Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success

Editor

In her editorial, Purcell expresses concern at the small number of
studies analysing primary outcomes to determine the effectiveness of
clinical decision support systems [1].

We evaluated the effect of a decision support algorithm in delivering
patient specific prompts to manage cholesterol in renal transplant
outpatients. Data was analysed retrospectively for a two-year period with
attention to changes in cholesterol levels, prescribing patterns of
statins and causes of underperformance.

The algorithm was designed to run for each renal transplant
outpatient follow up encounter. Using the most recent blood results for
individual patients, on-screen treatment recommendations were given for
those with a serum cholesterol of greater than or equal to 5.0mmol/l with
instructions regarding starting treatment, dose adjustment, subsequent
monitoring, dose titration and follow-up. The system incorporated the
features identified in Kawamoto’s paper suggested to improve patient care
[2].

At baseline, 36.7% of patients achieved a total serum cholesterol
level For patients followed concurrently in two units without the
algorithm, serum cholesterol measurements fell from 5.57 and 5.34mmol/l to
5.31 and 5.27mmol/l respectively, both higher than that achieved
contemporaneously at St James’s,(p=0.05).

Underperformance depended less on medical non-compliance than with
systematic features of the methodology and patient
preference/collaboration with treatment.

The introduction of the system coincided with significant reductions
in cholesterol levels in a population at specific risk, with increasing
numbers of patients on appropriate therapy and no serious adverse effects.
Our results illustrate the positive effect of decision support software on
populations.

References

1 Purcell GP. What makes a god clinical decision support system. BMJ
2005; 330:740-1

2 Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical
practice using clinical decision support systems: a systematic review of
trials to identify features critical to success. BMJ 2005; 330:765-8

3 Garthwaite EA, Will EJ, Bartlett C, Richardson D, Newstead CG.
Patient specific prompts in the cholesterol management of renal transplant
outpatients: results and analysis of underperformance. Transplantation
2004; 15;78(7):1042-7

Competing interests:
None declared