consultation time. (+ effect) | |||
6. Fiks et al. [40], USA. | Hospital/Integrated into EHR | Practitioners |
Multifaceted CCDSS: EHR based clinical alerts for influenza vaccine |
Primary outcome: Increased Influenza vaccination rates. (+ effect, but not significant) | |||
7. Bell et al. [41], USA. | Hospital/Integrated into EHR | Practitioners |
Multifaceted CCDSS: EHR based CDS alerts and reminders based on pediatric asthma management tool (PACT) which captured asthma symptom frequency, asthma severity, facilitated ordering of controller medications, spirometry and ACP (asthma action plan) |
Primary outcome: Increase in the number of controller medication prescriptions, and up-to-date asthma action plan (ACP). (+ effect, but not significant). Increase in the use of spirometry in the intervention group (+ effect, but not significant) | |||
8. Rasmussen et al. [42], Denmark | Stand-alone (internet based) | Patients |
Multifaceted CCDSS: Internet based asthma monitoring tool consisting of an asthma diary, action plan and a decision support for the physician | Significantly more patients using inhaled corticosteroids in the internet and specialist group (+ effect) |
Primary outcome: Significant improvement in asthma symptoms, AQLQ, lung function, but no change in airway responsiveness (+ effect) | ||
9. Dexheimer et al. [43], USA. | Hospital/Integrated | Practitioners (ED physician) |
Multifaceted CCDSS: Computerized detection system screened and identified patients with asthma exacerbation and a guideline based management protocol |
Secondary outcome: No difference in asthma education charted, medication prescribed, follow-up appointment scheduled (No effect) | No difference in admission rate or ED length of stay (no effect) |
Primary outcome: No significant difference in the time taken to make a ED disposition decision (no effect) | |
10. Smith et al. [44], UK. | Community/Integrated (with the EHR) | Practitioners |
Multifaceted CCDSS: EHR based alerts to flag the at-risk status of patients to improve patient access and opportunistic management | Relative increase in LABA usage and decrease in nebulized B-agonists (+ effect) |
Primary outcome: No significant difference in the number of people experiencing exacerbations. Relative reduction in people experiencing hospitalizations, accident and emergency attendances, out-of-hour contacts and other health care use. (+ effect, but not significant) | Cost –effectiveness outcome: Adjusted mean health care (NHS) cost lower among intervention practices compared to control practices (+ effect) | |
11. Kattan et al. [45], USA. | Community/Stand-alone | Practitioners |
Drug therapy management based CCDSS: Computer generated letter recommending change in controller medications based on NAEPP guidelines |
Primary outcome: Significant increase in scheduled visits leading to stepping up of asthma medications (+ effect) | Significant decrease in ED visits. No difference in maximum number of symptom days and school days missed, decrease in the number of days with activity limitation. | Intervention-reduced asthma related cost to the health services and was cost-effective. (+ effect) | |
12. Tierney et al. [46], USA. | Hospital/Integrated | Practitioners (Physicians and pharmacists) |
Multifaceted CCDSS: Care suggestions focusing on immunization, prescription and smoking advice |
Primary outcome: No difference in the adherence to guideline-based care suggestions measured as the number of tests and treatment ordered (No effect) | No effect on quality of life, clinical symptoms, medication adherence and compliance, ED visits or hospitalizations (No effect) | Significantly higher health care costs in the group receiving only physician intervention. Physicians attitude towards guidelines was mixed | |
13. Martens et al. [47], Netherlands. | Community/Integrated | Practitioners (GPs) |
Drug therapy management based CCDSS: Guideline based reminders when prescribing antibiotics, asthma/COPD and cholesterol prescriptions |
Primary outcome: Reductions in the number of prescriptions according to the guidelines (+ effect, but not significant) | Providers perceived the CRS as stable and user friendly (+ effect, but not significant) | ||
14. Martens et al. [48], Netherlands. | Community/Integrated | Practitioners (GPs) |
Drug therapy management based CCDSS: Guideline based reminders when prescribing antibiotics, asthma/COPD and cholesterol prescriptions |
Primary outcome: Clinically meaningful results seen in not prescribing certain drugs in the intervention group (+ effect, but not significant) | |||
15. Martens et al. [49], Netherlands. | Community/Integrated | Practitioners (GPs) |
Drug therapy management based CCDSS: Guideline based reminders when prescribing antibiotics, asthma/COPD and cholesterol prescriptions | Significant learning curve was found (shows improvement in user knowledge) (+ effect) |
Primary outcome: Provider use: Only 9% drop-out rate (because of technical problems requiring multiple updates) (+but not significant effect) Provider satisfaction: Positive attitude to the content of the reminders and satisfied with the user friendliness | ||
16. Kuilboer et al. [50], Netherlands. | Community/Integrated | Practitioners (General practitioners) |
Multifaceted CCDSS: Asthma critic evaluates whether the patient has asthma or COPD, reviews the physicians treatment, and generates feedback |
Primary outcome: Significant increase in the average number of contacts. Significant decrease in the average number of cromogylate prescriptions. No statistically significant change in the antihistamines, deptropine, and oral bronchodilator prescriptions per asthma/COPD patient per practice (+ effect) | Significant increase in FEV1 (forced expiratory volume), and peak-flow measurements per asthma/COPD patient per practice (+ effect) | ||
17. Poels et al. [51], Netherlands. | Community/Stand-alone (spirometry expert system) | Practitioners (GPs) |
Multifaceted CCDSS: Presentation of data for diagnosis and management of chronic airway disease |
Primary outcome: No difference in between the two groups (Spirometry expert system and sham information) in the diagnosis of COPD, asthma and absence of respiratory disease or in medication changes. Secondary: Slightly more additional diagnostic tests in the expert group (No effect) | |||
18. Poels et al. [52], Netherlands. | Community/Integrated? (not clear) | Practitioners (GPs) |
Multifaceted CCDSS: Spirometry expert support for change in diagnosis and management |
Primary outcome: No differences in the proportion of changed diagnosis between the three groups (spirometry expert system, chest physician and usual care). Also no difference between the groups in referral rate, additional diagnostic tests and medication changes (No effect) | |||
19. Frickton et al. [53], USA. | Community/Integrated (with the EDR) | Practitioners (Dentists) and patients |
Multifaceted CCDSS: EDR (Electronic dental record) based alerts notifying the dentists of the presence of a medically complex condition in a patient with a link to modify dental care appropriately |
Primary outcome: Significant increase in the frequency of dentists accessing guidelines (number of website hits and number of providers using the guideline). Only number of hits sustained after 6 months. After 9 months provider use returned to baseline levels (+ effect) |