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
  • HAD5726 CATCH IT Presentation

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