Evaluation of effectiveness and cost-effectiveness of a clinical decision support system in managing hypertension in resource constrained primary health care settings: results from a cluster randomized trial

Abstract

Background: Randomized control trials from the developed world report that clinical decision support systems (DSS) could provide an effective means to improve the management of hypertension (HTN). However, evidence from developing countries in this regard is rather limited, and there is a need to assess the impact of a clinical DSS on managing HTN in primary health care center (PHC) settings.

Methods and results: We performed a cluster randomized trial to test the effectiveness and cost-effectiveness of a clinical DSS among Indian adult hypertensive patients (between 35 and 64 years of age), wherein 16 PHC clusters from a district of Telangana state, India, were randomized to receive either a DSS or a chart-based support (CBS) system. Each intervention arm had 8 PHC clusters, with a mean of 102 hypertensive patients per cluster (n=845 in DSS and 783 in CBS groups). Mean change in systolic blood pressure (SBP) from baseline to 12 months was the primary endpoint. The mean difference in SBP change from baseline between the DSS and CBS at the 12th month of follow-up, adjusted for age, sex, height, waist, body mass index, alcohol consumption, vegetable intake, pickle intake, and baseline differences in blood pressure, was -6.59 mm Hg (95% confidence interval: -12.18 to -1.42; P=0.021). The cost-effective ratio for CBS and DSS groups was $96.01 and $36.57 per mm of SBP reduction, respectively.

Conclusion: Clinical DSS are effective and cost-effective in the management of HTN in resource-constrained PHC settings.

Clinical trial registration url: http://www.ctri.nic.in. Unique identifier: CTRI/2012/03/002476.

Keywords: cluster randomized trials; computers; cost‐effectiveness; effectiveness; hypertension.

Figure 1.

Consort flow chart. CBS indicates chart‐based support; DSS, decision support systems; MITT, modified intention to treat; PHC, primary health care center.

Figure 2.

Randomization procedure followed during the study. CBS indicates chart‐based support; CHC, community health center; DSS, decision support systems; PHC, primary health care center.

Figure 3.

Mean blood pressure in randomized groups by month and differences versus baseline. CBS indicates chart‐based support; CI, confidence interval; DBP, diastolic blood pressure; DSS, decision support systems; SBP, systolic blood pressure.

Figure 4.

Comparison of CBS and DSS groups: BP under control (SBP <140 and DBP <90 mm Hg). BP indicates blood pressure; CBS, chart‐based support; DBP, diastolic blood pressure; DSS, decision support systems; SBP, systolic blood pressure.