Evaluation of computer based clinical decision support system and risk chart for management of hypertension in primary care: randomised controlled trial Randomised controlled trial of computer-held medical records in hypertensive patients. Improving Hypertension Control: Impact of Computer Feedback and Physician Education Impact of Computerized Decision Support on Blood Pressure Management and Control: A Randomized Controlled Trial Patient informatics: using a computerized system to monitor patient compliance in the treatment of hypertension. Medical Information Systems: Assessing Impact in the Areas of Hypertension, Obesity and Renal Disease Mobile phone-based remote patient monitoring system for management of hypertension in diabetic patients. 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. Failure of computerized treatment suggestions to improve health outcomes of outpatients with uncomplicated hypertension: results of a randomized controlled trial. Using electronic patient records to inform strategic decision making in primary care The Impact of a Multidisciplinary Information Technology–Supported Program on Blood Pressure Control in Primary Care ‘Decision support system (DSS) for prevention of cardiovascular disease (CVD) among hypertensive (HTN) patients in Andhra Pradesh, India’ – a cluster randomised community intervention trial Electronic communications and home blood pressure monitoring (e-BP) study: design, delivery, and evaluation framework. Treatment of hypertension by computer and physician-a prospective controlled study. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: Methods of a decision-maker-researcher partnership systematic review Hypertension Intervention Nurse Telemedicine Study (HINTS): testing a multifactorial tailored behavioral/educational and a medication management intervention for blood pressure control. Hypertension telemanagement in blacks.
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 A total of 278 hypertensive patients in three clinics were r and omly allocated to have their medical records held in a computer system ( 136 ) or on st and ard hospital notes ( 142 ) . For the computer system the doctor completed a structured input form , and the information on symptoms , physical findings , and diagnoses was more complete than that in the st and ard notes . This result ed in certain symptoms and risk factors being recognised more often when the computer system was used . The hypertension clinics ' routines were not disrupted by the introduction of a computer-held system , and follow-up consultation times were not affected by the type of records kept , although the first consultation took eight minutes longer when computer documents were completed . The patients remained in the trial for one year and clinical management was assessed from blood pressure control , drop-out rates , and the frequency of performing investigations . These estimates of management showed no significant difference between the two groups , but the attempt to tailor the computer system to help management made the system acceptable to the doctors using it . The computer system continues to be used and is providing data for research into hypertension Two interventions design ed to help physicians manage hypertensive patients were evaluated in a controlled trial : 1 ) computer-generated feedback to facilitate identification of poorly controlled patients ; and 2 ) a physician education program on clinical management strategies , emphasizing patient compliance . Four physician practice teams received either computer feedback , the education program , both , or neither . Feedback team physicians received seven monthly listings of the latest visits and blood pressures of their hypertensive patients . The self-administered learning program included written clinical simulations and associated didactic material .  Experimental and control physicians were similar in baseline knowledge , patient mix and level of training . All feedback team physicians requested appointments for listed patients , and their patients made twice as many visits as control patients during the intervention period ( p < 0.05 ) . Education team physicians showed significant gains on a content-specific post-intervention test : mean score 84 per cent compared with 74 per cent for the control group ( p < 0.005 ) . All patient groups showed improvement in blood pressure over the study period . However , no differences between intervention teams could be detected ( p > 0.20 ) . The probability of missing a 10 mm interteam difference in outcome diastolic pressure was 1 per cent ( power of 0.99 ) . Strategies for further improvement in outpatient hypertension management may need to come from outside the traditional medical model BACKGROUND We conducted a cluster r and omized controlled trial to examine the effectiveness of computerized decision support ( CDS ) design ed to improve hypertension care and outcomes in a racially diverse sample of primary care patients . METHODS We r and omized 2,027 adult patients receiving hypertension care in 14 primary care practice s to either 18 months of their physicians receiving CDS for each hypertensive patient or to usual care without computerized support for the control group .  We assessed prescribing of guideline -recommended drug therapy and levels of blood pressure control for patients in each group and examined if the effects of the intervention differed by patients ’ race/ethnicity using interaction terms . MEASUREMENTS AND MAIN RESULTS Rates of blood pressure control were 42 % at baseline and 46 % at the outcome visit with no significant differences between groups . After adjustment for patients ’ demographic and clinical characteristics , number of prior visits , and levels of baseline blood pressure control , there were no differences between intervention groups in the odds of outcome blood pressure control . The use of CDS to providers significantly improved Joint National Committee ( JNC ) guideline adherent medication prescribing compared to usual care ( 7 % versus 5 % , P < 0.001 ) ; the effects of the intervention remained after multivariable adjustment ( odds ratio [ OR ] 1.39 [ CI , 1.13–1.72 ] ) and the effects of the intervention did not differ by patients ’ race and ethnicity . CONCLUSIONS CDS improved appropriate medication prescribing with no improvement in disparities in care and overall blood pressure control . Future work focusing on improvement of these interventions and the study of other practical interventions to reduce disparities in hypertension-related outcomes is needed A group of investigators at a major teaching hospital have prepared a study design ed to test the hypothesis that patient outcomes related to hypertension will be improved by increased compliance , as defined by consistent daily compliance with prescribed medical regimen . The study will test the effectiveness of the following interventions in improving compliance : 1 )  improved access to medication , 2 ) computerized phone follow-up , and 3 )  one-on-one follow-up conversations concerning compliance issues . This paper is intended to describe the pending study in detail while focusing on the computerized phone system that will be used in the treatment group of the controlled study for compliance This study describes the influence of a computerized medical record summary system in three disease areas ( hypertension , obesity and renal disease ) observed in the course of a controlled , r and omized and prospect i ve study of 479 Northwestern University Clinic patients . Experimental patients , who had available automated record summaries , and control patients , who had available only the manual record  , were compared on several medical tests and procedures whose yearly occurrence was considered good medical practice for this patient population , and were compared as well on several measures of outcome of medical care . Evidence suggesting better care and outcome of care among patients with computerized record summaries available is presented BACKGROUND Rising concern over the poor level of blood-pressure ( BP ) control among hypertensive patients has prompted search es for novel ways of managing hypertension . The objectives of this study were to develop and pilot-test a home BP tele-management system that actively engages patients in the process of care . METHODS Phase 1 involved a series of focus-group meetings with patients and primary care providers to guide the system 's development . In Phase 2 , 33 diabetic patients with uncontrolled ambulatory hypertension were enrolled in a 4-month pilot study , using a before- and -after design to assess its effectiveness in lowering BP , its acceptability to users , and the reliability of home BP measurements . RESULTS The system , developed using commodity hardware , comprised a Bluetooth-enabled home BP monitor , a mobile phone to receive and transmit data , a central server for data processing , a fax-back system to send physicians ' reports , and a  BP alerting system . In the pilot study , 24-h ambulatory BP fell by 11/5 ( + /-13/7 SD ) mm Hg ( both P < .001 ) , and BP control improved significantly . Substantially more home readings were received by the server than expected , based on the preset monitoring schedule . Of 42 BP alerts sent to patients , almost half ( n = 20 ) were due to low BP . Physicians received no critical BP alerts . Patients perceived the system as acceptable and effective . CONCLUSIONS The encouraging results of this study provide a strong rationale for a long-term , r and omized , clinical trial to determine whether this home BP tele-management system improves BP control in the community among patients with uncontrolled hypertension 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 STUDY OBJECTIVE To assess the effects of evidence -based treatment suggestions for hypertension made to physicians and pharmacists using a comprehensive electronic medical record system . DESIGN R and omized controlled trial with a 2 x 2 factorial design of physician and pharmacist interventions , which result ed in four groups of patients :  physician intervention only , pharmacist intervention only , intervention by physician and pharmacist , and intervention by neither physician nor pharmacist ( control ) . SETTING Academic primary care internal medicine practice . SUBJECTS Seven hundred twelve patients with uncomplicated hypertension . MEASUREMENTS AND MAIN RESULTS Suggestions were displayed to physicians on computer workstations used to write outpatient orders and to pharmacists when filling prescriptions . The primary end point was generic health-related quality of life . Secondary end points were symptom profile and side effects from antihypertensive drugs , number of emergency department visits and hospitalizations , blood pressure measurements , patient satisfaction with physicians and pharmacists , drug therapy compliance , and health care charges . In the control group , implementation of care changes in accordance with treatment suggestions was observed in 26 % of patients . In the intervention groups , compliance with suggestions was poor , with treatment suggestions implemented in 25 % of patients for whom suggestions were displayed only to pharmacists , 29 % of those for whom suggestions were displayed only to physicians , and 35 % of the group for whom both physicians and pharmacists received suggestions ( p=0.13 ) . Intergroup differences were neither statistically significant nor clinical ly relevant for generic health-related quality of life , symptom and side-effect profiles , number of emergency department visits and hospitalizations , blood pressure measurements , charges , or drug therapy compliance . CONCLUSION Computer-based intervention using a sophisticated electronic physician order-entry system failed to improve compliance with treatment suggestions or outcomes of patients with uncomplicated hypertension Although absolute risk of death associated with raised blood pressure increases with age , the benefits of treatment are greater in elderly patients . Despite this , the ' rule of halves ' particularly applies to this group . We conducted a r and omised controlled trial to evaluate different levels of feedback design ed to improve identification , treatment and control of elderly hypertensives . Fifty-two general practice s were r and omly allocated to either : Control ( n=19 ) , Audit only feedback ( n=16 ) or Audit plus Strategic feedback , prioritising patients by absolute risk ( n=17 ) . Feedback was based on electronic data , annually extracted from practice computer systems . Data were collected for 265,572 patients , 30,345 aged 65 - 79 . The proportion of known hypertensives  in each group with BP recorded increased over the study period and the numbers of untreated and uncontrolled patients reduced . There was a significant difference in mean systolic pressure between the Audit plus Strategic and Audit only groups and significantly greater control in the Audit plus Strategic group . Providing patient-specific practice feedback can impact on identification and management of hypertension in the elderly and produce a significant increase in control Background —Hypertension is a leading mortality risk factor yet inadequately controlled in most affected subjects . Effective programs to address this problem are lacking . We hypothesized that an information technology – supported management program could help improve blood pressure ( BP ) control . Methods and Results —This r and omized controlled trial included 223 primary care hypertensive subjects with mean 24-hour BP > 130/80 and daytime BP > 135/85 mm Hg measured with ambulatory monitoring ( ABPM ) . Intervention subjects received a BP monitor and access to an information technology – supported adherence and BP monitoring system providing nurses , pharmacists , and physicians with monthly reports . Control subjects received usual care . The mean ( ±SD ) follow-up was 348 ( ±78 ) and 349 ( ±84 ) days in the intervention and control group , respectively . The primary end point of the change in the mean 24-hour ambulatory BP was consistently greater in intervention subjects for both systolic ( −11.9 versus −7.1 mm Hg ; P<0.001 ) and diastolic BP ( −6.6 versus −4.5 mm Hg ; P=0.007 ) . The proportion of subjects that achieved Canadian Guideline target BP ( 46.0 % versus 28.6 % ) was also greater in the intervention group ( P=0.006 ) . We observed similar BP declines for ABPM and self-recorded home BP suggesting the latter could be an alternative for confirming BP control . The intervention was associated with more physician-driven antihypertensive dose adjustments or changes in agents ( P=0.03 ) , more antihypertensive classes at study end ( P=0.007 ) , and a trend toward improved adherence measured by prescription refills ( P=0.07 ) . Conclusions —This multidisciplinary information technology – supported program that provided feedback to patients and healthcare providers significantly improved blood pressure levels in a primary care setting Background Very few studies having decision support systems as an intervention report on patient outcomes for cardiovascular disease in the Western world . The potential role of decision support system for the management of blood pressure among Indian hypertensives remains unclear . We propose a cluster r and omised trial that aims to test the effectiveness and cost effectiveness of DSS among Indian hypertensive patients . Methods The trial design is a cluster r and omised community intervention trial , in which the participants would be adult male and female hypertensive patients , in the age group of 35 to 64 years , reporting to the Primary Health Care centres of Mahabubnagar district , And hra Pradesh , India . The objective of the study is to test the effectiveness and compare the cost effectiveness and cost utility among hypertensive subjects r and omized to receive either decision support system or a chart based algorithmic support system in urban and rural areas of a district in the state of And hra Pradesh , India ( baseline versus 12 months follow up ) . The primary outcome would be a comparison of the systolic blood pressure at 0 and 12 months among hypertensive patients r and omized to receive the decision support system or the chart based algorithmic support system . Computer generated r and omisation and an investigator and analyser blinded method would be followed . 1600 participants ; 800 to each arm ; each arm having eight clusters of hundred participants each have been recruited between 01 August 2011 - 01 March 2012 . A twelve month follow up will be completed by March 2013 and results are expected by April 2013 . Discussion This cluster r and omized community intervention trial on DSS will enable policy makers to find out the effectiveness , cost effectiveness and cost utility of decision support system for management of blood pressure among hypertensive patients in India . Most of the previous studies on decision support system have focused on physician performance , adherence and on preventive care reminders . The uniqueness of the proposed study lies in finding out the effectiveness of a decision support system on patient related outcomes .Trial registration CTRI/2012/03/002476 , Clinical Trial Registry - India BACKGROUND R and omized controlled trials have provided unequivocal evidence that treatment of hypertension decreases mortality and major disability from cardiovascular disease ; however , blood pressure remains inadequately treated in most affected individuals . This large gap continues despite the facts that more than 90 % of adults with hypertension have health insurance , and hypertension is the leading cause of visits to the doctor . New approaches are needed to improve hypertension care . OBJECTIVES The Electronic Communications and Home Blood Pressure Monitoring ( e-BP ) study is a three-arm r and omized controlled trial design ed to determine whether care based on the Chronic Care Model and delivered over the Internet improves hypertension care . The primary study outcomes are systolic , diastolic , and blood pressure control ; secondary outcomes are medication adherence , patient self-efficacy , satisfaction and quality of life , and healthcare utilization and costs . METHODS Hypertensive patients receiving care at Group Health medical centers are eligible if they have uncontrolled blood pressure on two screening visits and access to the Web and an e-mail address . Study participants are r and omly assigned to three intervention groups : ( a ) usual care ; ( b ) home blood pressure monitoring receipt and proficiency training on its use and the Group Health secure patient website ( with secure e-mail access to their healthcare provider , access to a shared medical record , prescription refill and other services ) ; or ( c ) this plus pharmacist care management ( collaborative care management between the patient , the pharmacist , and the patient 's physician via a secure patient website and the electronic medical record ) . CONCLUSION We will determine whether a new model of patient-centered care that leverages Web communications , self-monitoring , and collaborative care management improves hypertension control . If this model proves successful and cost-effective , similar interventions could be used to improve the care of large numbers of patients with uncontrolled hypertension Abstract One hundred and sixteen patients with hypertension were allocated r and omly to treatment by a computer program or by physicians . All were under the care of physicians in one of two hypertension clinics , but for computer treated patients ( C ) the program provided physicians with treatment recommendations which they were free to follow or reject whereas no recommendations were made for physician treated patients ( P ) . The computer program could use thiazide , alphamethyldopa , hydralazine or quanethidine ; physicians used whatever drugs they wished . Blood pressure ( BP ) response was similar for both groups , as were drug side effects and overt non-compliance with treatment . A computer program such as this one could guide allied health workers in setting s where expert physicians are scarce , improving large scale treatment of hypertension Background Computerized clinical decision support systems are information technology-based systems design ed to improve clinical decision-making . As with any healthcare intervention with cl aims to improve process of care or patient outcomes , decision support systems should be rigorously evaluated before widespread dissemination into clinical practice . Engaging healthcare providers and managers in the review process may facilitate knowledge translation and uptake . The objective of this research was to form a partnership of healthcare providers , managers , and research ers to review r and omized controlled trials assessing the effects of computerized decision support for six clinical application areas : primary preventive care , therapeutic drug monitoring and dosing , drug prescribing , chronic disease management , diagnostic test ordering and interpretation , and acute care management ; and to identify study characteristics that predict benefit . Methods The review was undertaken by the Health Information Research Unit , McMaster University , in partnership with Hamilton Health Sciences , the Hamilton , Niagara , Haldim and , and Brant Local Health Integration Network , and pertinent healthcare service teams . Following agreement on information needs and interests with decision-makers , our earlier systematic review was up date d by search ing Medline , EMBASE , EBM Review data bases , and Inspec , and review ing reference lists through 6 January 2010 . Data extraction items were exp and ed according to input from decision-makers . Authors of primary studies were contacted to confirm data and to provide additional information . Eligible trials were organized according to clinical area of application . We included r and omized controlled trials that evaluated the effect on practitioner performance or patient outcomes of patient care provided with a  computerized clinical decision support system compared with patient care without such a system . Results Data will be summarized using descriptive summary measures , including proportions for categorical variables and means for continuous variables . Univariable and multivariable logistic regression models will be used to investigate associations between outcomes of interest and study specific covariates . When reporting results from individual studies , we will cite the measures of association and p-values reported in the studies . If appropriate for groups of studies with similar features , we will conduct meta-analyses . Conclusion A decision-maker- research er partnership provides a model for systematic review s that may foster knowledge translation and uptake BACKGROUND Only 31 % of Americans with hypertension have their blood pressure ( BP ) under effective control . We describe a study that tests 3 different interventions in a r and omized controlled trial using home BP telemedicine monitoring . METHODS A sample of hypertensive patients with poor BP control at baseline ( N = 600 ) are r and omized to 1 of 4 arms : ( 1 ) control group -- a group of hypertensive patients who receive usual care ; ( 2 ) nurse-administered tailored behavioral intervention ; ( 3 ) nurse-administered medication management according to a hypertension decision support system ; ( 4 ) combination of the 2 interventions . The interventions are triggered based on home BP values transmitted via telemonitoring devices over st and ard telephone lines . The tailored behavioral intervention involves promoting adherence with medication and health behaviors . Patients r and omized to the medication management or the combined arm have their hypertension regimen changed by the study team using a vali date d hypertension decision support system based on evidence -based hypertension treatment guidelines and individualized to patients ' comorbid illnesses . The primary outcome is BP control : < or = 140/90 mm Hg ( nondiabetic ) and < or = 130/80 mm Hg ( diabetics ) measured at 6-month intervals over 18 months ( 4 total measurements ) . CONCLUSIONS Given the increasing prevalence of hypertension and our inability to achieve adequate BP control using traditional models of care , testing novel interventions in patients ' homes may improve access , quality , and outcomes We propose evaluation of a multi-component home automated telemanagement system providing integrated support to both clinicians and patients in implementing hypertension treatment guidelines . In a r and omized clinical study , 550 blacks with hypertension are followed for 18 months . The major components of the intervention and control groups are identical and are based on the current st and ard of care . For the purpose of this study , we define " st and ard of care " as the expected evidence -based care provided according to the current hypertension treatment guidelines . Although intervention and control groups are similar in terms of their care components , they differ in the mode of care delivery . For the control group the best attempt is made to deliver all components of a guideline -concordant care in a routine clinical environment whereas for the intervention group the routine clinical environment is enhanced with health information technology that assists clinicians and patients in working together in implementing treatment guidelines . The home automated telemanagement system guides patients in following their individualized treatment plans and helps care coordination team in monitoring the patient progress . The study design is aim ed at addressing the main question of this trial : whether the addition of the information technology-enhanced care coordination in the routine primary care setting can improve delivery of evidence -based hypertension care in blacks . The outcome parameters include quality of life , medical care use , treatment compliance , psychosocial variables , and improvement in blood pressure control rates . The trial will provide insight on the potential impact of information technology-enhanced care coordination in blacks with poorly controlled hypertension
: It seems that computers have a favourable effect on the uptake and follow up of patients in hypertension management .
STUDY OBJECTIVE : To assess the effect of computers and computer-based clinical decision support systems on the  management of hypertension .