The Treatment of cardiovascular Risk in Primary care using Electronic Decision suppOrt (TORPEDO) study: intervention development and protocol for a cluster randomised, controlled trial of an electronic decision support and quality improvement intervention in Australian primary healthcare Randomized trial of a computerized coronary heart disease risk assessment tool in HIV-infected patients receiving combination antiretroviral therapy. Improving cardiovascular risk management: a randomized, controlled trial on the effect of a decision support tool for patients and physicians Cluster-randomized, controlled trial of computer-based decision support for selecting long-term anti-thrombotic therapy after acute ischaemic stroke. Shared electronic vascular risk decision support in primary care: Computerization of Medical Practices for the Enhancement of Therapeutic Effectiveness (COMPETE III) randomized trial. Effectiveness of a tailored intervention to improve cardiovascular risk management in primary care: study protocol for a randomised controlled trial Cardiovascular Risk Assessment Based on US Cohort Studies: Findings From a National Heart, Lung, and Blood Institute Workshop Randomised evaluation of a specific training of general practitioners in cardiovascular prevention Effects of individual risk factors on the incidence of cardiovascular events in the treated hypertensive patients of the Hypertension Optimal Treatment Study. HOT Study Group. Information and Risk Modification Trial (INFORM): design of a randomised controlled trial of communicating different types of information about coronary heart disease risk, alongside lifestyle advice, to achieve change in health-related behaviour Multifactor cardiovascular disease risk reduction in medically underserved, high-risk patients. Absolute Cardiovascular Disease Risk and Shared Decision Making in Primary Care: A Randomized Controlled Trial An Economic Evaluation of Four Work Site Based Cardiovascular Risk Factor Interventions Predicting the 30-Year Risk of Cardiovascular Disease: The Framingham Heart Study Use of a computer decision support system and antimicrobial therapy appropriateness. Implementing clinical guidelines in the treatment of hypertension in general practice. Evaluation of patient outcome related to implementation of a computer-based clinical decision support system. Evaluation of computer based clinical decision support system and risk chart for management of hypertension in primary care: randomised controlled trial
Background Large gaps exist in the implementation of guideline recommendations for cardiovascular disease ( CVD ) risk management .  Electronic decision support ( EDS ) systems are promising interventions to close these gaps but few have undergone clinical trial evaluation in Australia . We have developed HealthTracker , a multifaceted EDS and quality improvement intervention to improve the management of CVD risk . Methods / design It is hypothesised that the use of HealthTracker over a 12-month period will result in : ( 1 ) an increased proportion of patients receiving guideline -indicated measurements of CVD risk factors and ( 2 ) an increased proportion of patients at high risk will receive guideline -indicated prescriptions for lowering their CVD risk . Sixty health services ( 40 general practice s and 20 Aboriginal Community Controlled Health Services ( ACCHSs ) will be r and omised in a 1:1 allocation to receive either the intervention package or continue with usual care , stratified by service type , size and participation in existing quality improvement initiatives . The intervention consists of point-of-care decision support ; a risk communication interface ; a clinical audit tool to assess performance on CVD-related indicators ; a quality improvement component comprising peer-ranked data feedback and support to develop strategies to improve performance .  The control arm will continue with usual care without access to these intervention components . Quantitative data will be derived from cross-sectional sample s at baseline and end of study via automated data extraction . Detailed process and economic evaluations will also be conducted . Ethics and dissemination The general practice component of the study is approved by the University of Sydney Human Research Ethics Committee ( HREC ) and the ACCHS component is approved by the Aboriginal Health and Medical Research Council HREC . Formal agreements with each of the participating sites have been signed . In addition to the usual scientific forums , results will be disseminated via newsletters , study websites , face-to-face feedback forums and workshops . Trial registration The trial is registered with the Australian Clinical Trials Registry ACTRN 12611000478910 BACKGROUND Exposure to combination antiretroviral therapy ( cART ) can lead to important metabolic changes and increased risk of coronary heart disease ( CHD ) . Computerized clinical decision support systems have been advocated to improve the management of patients at risk for CHD but it is unclear whether such systems reduce patients ' risk for CHD . METHODS We conducted a cluster trial within the Swiss HIV Cohort Study ( SHCS ) of HIV-infected patients , aged 18 years or older , not pregnant and receiving cART for > 3 months . We r and omized 165 physicians to either guidelines for CHD risk factor management alone or guidelines plus CHD risk profiles . Risk profiles included the Framingham risk score , CHD drug prescriptions and CHD events based on biannual assessment s , and were continuously up date d by the SHCS data centre and integrated into patient charts by study nurses . Outcome measures were total cholesterol , systolic and diastolic blood pressure and Framingham risk score . RESULTS A total of 3,266 patients ( 80 % of those eligible ) had a final assessment of the primary outcome at least 12 months after the start of the trial . Mean ( 95 % confidence interval ) patient differences where physicians received CHD risk profiles and guidelines , rather than guidelines alone , were total cholesterol -0.02 mmol/l ( -0.09 - 0.06 ) , systolic blood pressure -0.4 mmHg ( -1.6 - 0.8 ) , diastolic blood pressure -0.4 mmHg ( -1.5 - 0.7 ) and Framingham 10-year risk score -0.2 % ( -0.5 - 0.1 ) . CONCLUSIONS Systemic computerized routine provision of CHD risk profiles in addition to guidelines does not significantly improve risk factors for CHD in patients on cART Background There is nonoptimal adherence of general practitioners ( GPs ) and patients to cardiovascular risk reducing interventions . GPs find it difficult to assimilate multiple risk factors into an accurate assessment of cardiovascular risk . In addition , communicating cardiovascular risk to patients has proved to be difficult . Aims Improving primary prevention of cardiovascular disease ( CVD ) in primary care by enhancing patient involvement in the use of a decision support tool . Design Cluster r and omized trial . Methods Thirty-four GPs included patients ( 40 - 75 years old ) without CVD . In an interactive , small group training session lasting 4h , the GPs in the intervention group were trained to use the guidelines on cardiovascular risk and a decision support tool . The control group received educational material s about the guidelines on paper .  GPs ’ clinical performance and patients ’ risk perception and self-reported lifestyles were measured at baseline and after 6 months . Results Thirty-four GPs recorded 490 consultations , 276 in the intervention and 214 in the control group . After 6 months , no significant effect of the intervention on the GPs ’ performance or the patients ’ risk perception was found . There was only an effect on self-reported lifestyle , in that more men in the intervention group than in the control group increased their physical activity ( odds ratio 3.8 , 95 % confidence interval 1.7–8.7 ) . Conclusion The 4-h interactive , small group training did not guarantee correct application of the decision support tool and as such failed to improve GPs ’ performance or correct patients ’ risk perception . The positive effect on physical activity justifies further research on patient involvement . Eur J Cardiovasc Prev Rehabil 14 : 44 - 50 © 2007 The European Society of BACKGROUND Identifying the appropriate long-term anti-thrombotic therapy following acute ischaemic stroke is a challenging area in which computer-based decision support may provide assistance . AIM To evaluate the influence on prescribing practice of a computer-based decision support system ( CDSS ) that provided patient-specific estimates of the expected ischaemic and haemorrhagic vascular event rates under each potential anti-thrombotic therapy . DESIGN Cluster-r and omized controlled trial . METHODS We recruited patients who presented for a first investigation of ischaemic stroke or TIA symptoms , excluding those with a poor prognosis or major contraindication to anticoagulation . After observation of routine prescribing practice ( 6 months ) in each hospital , centres were r and omized for 6 months to either control ( routine practice observed ) or intervention ( practice observed while the CDSS provided patient-specific information ) . We compared , between control and intervention centres , the risk reduction ( estimated by the CDSS ) in ischaemic and haemorrhagic vascular events achieved by long-term anti-thrombotic therapy , and the proportions of subjects prescribed the optimal therapy identified by the CDSS . RESULTS Sixteen hospitals recruited 1952 subjects . When the CDSS provided information , the mean relative risk reduction attained by prescribing increased by 2.7 percentage units ( 95%CI -0.3 to 5.7 ) and the odds ratio for the optimal therapy being prescribed was 1.32 ( 0.83 to 1.80 ) . Some 55 % ( 5/9 ) of clinicians believed the CDSS had influenced their prescribing . CONCLUSIONS Cluster-r and omized trials provide excellent frameworks for evaluating novel clinical management methods . Our CDSS was feasible to implement and acceptable to clinicians , but did not substantially influence prescribing practice for anti-thrombotic drugs after acute ischaemic stroke BACKGROUND Computerized decision support systems ( CDSSs ) linked with electronic medical records ( EMRs ) are promoted as an effective means of improving patient care . However , very few high- quality studies are set in routine , community-based clinical care , and no consistent evidence of an effect on patient outcomes has been found . METHODS A r and omized controlled trial among EMR-using primary care practice s in Ontario , Canada . Patients 55 years or older with previous vascular events , diabetes mellitus , hypertension , or hypercholesterolemia were r and omized to the Computerization of Medical Practice s for the Enhancement of Therapeutic Effectiveness ( COMPETE III ) CDSS intervention or to usual care . The intervention included personally tailored electronic vascular risk monitoring and treatment advice shared between the physician and patient , risk calculation , and a clinical re source . The primary outcome was a composite score of 8 recommended process outcomes at 1 year . Data collectors were blinded to group allocation . Analysis used the intention-to-treat principle with multiple imputation for missing data . RESULTS We r and omized and included in the analysis 1102 patients in 49 community-based physician practice s ( 53.4 % female ; mean age , 69.1 years ; 28.0 % with a previous vascular event ) . The intervention group ( 545 [ 49.5 % ] ) had a significantly greater improvement in mean process composite , with a difference of 4.70 ( P < .001 ) on a 27-point scale . Intervention patients had significantly higher odds of rating their continuity of care ( 4.18 ; P < .001 ) and their ability to improve their vascular health ( 3.07 ; P < .001 ) as improved . Despite this improvement , the clinical outcomes -vascular events , clinical variables , and quality of life-were not improved . CONCLUSION Despite favorable review s and important improvements in the complex processes required to reduce vascular risk , clinical outcomes remain unchanged Abstract Background Cardiovascular disease ( CVD ) is an important worldwide cause of mortality . In The Netherl and s , CVD is the leading cause of death for women and the second cause of death for men . Recommendations for diagnosis and treatment of CVD are not well implemented in primary care . In this study , we aim to examine the effectiveness of a tailored implementation program targeted at practice nurses to improve healthcare for patients with ( high risk for ) CVD . Methods / design A two-arm cluster r and omized trial is planned . We offer practice nurses a tailored program to improve adherence to six specific recommendations related to blood pressure and cholesterol target values , risk profiling and lifestyle advice . Practice nurses are offered training and feedback on their motivational interviewing technique and an e-learning program on cardiovascular risk management ( CVRM ) . They are also advised to screen for the presence and severity of depressive symptoms in patients . We also advise practice nurses to use selected E-health options ( selected websites and Twitter-consult ) in patients without symptoms of depression . Patients with mild depressive symptoms are referred to a physical exercise group . We recommend referring patients with major depressive symptoms for assessment and treatment of depressive symptoms if appropriate before starting CVRM .  Data from 900 patients at high risk of CVD or with established CVD will be collected in 30 general practice s in several geographical areas in The Netherl and s. The primary outcome measure is performance of practice nurses in CVRM and reflects application of recommendations for personalized counselling and education of CVRM patients . Patients ’ health-related lifestyles ( physical exercise , diet and smoking status ) will be measured with vali date d question naires and medical record audit will be performed to document estimated CVD risk . Additionally , we will survey and interview participating healthcare professionals for exploration of processes of change . The control practice s will provide usual care . Discussion Tailored interventions can improve healthcare . An underst and ing of the methods to reach the improved healthcare can be improved . This research contributes a share of it . Identification of the determinants of practice and developing implementation interventions were two steps which were completed . The subsequent step was implementation of the tailored intervention program . Trial registration Name trial register : Nederl and s trial registerWeb address of trial register : http://www.trialregister.nl Data of registration : 11 July 2013Number of registration : This report was derived from a workshop on cardiovascular risk assessment sponsored by the National Heart , Lung , and Blood Institute , which addressed whether risk equations developed in the Framingham Heart Study ( FHS ) for predicting new-onset coronary heart disease ( CHD ) apply to diverse population groups . Preparation for the workshop included a re analysis and comparison of prospect i ve studies in several different population s in which risk factors were related to cardiovascular outcomes . Some studies included fatal and nonfatal CHD end points , whereas others contained only CHD mortality . Extensive collaboration provided as much uniformity as possible with respect to both risk factors and CHD end points . The FHS has led in defining the quantitative impact of risk factors.1 Many potential risk factors were measured and related to cardiovascular outcomes . Several risk factors proved to be strong , largely independent predictors of cardiovascular disease ( CVD ) . These factors — advancing age , cigarette smoking , blood pressure ( particularly systolic ) , cholesterol in total serum and HDL , and diabetes — served as the basis for the development of risk prediction equations.1 If FHS risk estimates are to be widely used , they must apply widely in the US population . To document their transportability , they must be compared with prospect i ve studies in other population s. Although the FHS is the longest running prospect i ve study , there are other major studies . The cardiovascular end points of these other studies have varied . Some include cardiovascular morbidity and mortality ; others have only cardiovascular mortality . Among the end points , CHD is the most extensively reported ; for this reason , CHD was the primary focus of the workshop . # # # Multivariate Relative Risk Comparisons In preparation for the workshop , multivariate regression coefficients for each risk factor were compared in different population s with those of the FHS . Adjusted relative risk estimates make it possible to determine whether each independent risk factor confers a similar or different relative risk among different Objective - A lack of global cardiovascular ( CV ) risk approach is often observed in the clinical practice . Having conceived a clinical strategy aim ed at helping general practitioners ( GPs ) to assess and manage global CV risk in the daily practice , we wanted to evaluate the impact of a training promoting this strategy . Methods - R and omised controlled trial involving GPs registered in a continual medical education ( CME ) group . The intervention and control arms included 7 ( 123 GPs ) and 13 ( 220 GPs ) groups , respectively . The intervention was a training in CV prevention provided during a CME meeting . GPs answered a question naire four months after the training . The main outcome was the use of a global CV risk assessment tool . Secondary outcomes were the GPs ’ awareness of the CV diseases burden , knowledge of the CV risk factors , and CV therapeutic attitudes . Results - More trained GPs ( 76 % vs. 52 % ) used a global CV risk assessment tool ( p??=??0.003 ) . Significant differences were also observed for secondary outcomes : ( a ) awareness of CV diseases burden : more trained GPs were aware of the lethality from myocardial infa rct ion ( 37 % vs. 21 % , p??=??0.047 ) and considered it as the main cause of sudden death in adults ( 78 % vs. 59 % , p??=??0.018 ) ; ( b ) knowledge of risk factors : more trained GPs considered familial CV history ( 89 % vs. 73 % , p??=??0.021 ) and HDL-cholesterol ( 82 % vs.62 % , p??=??0.013 ) as important CV risk factors ; ( c ) therapeutic attitudes : fewer trained GPs used to prescribe a lipid-lowering drug based on a total cholesterol value without considering the other risk factors ( 44 % vs.65 % , p??=??0.013 ) . Conclusions - The global CV risk approach in the general practice was favourably influenced by this training provided during a CME meeting . The impact of the training on patients ’ outcomes should be addressed in a prospect i ve trial BACKGROUND The Hypertension Optimal Treatment ( HOT ) Study has provided information about cardiovascular events in 18790 hypertensives , subjected to pronounced blood pressure ( BP ) lowering for a mean of 3.8 years . The HOT study data have subsequently been analysed after stratification of the patients according to global cardiovascular risk , and it has been found that , despite intensive blood pressure lowering in all risk strata , morbid event rates increased with increasing risk stratum . OBJECTIVES Previously analysed global risk strata were based on combinations of risk factors . The analyses presented here were intended to provide information on the relative role that the presence of each individual factor may have in increasing cardiovascular risk , despite good BP control . METHODS Risk ratios ( RR ) for patients with and those without a risk factor were calculated with 95 % confidence intervals ( CI ) using a Cox proportional hazard model , and adjusted for all variables except the one under examination . RESULTS For all risk factors considered and for all types of event , RR were always greater than 1 , indicating a greater risk in the presence , compared with that in the absence of each factor . The male gender was a statistically significant risk for cardiovascular ( CV ) events , CV and total mortality and particularly for myocardial infa rct ion ( MI ) ; age > or = 65 years for CV events , stroke , CV and particularly total mortality ; smoking for all events analysed , but particularly for total mortality ( twice higher in smokers than in non-smokers ) ; high serum cholesterol ( > 6.8 mmol/l ) for CV events , MI and CV mortality ; high serum creatinine ( > 155 micromol/l ) for CV events , stroke , CV and total mortality ; diabetes for CV events , stroke , total mortality and particularly CV mortality ; and ischaemic heart disease for all events analysed . Adjusted RR were often close to or greater than 2 . CONCLUSIONS Each of the risk factors considered was found to be an important cause of residual risk , despite good BP control . These findings emphasize the importance of addressing other correctable risk factors , e.g. smoking , hypercholesterolaemia and diabetes , as well as rigorous control of blood pressure , and of initiating antihypertensive therapy before cardiovascular and renal damage becomes manifest Background Cardiovascular disease ( CVD ) remains the leading cause of death globally . Primary prevention of CVD requires cost-effective strategies to identify individuals at high risk in order to help target preventive interventions . An integral part of this approach is the use of CVD risk scores . Limitations in previous studies have prevented reliable inference about the potential advantages and the potential harms of using CVD risk scores as part of preventive strategies . We aim to evaluate short-term effects of providing different types of information about coronary heart disease ( CHD ) risk , alongside lifestyle advice , on health-related behaviours . Methods / Design In a parallel-group , open r and omised trial , we are allocating 932 male and female blood donors with no previous history of CVD aged 40–84 years in Engl and to either no intervention ( control group ) or to one of three active intervention groups : i ) lifestyle advice only ; ii ) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic characteristics ; and iii ) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic and genetic characteristics . The primary outcome is change in objective ly measured physical activity . Secondary outcomes include : objective ly measured dietary behaviours ; cardiovascular risk factors ; current medication and healthcare usage ; perceived risk ; cognitive evaluation of provision of CHD risk scores ; and psychological outcomes . The follow-up assessment takes place 12 weeks after r and omisation . The experiences , attitudes and concerns of a subset of participants will be also studied using individual interviews and focus groups . Discussion The INFORM study has been design ed to provide robust findings about the short-term effects of providing different types of information on estimated 10-year CHD risk and lifestyle advice on health-related behaviours . Trial registration Current Controlled Trials IS RCT N17721237 . Registered 12 January 2015 Few data exist on the effectiveness of cardiovascular disease ( CVD ) risk-reduction programs in patients with limited access to health care . The objective of this project was to evaluate a disease management approach to multifactor CVD risk reduction in patients with limited or no health insurance and low family income . Patients ( n = 148 ) were recruited from not-for-profit or free clinics and hospitals and r and omized to usual care or usual care plus team case management . Mean age was 59.3 years , 57 % were women , 50 % had less than a high school education , 57 % were Hispanic , and 64 % had no health insurance . All had > or = 1 increased risk factor for CVD , and 24.5 % had documented coronary artery disease . Follow-up measurements were obtained at 6 and 12 months . Primary outcomes were low-density lipoprotein cholesterol and systolic blood pressure . The disease management program was supervised by a physician , delivered by nurses and dietitians , and included comprehensive lifestyle changes and medications . Data were collected on 91 % of patients at 12 months . Disease management produced clinical ly important decreases in selected risk factors compared with usual care , including systolic blood pressure ( p < 0.01 ) and low-density lipoprotein cholesterol ( p < 0.03 ) . More patients with disease management than those with usual care moved from " high " and " very-high " risk to lower risk categories for selected risk factors . In conclusion , the disease management program had excellent retention and lower CVD risk factors and demonstrated the potential of such approaches for decreasing long-term disease burden in selected medically underserved population PURPOSE We wanted to determine the effect of promoting the effective communication of absolute cardiovascular disease ( CVD ) risk and shared decision making through disseminating a simple decision aid for use in family practice consultations . METHODS The study was based on a pragmatic , cluster r and omized controlled trial ( phase III ) with  continuing medical education ( CME ) groups of family physicians  as the unit of r and omization . In the intervention arm , 44 physicians ( 7 CME groups ) consecutively recruited 550 patients in whom cholesterol levels were measured . Forty-seven physicians in the control arm ( 7 CME groups ) similarly included 582 patients . Four hundred sixty patients ( 83.6 % ) of the intervention arm and 466 patients ( 80.1 % ) of the control arm were seen at follow-up . Physicians attended 2 interactive CME sessions and received a booklet , a paper-based risk calculator , and individual summary sheets for each patient . Control physicians attended 1 CME-session on an alternative topic . Main outcome measures were patient satisfaction and participation after the index consultation , change in CVD risk status , and decisional regret at 6 months ’ follow-up . RESULTS Intervention patients were significantly more satisfied with process and result ( Patient Participation Scale , difference 0.80 , P<.001 ) . Decisional regret was significantly lower at follow-up ( difference 3.39 , P = .02 ) . CVD risk decreased in both groups without a significant difference between study arms . CONCLUSION A simple transactional decision aid based on calculating absolute individual CVD risk and promoting shared decision making in CVD prevention can be disseminated through CME groups and may lead to higher patient satisfaction and involvement and less decisional regret , without negatively affecting global CVD risk We used outcome data from a r and omized work site intervention trial to examine the cost-effectiveness of four cardiovascular disease ( CVD ) risk reduction programs : health risk assessment ( HRA ) , risk factor education ( RFE ) , behavioral counseling ( BC ) , and behavioral counseling plus incentives ( BCI ) . Composite CVD risk scores were derived from measures of serum total cholesterol , blood pressure , number of cigarettes smoked , body mass index , and aerobic capacity . The economic evaluation of the programs focused on the subset of costs most sensitive to the differences between the interventions , and a sensitivity analysis examined some of the relevant cost variations . At the 6-month follow-up ( i.e. , the " action " or initiation stage of lifestyle change ) , the RFE , BC , and BCI interventions produced a significant reduction in cardiovascular risk . Incremental analyses demonstrated RFE to be more cost-effective , but not as clinical ly effective as BC ; BC was more cost-effective than RFE when assessment costs were included , and BCI was judged to be the least cost-effective . At the 12-month follow-up ( i.e. , the " maintenance " stage of lifestyle of change ) , BC was the only program found to produce a significant reduction in CVD risk .  Individualized behavioral counseling was found to be a cost-effective strategy for the initiation and maintenance of CVD risk factor reduction Background — Present cardiovascular disease ( CVD ) risk prediction algorithms were developed for a ≤10-year follow up period . Clustering of risk factors at younger ages and increasing life expectancy suggest the need for longer-term risk prediction tools . Methods and Results — We prospect ively followed 4506 participants ( 2333 women ) of the Framingham Offspring cohort aged 20 to 59 years and free of CVD and cancer at baseline examination in 1971–1974 for the development of “ hard ” CVD events ( coronary death , myocardial infa rct ion , stroke ) . We used a modified Cox model that allows adjustment for competing risk of noncardiovascular death to construct a prediction algorithm for 30-year risk of hard CVD . Cross-vali date d survival C statistic and calibration & khgr;2 were used to assess model performance . The 30-year hard CVD event rates adjusted for the competing risk of death were 7.6 % for women and 18.3 % for men . St and ard risk factors ( male sex , systolic blood pressure , antihypertensive treatment , total and high-density lipoprotein cholesterol , smoking , and diabetes mellitus ) , measured at baseline , were significantly related to the incidence of hard CVD and remained significant when up date d regularly on follow-up . Body mass index was associated positively with 30-year risk of hard CVD only in models that did not up date risk factors . Model performance was excellent as indicated by cross-vali date d discrimination C=0.803 and calibration & khgr;2=4.25 ( P=0.894 ) . In contrast , 30-year risk predictions based on different applications of 10-year functions proved inadequate . Conclusions — St and ard risk factors remain strong predictors of hard CVD over extended follow-up . Thirty-year risk prediction functions offer additional risk burden information that complements that of 10-year functions OBJECTIVE To determine whether  antimicrobial ( AM ) courses ordered with an antimicrobial computer decision support system ( CDSS ) were more likely to be appropriate than courses ordered without the CDSS . DESIGN Retrospective cohort study . Blinded expert review ers judged whether AM courses were appropriate , considering drug selection , route , dose , and duration . SETTING A 279-bed university-affiliated Department of Veterans Affairs ( VA ) hospital . PATIENTS A 500-patient r and om sample of in patients who received a therapeutic AM course between October 2007 and September 2008 . Intervention . An optional CDSS , available at the point of order entry in the VA computerized patient record system . RESULTS CDSS courses were significantly more likely to be appropriate ( 111/254 , 44 % ) compared with non-CDSS courses ( 81/246 , 33 % , P = .013 ) . Courses were more likely to be appropriate when the initial provider diagnosis of the condition being treated was correct ( 168/273 , 62 % ) than when it was incorrect , uncertain , or a sign or symptom rather than a disease ( 24/227 , 11 % , P < .001 . In multivariable analysis , CDSS-ordered courses were more likely to be appropriate than non-CDSS-ordered courses ( odds ratio [ OR ] , 1.83 ; 95 % confidence interval [ CI ] , 1.13 - 2.98 ) . Courses were also more likely to be judged appropriate when the initial provider diagnosis of the condition being treated was correct than when it was incorrect , uncertain , or a sign or symptom rather than a disease ( OR , 3.56 ; 95 % CI , 1.4 - 9.0 ) . CONCLUSIONS Use of the CDSS was associated with more appropriate AM use . To achieve greater improvements , strategies are needed to improve provider diagnoses of syndromes that are infectious or possibly infectious OBJECTIVE To evaluate the implementation of clinical guidelines for hypertension in general practice by use of a computer-based clinical decision support system ( CDSS ) and a specific implementation strategy . Evaluation of patient outcome . DESIGN R and omised study with health centres as units . The intervention group had the CDSS installed and made ready for use , doctors and assistants were trained and received a user-manual , the doctors were offered telephone repetitions , a seminar in risk intervention and , at the same seminar , further demonstration of the CDSS . The doctors received baseline registration s with information of how they treated their own hypertensive patients , and use of the CDSS was checked repeatedly . SETTING General practice in Sør- and Nord-Trøndelag counties in Norway , 380,000 inhabitants . PARTICIPANTS Seventeen health centres with 24 doctors and 984 patients in the intervention group . Data from 879 patients used in the final analyses . Twelve health centres with 29 doctors and 1255 patients in the control group . Data from 1119 patients used in the final analyses . MAIN OUTCOME MEASURES After an intervention period of 18 months , group differences in level of systolic and diastolic blood pressure , serum cholesterol , body mass index , and risk score for myocardial infa rct ion were calculated , as well as group differences in fractions of smokers . RESULTS Significant group difference in favour of intervention group : diastolic blood pressure 1 mmHg ( 95 % CI -1.89 , -0.17 ) . However , a significant baseline difference in systolic blood pressure in favour of control group of 2.7 mmHg ( 95 % CI 1.0 , 4.5 ) had been reduced to 1.2 mmHg ( 95 % CI -0.6 , 3.0 ) after intervention . CONCLUSION Implementation of clinical guidelines in the treatment of hypertensive patients in general practice by means of a CDSS and several other procedures for implementation did not affect patient outcome in any clinical ly significant way Abstract Objectives : To investigate the effect of a computer based clinical decision support system and a risk chart on absolute cardiovascular risk , blood pressure , and prescribing of cardiovascular drugs in hypertensive patients . Design : Cluster r and omised controlled trial . Setting : 27 general practice s in Avon . Participants : 614 patients aged between 60 and 79 years with high blood pressure . Interventions : Patients were r and omised to computer based clinical decision support system plus cardiovascular risk chart ; cardiovascular risk chart alone ; or usual care . Main outcome measures : Percentage of patients in each group with a five year cardiovascular risk≥10 % , systolic blood pressure , diastolic blood pressure , prescribing of cardiovascular drugs . Results : Patients in the computer based clinical decision support system and chart only groups were no more likely to have cardiovascular risk reduced to below 10 % than patients receiving usual care . Patients in the computer based clinical decision support group were more likely to have a cardiovascular risk≥10 % than chart only patients , odds ratio 2.3 ( 95 % confidence interval 1.1 to 4.8 ) . The chart only group had significantly lower systolic blood pressure compared with the usual care group ( difference in means−4.6 mm Hg ( 95 % confidence interval−8.4 to−0.8 ) . Reduction of diastolic blood pressure did not differ between the three groups . The chart only group were twice as likely to be prescribed two classes of cardiovascular drugs and over three times as likely to be prescribed three or more classes of drugs compared with the other groups . Conclusions : The computer based clinical decision support system did not confer any benefit in absolute risk reduction or blood pressure control and requires further development and evaluation before use in clinical care can be recommended . Use of chart guidelines are associated with a potentially important reduction in systolic blood pressure
Among CVRM patients , the results tended towards a beneficial effect of CDSS , but only LDL-c target attainment in diabetes patients reached statistical significance .
Prompting , integration into the electronical health record , patient empowerment , and medication support were related to more effective CVRM .
Conclusion We did not find a clear clinical benefit from CDSS in cardiovascular risk factor levels and target attainment .
Some features of CDSS seem more promising than others .
Clinical relevance of CDSS in CVRM might additionally be sought in the improvement of shared decision making and patient empowerment
Background Cardiovascular risk management ( CVRM ) is notoriously difficult because of multi-morbidity and the different phenotypes and severities of cardiovascular disease .
Computerized decision support systems ( CDSS ) enable the clinician to integrate the latest scientific evidence and patient information into tailored strategies .
The effect on cardiovascular risk factor management is yet to be confirmed .