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HAD5726 CATCH IT Presentation



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  • inferencing mechanism (usually a set of rules derived from the experts and evidence-based medicine)inference engine is a computer program that tries to derive answers from a knowledge base. It is the "brain" that expert systems use to reason about the information in the knowledge base for the ultimate purpose of formulating new conclusions
  • GASTON state of the art framework for building DSS, consists of an ontology-based guideline representation language, a guideline-modelling tool that enables guideline authors to formally describe and easily modify practice guidelines visually, and a guideline execution engineThe designers of the GASTON framework were willing to provide personal assistance in the development of CARDSS.
  • CARDSS consists of three different components, namely a CDSS, a host system, and a database. We will refer to the host system as patient information management system (PIMS).
  • The PIMS operates as front-end application that cardiac rehabilitation professionals use to conduct the needs assessment procedure and decide on cardiac rehabilitation therapies for their patients
  • Did the patient smoke prior to the admission to the hospital
  • How frequently in the last two weeks have you felt frustrated, impatient, or irritated?How frequently in the last two weeks have you felt worthless?
  • Public title, scientific title, acronym, study hypothesis, study design, country of recruitment
  • 5 control arm centres discontinued their participation. 3 were reluctant to continue participation as they believed that the benefits of CARDSS without CDS did not compensate for the increased workload of learning to work with the system. 1 had to stop participation because of a temporary lack of personnel, and another centre accidentally deleted its CARDSS database during an update of the server’s operating system in the last month of the trial.
  • IT: 4 centers unable to join study duringenrollment period since they were unable to update infrastructure in time. No information system was used in rehab centers prior to CARDSS.Organizational change: lifestyle change therapyAttrition:3 excluded from intervention due to not recording decisions into CARDSS , 3 discontinued from control due finding it not worth the extra work in implementing CARDSS without CDS1 from each grp for too much missing data from initial data auditResearch: however they tried to reduce bias by blinding investigators during allocation procedure, use of objective measures, external evaluator and statistician.
  • Stats: Calculations showed that with a 6 month follow-up, 36 centres needed to detect a 10% absolute difference in adherence with 80% power at a type I error risk (α) of 5%Covariates: age, sex, diagnosis, weekly vol of new pts, whether center is specialized rehab or part of academic hospital
  • However, if barriers are related to workflow or organizational barriers, change management stratsreq


  • 1. Goud R et al. Effect of guideline based computerised decision support on decision making of multidisciplinary teams: cluster randomised trial in cardiac rehabilitation. BMJ. 2009;338:b1440.
    CATCH-IT Presentation
    Andrew Cheng
  • 2. Outline
    Cardiac rehabilitation
    Decision support systems
    Trial design
    Follow up study
    Future study and other research
  • 3. Cardiac Rehabilitation
    Care provided after hospitalization for a cardiac incident or intervention
    Outpatient care (approx 6-12 weeks)
    improving physical condition
    regaining emotional balance
    reintegration (e.g. work resumption)
    patient education
    secondary prevention through lifestyle changes
  • 4. Cardiac Rehabilitation in the Netherlands
    Approx 100 outpatient clinics
    26,000 patients/year
    Large variation in
    referral patterns
    organization of treatment
    decision making
    Dutch Cardiac Rehabilitation Guidelines (2004)
    Needs assessment procedure
    4 types of therapy: exercise, education, relaxation, lifestyle change
  • 5. Cardiac Rehabilitation in the Netherlands
    Multidisciplinary teams
    Physical therapists
    Social workers
    Rehabilitation specialists
  • 6. Clinical Decision Support
    Computer system designed to assist physicians and other healthcare professionals in clinical decision making to enhance patient care
    Levels of CDS
    Documentation (EMR)
    Basic alerts (drug-drug interactions)
    Patient-specific recommendations
  • 7. Clinical Decision Support
  • 8. CARDSS
    Cardiac Rehabilitation Decision Support System
    Needs assessment procedure from guidelines
    assessment of rehab goals and therapies
    developed with the GASTON framework
    supports structured information gathering
    e.g. QoLquestionnaire
    System workflow integration
    Includes own electronic patient record (EPR)
    No cardiac rehab in NL used an information system
    Therefore, host system and database had to be included
    Additional functionalities linked to record
  • 9. CARDSS Studies
    0. Pilot Study (2003)
    R. Goud, N. Peek, A.M. Strijbis, P.A. de Clercq, A. Hasman, A computer-based guideline implementation system for cardiac rehabilitation screening, Comput. Cardiol. 32 (2005) 323–326.
    Effect of CARDSS on guideline adherence (2005)
    Cluster randomized trial
    CARDSS and barriers to implementation
    Follow up qualitative study
    CARDSS with feedback and outreach visits (2008-?)
    Ongoing cluster randomized trial
  • 10. Interest
    First study to my knowledge to evaluate the effect of CDS on decision making in teams
    For others:
    Health care settings with multidisciplinary teams interested in adding CDS to their center
    Health informaticians
  • 11. CARDSS Architecture
    clinical decision support system
    Host system
    Patient information management system (PIMS)
    Clinical information
    CDSS-related information
  • 12. 12
  • 13. 13
    The decision tree heart rehabilitation
    Risk Behaviour
    Head Questions
    Personal Info
    There is talk of risk behaviour? Question 1: Smoked the patient for prerecording in the hospital?
  • 14. Questionnaire Form
    1) You has the last how frequently frustrated himself two weeks, impatiently or has irritated felt?
    2) You has the last how frequently felt himself two weeks worthless or to a little able?
  • 15. 15
  • 16. Pilot Study
    Prototype version of CARDSS
    Started 2003, 2 months
    4 outpatient clinics volunteered, 134 patients
    No control group
    System was quickly accepted by its users and easily integrated into clinical workflows
    Several adjustments and additional functions were added to system
  • 17. CARDSS Study
    Care providers are more likely to adhere to clinical practice guidelines when they receive guideline-based decision support by an electronic system
    Trial registration
    Current Controlled Trials ISRCTN36656997
  • 18.
  • 19. Trial Website:
  • 20. Trial Design
    Cluster (center) randomization
    Intervention group: CARDSS with CDS
    Control group: CARDSS without CDS
    Duration: 6 months
    Started 2005
    Last center completed in July 2006
  • 21. Outcome measure
    Guideline adherence by care providers
    4 types of therapy
    2 Standard: exercise, education
    2 New: relaxation, lifestyle change
  • 22. Trial Participants
    Analysed:12 clinics, 1655 patients
    Analysed: 9 clinics, 1132 patients
  • 23. Results: Exercise Therapy
    Control (No CDS)
    Treatment (CDS)
    Adherence: 84.7%
    Adherence: 92.6%
    Significant change in adherence
  • 24. Results: Education Therapy
    Control (No CDS)
    Treatment (CDS)
    Adherence: 63.9%
    Adherence: 87.6%
    Significant change in adherence
  • 25. Results: Relaxation Therapy
    Control (No CDS)
    Treatment (CDS)
    Adherence: 34.1%
    Adherence: 59.6%
    Significant change in adherence
  • 26. Results: Lifestyle Change Therapy
    Control (No CDS)
    Treatment (CDS)
    Adherence: 54.1%
    Adherence: 57.4%
    No significant change in adherence
  • 27. Conclusions
    CARDSS improved adherence to guideline recommendations with respect to exercise, education, and relaxation therapy
    No effect for lifestyle change therapy
    Majority of clinics did not have therapy program available
    Considerable undertreatment of patients
    Many patients did not receive the treatment they were suppose to according to guidelines
    A lot of variation in adherence between clinics
  • 28. Limitations
    Required motivated multidisciplinary teams in centers with adequate IT infrastructure
    System cannot enforce changes requiring organizational change
    High attrition rate from implementing and learning how to use new system
    CARDSS comes with own EPR
    Authors also led development of the CDS system
  • 29. Limitations
    Possible Hawthorne or checklist effect
    Insufficient statistical power
    21 centers less than the calculated 36 necessary centers
    Not enough information on how the adjusted difference values and CI were calculated
    No explanation on how the covariates affect adherence
  • 30. Ethical Issues
    Ethics approval stated as not needed according to the medical ethics committee of the Academic Medical Centre in Amsterdam
  • 31. Questions for the authors
    Why not collect baseline adherence data?
    What is the reason for large variation in adherence between centers?
    Why was ethics approval not needed?
  • 32. Questions for the authors
    What effect did the initial learning curve to the system have on users’ performance and adherence to guidelines?
    How large of a role if any did usability of CARDSS play?
    How was patient compliance accounted for given its large influence on guideline adherence?
  • 33. Questions for the authours
    Why were non-CARDSS buyers not interested in the system?
    Specialized rehab centers less eager to implement CARDSS since they already developed own protocol more detailed than national guidelines
    CARDSS was not interoperable with other information systems
    Future versions will support interoperability
  • 34. Follow Up Qualitative Study
    Research Questions:
    What are the main barriers to implementation of the national guideline for cardiac rehabilitation?
    Which barriers were reduced by CARDSS?
  • 35. Study Design
    Semi-structured interviews with users of CARDSS
    nurses, physiotherapists
    21 participating clinics
    Same 21 in the first study
    29 interviews
  • 36. Results
    CARDSS improved implementation of guidelines when:
    Professionals were unfamiliar with the details of the guidelines
    CARDSS made it easier to follow the guideline
    e.g. calculation and interpretation of QoLscores
    Patients sometimes refused to undergo treatment
    e.g. willingness to participate in psychosocial therapy increased
  • 37. Results
    CARDSS did not improve implementation of guidelines when:
    Environmental barriers existed
    e.g. lack of facilities, no reimbursement, or believed there was no reimbursement
    Conflicts with other departments were present
    e.g. exercise test from another department required prior to needs assessment procedure
    Organizational change needed
  • 38. Conclusions
    CDS systems can provide advice at the point of care
    The knowledge base can be based on practice guidelines
    Improves adherence if barriers are related to knowledge or complexity of the guidelines
  • 39. Implications
    CDS when implemented properly may improve adherence to clinical guidelines and help standardize care in multidisciplinary teams
    If CDS can be provided through the resident EPR already in use, one of the barriers to implementation is removed
    Change management strategies is required for barriers relating to workflow or organization changes
  • 40. Third Follow Up Study
    Clustered randomized trial
    Aim: Standardize the work processes in heart rehabilitation centers
    Stage 1: Jan 2008, duration 6 months?
    Stage 2: Late 2008, duration 15 months?
  • 41. Principal Authours
    Dr. Niels Peek
    project LEADER CARDSS-project
    University professor
    Academically medical centre Amsterdam
    Department clinical information science
    Dr. Rick Goud
    project executant CARDSS-project
    Research scientist
    Academically medical centre Amsterdam
    Department clinical information science
  • 42. Other Research
    Subjective usability of the CARDSS guideline-based decision support system
    Studies in health technology and informatics
    Goud R, Jaspers MW, Hasman A, Peek N. Subjective usability of the CARDSS guideline-based decision support system. Stud Health Technol Inform. 2008;136:193-8.
    Investigate subjective usability of a guideline-based CDSS for outpatient cardiac rehabilitation
    Questionnaire to 68 professionals from 28 outpatient clinics
    Professionals who managed to smoothly integrate the system with their daily routine were more satisfied with ease of system use
  • 43. Other Research
    Development of a guideline-based decision support system with explanation facilities for outpatient therapy.
    Computer methods and programs in biomedicine
    Goud R, Hasman A, Peek N. Development of a guideline-based decision support system with explanation facilities for outpatient therapy. Comput Methods Programs Biomed. 2008 Aug;91(2):145-53.
    Design considerations
    CARDSS architecture
    Functionalities of CARDSS
  • 44. The End
    Thank you