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Randomized Controlled Trial
. 2017 Feb 28;12(2):e0170974.
doi: 10.1371/journal.pone.0170974. eCollection 2017.

Effectiveness and usage of a decision support system to improve stroke prevention in general practice: A cluster randomized controlled trial

Derk L Arts  1   2 , Ameen Abu-Hanna  2 , Stephanie K Medlock  2 , Henk C P M van Weert  1
Affiliations
Randomized Controlled Trial

Effectiveness and usage of a decision support system to improve stroke prevention in general practice: A cluster randomized controlled trial

Derk L Arts et al. PLoS One. .

Abstract

Background: Adherence to guidelines pertaining to stroke prevention in patients with atrial fibrillation is poor. Decision support systems have shown promise in increasing guideline adherence.

Aims: To improve guideline adherence with a non-obtrusive clinical decision support system integrated in the workflow. Secondly, we seek to capture reasons for guideline non-adherence.

Design and setting: A cluster randomized controlled trial in Dutch general practices.

Method: A decision support system was developed that implemented properties positively associated with effectiveness: real-time, non-interruptive and based on data from electronic health records. Recommendations were based on the Dutch general practitioners guideline for atrial fibrillation that uses the CHA2DS2-VAsc for stroke risk stratification. Usage data and responses to the recommendations were logged. Effectiveness was measured as adherence to the guideline. We used a chi square to test for group differences and a mixed effects model to correct for clustering and baseline adherence.

Results: Our analyses included 781 patients. Usage of the system was low (5%) and declined over time. In total, 76 notifications received a response: 58% dismissal and 42% acceptance. At the end of the study, both groups had improved, by 8% and 5% respectively. There was no statistically significant difference between groups (Control: 50%, Intervention: 55% P = 0.23). Clustered analysis revealed similar results. Only one usable reasons for non-adherence was captured.

Conclusion: Our study could not demonstrate the effectiveness of a decision support system in general practice, which was likely due to lack of use. Our findings should be used to develop next generation decision support systems that are effective in the challenging setting of general practice.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. The CONSORT flow diagram.
Fig 2
Fig 2. The notification window in its expanded state, showing three notifications, with the AF notification at the top of the list that includes other notifications originating from other clinical rules.
Fig 3
Fig 3. The popup after clicking on a notification, containing background information, an actionable recommendation and response buttons that allowed the GP to either accept (1) or decline (2) the advice.
Fig 4
Fig 4. Usage of the CDDS plugin over time.
Blue dots indicate clicked notifications, red dots indicate responses to recommendations (clicking accept or decline), orange dots indicate the number of times the GP hovered over the notification window with their mouse regardless of whether the notification was opened.
Fig 5
Fig 5. User activity
Average usage (responses / notification) per general practitioner.
See this image and copyright information in PMC

References

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