Can computerized clinical decision support systems improve practitioners' diagnostic test ordering behavior? A decision-maker-researcher partnership systematic review

Roshanov, Pavel S; You, John J; Dhaliwal, Jasmine; Koff, David; Mackay, Jean A; Weise-Kelly, Lorraine; Navarro, Tamara; Wilczynski, Nancy L; Brian Haynes, R

doi:10.1186/1748-5908-6-88

Implementation Science

Table 1 Summary results for CCDSS trials of diagnostic test ordering^a

From: Can computerized clinical decision support systems improve practitioners' diagnostic test ordering behavior? A decision-maker-researcher partnership systematic review

Study	Methods score	Indication	No. of centres/providers/patients	Diagnostic process (DP) outcomes	CCDSS Effect^b
Disease Monitoring
Gilutz, 2009[25]	7	Reminders for monitoring and treatment of dyslipidemia in primary care patients with known coronary artery disease.	112*/600/7,448	Adequate frequency of lipoprotein monitoring.	+
Holbrook, 2009[26, 27]	7	Web-based tracking of diabetes monitoring in adults in primary care.	18/46/511*	Semiannual measurement of glycated Hb, LDL-C, or albuminuria; semiannual foot surveillance; quarterly measurement of BP or BMI.	+
Maclean, 2009[28, 29]	8	Reminders for the management of diabetes in primary care.	64*/132/7,412	Testing that was timely for A1C, lipids, serum creatinine, or urine microalbumin.	+
Peterson, 2008[30]	10	Visit reminders and patient-specific physician alerts and progress reports for organization of primary care in patients with type 2 diabetes.	24*/238/7,101	Improvement in Process of Care Index (annual BP monitoring; eye and foot exams; renal, HbA1c, and LDL-C testing).	+
Borbolla, 2007[31]	7	Recommendations for monitoring of BP in outpatients and primary care patients with chronic disease.	.../182*/2,315	BP measurement for appropriate patients.	+
Lester, 2006[32, 33]	8	Recommendations for the management of dyslipidemia in primary care.	1/14/235*	Time to first measured LDL.-C.	0
Cobos^c, 2005[34]	10	Recommendations for hypercholesterolemia therapy, follow-up visit frequency, and laboratory test ordering for patients with hypercholesterolemia in primary care.	42*/.../2,221	Number of patient assessments (lipids).	0
Plaza, 2005[35]	9	Recommendations for cost-effective management of asthma in primary care.	.../20*/198	Use of spirometry, conventional blood tests, total immunoglobulin E, skin allergy tests, or thorax radiography.	0
Sequist, 2005[36]	6	Reminders for management of diabetes and coronary artery disease in primary care.	20*/194/6,243	Receipt of annual cholesterol or dilated eye exams, or biennial HbA1c exams.	0
Tierney, 2005[37]	9	Recommendations for the management of asthma and chronic obstructive pulmonary disease in adults in primary care.	4/266*/706	Adherence to suggestions to obtain pulmonary function tests.	0
Mitchell 2004[38]	7	Feedback for identification, treatment, and control of hypertension in elderly patients in primary care.	52*/.../30,345	Patients with BP not measured.	0
Eccles, 2002[39, 40]	10	Recommendations for management of asthma or angina in adults in primary care.	62*/.../4,506	Adherence to angina guideline recommendations for recording/advising on BP; weight; electrocardiograms; thyroid function; Hb, lipid, cholesterol, blood glucose, and HbA1c levels; and assessment of lung function.	0
Demakis, 2000[41]	7	Reminders for screening, monitoring, and counselling in accordance with predefined standards of care in ambulatory care.	12*/275/12,989	Compliance with standards of care for coronary artery disease (lipid levels), hypertension (weight, exercise, sodium) and diabetes (glycosylated Hb, urinalysis, eye and foot exams).	+
Hetlevik, 1999[42–44]	8	Recommendations for diagnosis and management of hypertension, diabetes mellitus, and dyslipidemia in primary care.	56*/56/3,273	Hypertensive or diabetic patients without recorded data for BP, serum cholesterol, or BMI; and diabetic patients without HbA1c recorded.	0
Lobach, 1997[45]	6	Recommendations for the primary care of diabetes mellitus for outpatients, including screening, vaccination, and HbA1c monitoring.	1/58*/497	Compliance with diabetes management recommendations for foot, ophthalmologic, and complete physical exams; chronic glycemia monitoring; urine protein determination; and cholesterol levels.	0
Mazzuca, 1990[46]	7	Reminders for management of type 2 diabetes mellitus in outpatients.	4*/114/279	Adherence to recommendations for lab ordering for glycosylated Hb and fasting blood sugar; and initiation of home-monitored blood glucose.	0
Rogers, 1984[47–49]	4	Recommendations for the management of hypertension, obesity and renal disease in outpatients.	1/.../484*	Renal function or potassium exams, fundoscopy, or intravenous pyelograms for hypertensive patients; and renal function exams, urine analysis, or urine culture for patients with renal disease.	0
Treatment Monitoring
Lo, 2009[50]	10	Alerts for ordering laboratory tests when prescribing new medications in primary care.	22*/366/2,765	Ordering appropriate baseline laboratory tests.	0
Matheny, 2008[51]	8	Reminders for routine medication laboratory monitoring in primary care.	20*/303/1922	Ordering appropriate laboratory tests.	0
Feldstein, 2006a[52, 53]	10	Reminders to order laboratory tests when prescribing new medications in primary care.	15*/200/961	Completion of all baseline laboratory monitoring by day 25.	+
Palen, 2006[54]	9	Reminders for laboratory monitoring based on medication orders in primary care.	16/207*/26,586	Compliance with ordering the recommended laboratory tests.	0
Cobos^c, 2005[34]	10	Recommendations for hypercholesterolemia therapy, follow-up visit frequency, and laboratory test ordering for patients with hypercholesterolemia in primary care.	42*/.../2,221	Number of patient assessments (aspartate or alanine aminotransferase, or creatine kinase).	+
Raebel, 2005[55]	8	Alerts to order laboratory tests when prescribing new medications in primary care.	.../.../400,000*	Drug dispensing with completed baseline laboratory monitoring.	+
McDonald, 1980[56]	5	Detection and management of mainly medication-related problems in outpatients.	1/31*/...	Adherence to reminders for recording a finding or ordering a test.	+
McDonald, 1976[57]	2	Recommendations for laboratory tests to detect potential medication-related events in adults attending a diabetes clinic.	1/.../226*	Compliance with ordering required tests for monitoring drug effects.	+
Diagnosis
Sundaram, 2009[58]	7	Reminders for risk assessment and screening for human immunodeficiency virus in primary care.	5/32*/26,042	Change in human immunodeficiency virus testing rates.	0
Roukema, 2008[59]	7	Recommendations for the diagnostic management for children with fever without apparent source in the emergency department.	1/15/164*	Lab tests ordered.	+
Downs, 2006[60]	9	Prompts for the investigation and management of dementia in primary care.	35*/.../450	Detection of dementia and compliance with diagnostic guidelines.	+
Feldstein, 2006b[61]	8	Reminders for detection and treatment of osteoporosis in high-risk women in primary care who experienced a fracture.	15/159/311*	Receipt of bone mineral density measurement or osteoporosis medication.	+
Flottorp, 2002[62, 63]	9	Recommendations for management of urinary tract infections in women or sore throat in primary care.	142*/.../...	Use of laboratory tests for sore throat or urinary tract infection.	+
McDonald, 1984[64]	6	Reminders for cancer screening (stool occult blood, mammogram), counselling (weight reduction), immunization (influenza, pneumococcal) in addition to >1000 physician behavior rules for outpatients.	1*/130/12467	Response to reminders for occult blood, cervical smear, hematocrit, chest roentgenogram, tuberculosis skin test, serum K, mammography, reticulocytes, iron/iron binding, liver enzymes, and tests for specific conditions.	+
Other
Thomas, 2006[15]	8	Reminders to reduce inappropriate laboratory test orders in primary care.	85*/370/...	Targeted tests requested.	+
Javitt, 2005[65]	6	Recommendations for management of patients whose care deviates from recommended practices in primary care.	.../.../39,462*	Compliance with diagnostic test ordering recommendations.	....
Bates, 1999[66]	8	Reminders to reduce redundant clinical laboratory tests in hospital inpatients.	1/.../16,586*	Tests performed after reminder triggered.	+
Overhage, 1997[68]	8	CCDSS identified 'corollary orders' (tests or treatments needed to monitor or ameliorate the effects of other tests or treatments) to prevent errors of omission for any of 87 target tests and treatments in hospital inpatients on a general medicine ward.	1*/92/2,181	Compliance with corollary orders.	....
Tierney, 1988[67]	6	Provides information to reduce ordering of unnecessary diagnostic tests in primary care.	1/112/9,496*	Probability of abnormal study test.	+

Abbreviations: ACE, angiotensin-converting enzyme; BMI, body mass index; BP, blood pressure; CCDSS, computerized clinical decision support system; Hb, hemoglobin; LDL-C, low-density lipoprotein cholesterol.
*Unit of allocation.
^aEllipses (...) indicate item was not assessed or could not be evaluated.
^bOutcomes are evaluated for effect as positive (+) or negative (-) for CCDSS, or no effect (0), based on the following hierarchy. An effect is defined as ≥50% of relevant outcomes showing a statistically significant difference (2p< 0.05):
1. If a single primary outcome is reported, in which all components are applicable, this is the only outcome evaluated.
2. If >1 primary outcome is reported, the ≥50% rule applies and only the primary outcomes are evaluated.
3. If no primary outcomes are reported (or only some of the primary outcome components are relevant) but overall analyses are provided, the overall analyses are evaluated as primary outcomes. Subgroup analyses are not considered.
4. If no primary outcomes or overall analyses are reported, or only some components of the primary outcome are relevant for the clinical care area, any reported prespecified outcomes are evaluated.
5. If no clearly pre-specified outcomes are reported, any available outcomes are considered.
6. If statistical comparisons are not reported, 'effect' is designated as not evaluated (...).
^cGives suggestions for monitoring of disease and treatment and is included in both categories. Outcomes were analyzed separately in each category but overall analysis of effectiveness (reported in text) was assessed for all diagnostic testing outcomes.

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ISSN: 1748-5908

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