Outcomes of clinical decision support (CDS) and correlates of CDS use for home care patients with high medication regimen complexity: a randomized trial

Abstract

Rationale, aims and objectives: To assess the outcomes of a clinical decision support (CDS) intervention designed for home care patients with high medication regimen complexity (MRC) and to examine correlates of CDS use.

Method: The CDS consisted of a computerized algorithm that identified high MRC patients, electronic alerts and a care management module. Nurses were randomized upon identification of an eligible patient. Full intention to treat and intervention group-only analyses were completed. Regression-adjusted outcomes were hospitalization, emergency department use and reduction in MRC.

Results: Five hundred nurses were randomized with 7919 of their patients. Approximately 20% of the intervention group was hospitalized versus 21% in the control group; 16.5% versus 16.7% had an emergency department visit; and 6% in each group dropped below the high MRC threshold. No statistically significant differences were found in the intention to treat analysis. Eighty-two percent of intervention nurses used the CDS but for only 42% of their patients. Among intervention patients, CDS use (vs. non-use) was associated with reduced MRC and hospitalization. CDS use was associated with various clinician and patient characteristics.

Conclusion: CDS use was limited, negating the impact of the intervention overall. Findings on correlates of CDS use and the relationship between CDS use and positive outcomes suggest that CDS use and outcomes could be enhanced by avoiding short patient lengths of stay, improving continuity of care, increasing reliance on salaried nurses and/or increasing per diem nurses' incentives to use CDS.

Keywords: MRCI; clinical decision support; home health care; hospitalization risk; medication regimen complexity; nurses.

Figure 1

Nurse/Patient Flow Diagram Note: All patients who were identified as having a complex medication regimen were randomized along with their nurses; no exclusion criteria were applied. Intervention components were automated so all nurses in the intervention group received the alert and access to the CDS for each of their eligible patients – so there were no intervention drops.

Figure 2

Patient Outcomes by Study Group – Full Intention to Treat sample Note: Patient and nurse characteristics that were significantly different at a p<0.20 level were included in multivariate models. Analysis is adjusted for clustering at the nurse level.

Figure 3

Patient Outcomes by CDS Group Note: Patient and nurse characteristics that were significantly different at a p<0.20 level were included in multivariate models. Analysis is adjusted for clustering at the nurse level.