title: Outcomes of clinical decision support (CDS) and correlates of CDS use for home care patients with high medication regimen complexity: a randomized trial. Effects of a computerized decision support system in improving pharmacological management in high-risk cardiovascular patients: A cluster-randomized open-label controlled trial Electronic Alerts Versus On-Demand Decision Support to Improve Dyslipidemia Treatment: A Cluster Randomized Controlled Trial Improving diabetes processes of care in managed care. 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abstract: RATIONALE , AIMS AND OBJECTIVES To assess the outcomes of a clinical decision support ( CDS ) intervention design ed 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 r and omized 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 r and omized 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 This study was aim ed to investigate the effects of computerized decision support system in improving the prescription of drugs for cardiovascular prevention . A total of 197 Italian general practitioners were r and omly allocated to receive either the alerting computerized decision support system integrated into st and ard software ( intervention arm ) or the st and ard software alone ( control arm ) . Data on 21230 patients with diabetes , 3956 with acute myocardial infa rct ion , and 2158 with stroke were analysed . The proportion of patients prescribed with cardiovascular drugs and days of drug – drug interaction exposure were evaluated . Computerized decision support system significantly increased the proportion of patients with diabetes prescribed with antiplatelet drugs ( intervention : + 2.7 % vs. control : + 0.15 % ; p < 0.001 ) or lipidlowering drugs ( + 4.2 % vs. + 2.8 % ; p = 0.001 ) . A statistically significant decrease in days of potential interactions has been observed only among patients with stroke ( −1.2 vs. −0.5 days/person-year ; p = 0.001 ) . In conclusion , computerized decision support system  significantly increased the use of recommended cardiovascular drugs in diabetic patients , but it did not influence the exposure to potential Background — Indirect evidence shows that alerting users with clinical decision support systems seems to change behavior more than requiring users to actively initiate the system . However , r and omized trials comparing these methods in a clinical setting are lacking . We studied the effect of both alerting and on-dem and decision support with respect to screening and treatment of dyslipidemia based on the guidelines of the Dutch College of General Practitioners . Methods and Results — In a clustered r and omized trial design , 38 Dutch general practice s ( 77 physicians ) and 87 886 of their patients ( 39 433 men 18 to 70 years of age and 48 453 women 18 to 75 years of age ) who used the ELIAS electronic health record participated . Each practice was assigned to receive alerts , on-dem and support , or no intervention . We measured the percentage of patients screened and treated after 12 months of follow-up . In the alerting group , 65 % of the patients requiring screening were screened ( relative risk versus control=1.76 ; 95 % confidence interval , 1.41 to 2.20 ) compared with 35 % of patients in the on-dem and group ( relative risk versus control=1.28 ; 95 % confidence interval , 0.98 to 1.68 ) and 25 % of patients in the control group . In the alerting group , 66 % of patients requiring treatment were treated ( relative risk versus control=1.40 ; 95 % confidence interval , 1.15 to 1.70 ) compared with 40 % of patients ( relative risk versus control=1.19 ; 95 % confidence interval , 0.94 to 1.50 ) in the on-dem and group and 36 % of patients in the control group . Conclusion — The alerting version of the clinical decision support systems significantly improved screening and treatment performance for dyslipidemia by general practitioners OBJECTIVE To evaluate the impact of systematic patient evaluation and patient and provider feedback on the processes and intermediate outcomes of diabetes care in Independent Practice Association model internal medicine practice s. RESEARCH DESIGN AND METHODS Nine practice s providing care to managed care patients were r and omly assigned as intervention or comparison sites . Intervention-site subjects had Annual Diabetes Assessment Program ( ADAP ) assessment s ( HbA(1c  ) , blood pressure , lipids , smoking , retinal photos , urine microalbumin , and foot examination ) at years 1 and 2 . Comparison-site subjects had ADAP assessment s at year 2 . At Intervention sites , year 1 ADAP results were review ed with subjects , mailed to providers , and incorporated into electronic medical records with guideline -generated suggestions for treatment and follow-up . Medical records were evaluated for both groups for the year before both the year 1 and year 2 ADAP assessment s. Processes and intermediate outcomes were compared using linear and logistic mixed hierarchical models . RESULTS Of 284 eligible subjects , 103 of 173 ( 60 % ) at the Intervention sites and 71 of 111 ( 64 % ) at the comparison sites participated ; 83 of 103 ( 81 % ) of the intervention-site subjects returned for follow-up at year 2 . Performance of the six recommended assessment s improved in intervention-site subjects at year 2 compared with year 1 ( 5.8 vs. 4.3 , P = 0.0001 ) and compared with comparison-site subjects at year 2 ( 4.2 , P = 0.014 ) . No significant changes were noted in intermediate outcomes . CONCLUSIONS The ADAP significantly improved processes of care but not intermediate outcomes . Additional interventions are needed to improve intermediate outcomes PURPOSE Dyslipidemia treatment dramatically decreases coronary heart disease risk in diabetes , yet only a minority of these patients are screened or achieve optimal low-density lipoprotein ( LDL ) cholesterol levels . Our aim was to increase the percentage of diabetic patients in whom lipid management was achieved through electronic and direct educational detailing . METHODS The study cohort comprised 884 diabetic patients at 12 primary care practice s. Practice sites were r and omized to one of three intervention groups : electronic educational detailing , direct ( face-to-face ) educational detailing , or control . Direct and electronic detailing were performed over a 12-month period . All sites were notified of our goal to enhance lipid testing among diabetic patients . Chart abstract ion was performed 15 months after the start of the intervention . For the entire population ( n=884 ) , the proportion of patients with lipid testing was calculated , and changes from pre- to postintervention were compared across groups . We compared pre- and postintervention LDL-cholesterol changes between groups using least square means to account for site variation . RESULTS Favorable provider actions increased significantly with the intervention ( + 22 % compared with + 6 % in controls , P=.01 ) . By logistic regression , electronic detailing increased the likelihood of lipid testing ( odds ratio 3.0 , confidence interval 1.6 - 5.7 ) , as did direct detailing ( odds ratio 1.8 , confidence interval 0.9 - 3.7 ) in patients with no preintervention LDL test ( n=432 ) . Lipid testing tended to increase to a greater extent at intervention sites ( + 23 % for the combination of electronic and direct detailing vs + 11 % for controls , P=.06 ) . CONCLUSIONS Brief educational detailing either through direct or electronic communication favorably impacts provider behavior regarding dyslipidemia care for diabetic patients Background Very few studies having decision support systems as an intervention report on patient outcomes for cardiovascular disease in the Western world . The potential role of decision support system for the management of blood pressure among Indian hypertensives remains unclear . We propose a cluster r and omised trial that aims to test the effectiveness and cost effectiveness of DSS among Indian hypertensive patients . Methods The trial design is a cluster r and omised community intervention trial , in which the participants would be adult male and female hypertensive patients , in the age group of 35 to 64 years , reporting to the Primary Health Care centres of Mahabubnagar district , And hra Pradesh , India . The objective of the study is to test the effectiveness and compare the cost effectiveness and cost utility among hypertensive subjects r and omized to receive either decision support system or a chart based algorithmic support system in urban and rural areas of a district in the state of And hra Pradesh , India ( baseline versus 12 months follow up ) . The primary outcome would be a comparison of the systolic blood pressure at 0 and 12 months among hypertensive patients r and omized to receive the decision support system or the chart based algorithmic support system . Computer generated r and omisation and an investigator and analyser blinded method would be followed . 1600 participants ; 800 to each arm ; each arm having eight clusters of hundred participants each have been recruited between 01 August 2011 - 01 March 2012 . A twelve month follow up will be completed by March 2013 and results are expected by April 2013 . Discussion This cluster r and omized community intervention trial on DSS will enable policy makers to find out the effectiveness , cost effectiveness and cost utility of decision support system for management of blood pressure among hypertensive patients in India . Most of the previous studies on decision support system have focused on physician performance , adherence and on preventive care reminders . The uniqueness of the proposed study lies in finding out the effectiveness of a decision support system on patient related outcomes .Trial registration CTRI/2012/03/002476 , Clinical Trial Registry - India Background Electronic guideline -based decision support systems have been suggested to successfully deliver the knowledge embedded in clinical practice guidelines . A number of studies have already shown positive findings for decision support systems such as drug-dosing systems and computer-generated reminder systems for preventive care services . Methods A systematic literature search ( 1990 to December 2008 ) of the English literature indexed in the Medline data base , Embase , the Cochrane Central Register of Controlled Trials , and CRD ( DARE , HTA and NHS EED data bases ) was conducted to identify evaluation studies of electronic multi-step guideline implementation systems in ambulatory care setting s. Important inclusion criterions were the multidimensionality of the guideline ( the guideline needed to consist of several aspects or steps ) and real-time interaction with the system during consultation . Clinical decision support systems such as one-time reminders for preventive care for which positive findings were shown in earlier review s were excluded . Two comparisons were considered : electronic multidimensional guidelines versus usual care ( comparison one ) and electronic multidimensional guidelines versus other guideline implementation methods ( comparison two ) . Results Twenty-seven publications were selected for analysis in this systematic review . Most design s were cluster r and omized controlled trials investigating process outcomes more than patient outcomes . With success defined as at least 50 % of the outcome variables being significant , none of the studies were successful in improving patient outcomes . Only seven of seventeen studies that investigated process outcomes showed improvements in process of care variables compared with the usual care group ( comparison one ) . No incremental effect of the electronic implementation over the distribution of paper versions of the guideline was found , neither for the patient outcomes nor for the process outcomes ( comparison two ) . Conclusions There is little evidence at the moment for the effectiveness of an increasingly used and commercialised instrument such as electronic multidimensional guidelines . After more than a decade of development of numerous electronic systems , research on the most effective implementation strategy for this kind of guideline -based decision support systems is still lacking . This conclusion implies a considerable risk towards inappropriate investments in ineffective implementation interventions and in suboptimal care BACKGROUND Optimal care for patients with diabetes is difficult to achieve in clinical practice . OBJECTIVE To evaluate the impact of a registry and decision support system on processes of care , and physiologic control . PARTICIPANTS R and omized trial with clustering at the practice level , involving 7,412 adults with diabetes in 64 primary care practice s in the Northeast . INTERVENTIONS Provider decision support ( reminders for overdue diabetes tests , alerts regarding abnormal results , and quarterly population reports with peer comparisons ) and patient decision support ( reminders and alerts ) . MEASUREMENTS AND MAIN RESULTS Process and physiologic outcomes were evaluated in all subjects . Functional status was evaluated in a r and om patient sample via question naire . We used multiple logistic regression to quantify the effect , adjusting for clustering and potential confounders . Intervention subjects were significantly more likely to receive guideline -appropriate testing for cholesterol ( OR = 1.39 ; [ 95%CI 1.07 , 1.80 ] P = 0.012 ) , creatinine ( OR = 1.40 ; [ 95%CI 1.06 , 1.84 ] P = 0.018 ) , and proteinuria ( OR = 1.74 ; [ 95%CI 1.13 , 1.69 ] P = 0.012 ) , but not A1C ( OR = 1.17 ; [ 95 % CI 0.80 , 1.72 ] P = 0.43 ) . Rates of control of A1C and LDL cholesterol were similar in the two groups . There were no differences in blood pressure , body mass index , or functional status . CONCLUSIONS A chronic disease registry and decision support system based on easily obtainable laboratory data was feasible and acceptable to patients and providers . This system improved the process of laboratory monitoring in primary care , but not physiologic control Abstract Objectives : To investigate the effect of a computer based clinical decision support system and a risk chart on absolute cardiovascular risk , blood pressure , and prescribing of cardiovascular drugs in hypertensive patients . Design : Cluster r and omised controlled trial . Setting : 27 general practice s in Avon . Participants : 614 patients aged between 60 and 79 years with high blood pressure . Interventions : Patients were r and omised to computer based clinical decision support system plus cardiovascular risk chart ; cardiovascular risk chart alone ; or usual care . Main outcome measures : Percentage of patients in each group with a five year cardiovascular risk≥10 % , systolic blood pressure , diastolic blood pressure , prescribing of cardiovascular drugs . Results : Patients in the computer based clinical decision support system and chart only groups were no more likely to have cardiovascular risk reduced to below 10 % than patients receiving usual care . Patients in the computer based clinical decision support group were more likely to have a cardiovascular risk≥10 % than chart only patients , odds ratio 2.3 ( 95 % confidence interval 1.1 to 4.8 ) . The chart only group had significantly lower systolic blood pressure compared with the usual care group ( difference in means−4.6 mm Hg ( 95 % confidence interval−8.4 to−0.8 ) . Reduction of diastolic blood pressure did not differ between the three groups . The chart only group were twice as likely to be prescribed two classes of cardiovascular drugs and over three times as likely to be prescribed three or more classes of drugs compared with the other groups . Conclusions : The computer based clinical decision support system did not confer any benefit in absolute risk reduction or blood pressure control and requires further development and evaluation before use in clinical care can be recommended . Use of chart guidelines are associated with a potentially important reduction in systolic blood pressure BACKGROUND Computerized decision support systems ( CDSSs ) linked with electronic medical records ( EMRs ) are promoted as an effective means of improving patient care . However , very few high- quality studies are set in routine , community-based clinical care , and no consistent evidence of an effect on patient outcomes has been found . METHODS A r and omized controlled trial among EMR-using primary care practice s in Ontario , Canada . Patients 55 years or older with previous vascular events , diabetes mellitus , hypertension , or hypercholesterolemia were r and omized to the Computerization of Medical Practice s for the Enhancement of Therapeutic Effectiveness ( COMPETE III ) CDSS intervention or to usual care . The intervention included personally tailored electronic vascular risk monitoring and treatment advice shared between the physician and patient , risk calculation , and a clinical re source . The primary outcome was a composite score of 8 recommended process outcomes at 1 year . Data collectors were blinded to group allocation . Analysis used the intention-to-treat principle with multiple imputation for missing data . RESULTS We r and omized and included in the analysis 1102 patients in 49 community-based physician practice s ( 53.4 % female ; mean age , 69.1 years ; 28.0 % with a previous vascular event ) . The intervention group ( 545 [ 49.5 % ] ) had a significantly greater improvement in mean process composite , with a difference of 4.70 ( P < .001 ) on a 27-point scale . Intervention patients had significantly higher odds of rating their continuity of care ( 4.18 ; P < .001 ) and their ability to improve their vascular health ( 3.07 ; P < .001 ) as improved . Despite this improvement , the clinical outcomes -vascular events , clinical variables , and quality of life-were not improved . CONCLUSION Despite favorable review s and important improvements in the complex processes required to reduce vascular risk , clinical outcomes remain unchanged OBJECTIVE —The Diabetes Care Protocol combines task delegation ( a practice nurse ) , computerized decision support , and feedback every 3 months . We studied the effect of the Diabetes Care Protocol on A1C and cardiovascular risk factors in type 2 diabetic patients in primary care . RESEARCH DESIGN AND METHODS —In a cluster r and omized trial , mean changes in cardiovascular risk factors between the intervention and control groups after 1 year were calculated by generalized linear models . RESULTS —Throughout the Netherl and s , 26 intervention practice s included 1,699 patients and 29 control practice s 1,692 patients . The difference in A1C change was not significant , whereas total cholesterol , LDL cholesterol , and blood pressure improved significantly more in the intervention group . The 10-year coronary heart disease risk estimate of the UK Prospect i ve Diabetes Study improved 1.4 % more in the intervention group . CONCLUSIONS —Delegation of routine diabetes care to a practice nurse combined with computerized decision support and feedback did not improve A1C but reduced cardiovascular risk in type 2 diabetes patients Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more OBJECTIVE Management of diabetes is frequently suboptimal in primary care setting s , where providers often fail to intensify therapy when glucose levels are high , a problem known as clinical inertia . We asked whether interventions targeting clinical inertia can improve outcomes . RESEARCH DESIGN AND METHODS A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center . We studied all patients ( 4,138 ) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were r and omized to be control subjects or to receive one of three interventions . Instead of consultative advice , the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient 's visit , individual face-to-face feedback on performance for 5 min every 2 weeks , or both . RESULTS Over an average patient follow-up of 15 months within the intervention site , improvements in and final HbA1c ( A1C ) with feedback + reminders ( deltaA1C 0.6 % , final A1C 7.46 % ) were significantly better than control ( deltaA1C 0.2 % , final A1C 7.84 % , P < 0.02 ) ; changes were smaller with feedback only and reminders only ( P = NS vs. control ) . Trends were similar but not significant with systolic blood pressure ( sBP ) and LDL cholesterol . Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabetes Association goals for both A1C and sBP . Over a 2-year period , overall glycemic control improved in the intervention site but did not change in other primary care sites ( final A1C 7.5 vs. 8.2 % , P < 0.001 ) . CONCLUSIONS Feedback on performance aim ed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control . Partnering generalists with diabetes specialists may be important to enhance diabetes management in other primary care setting Objective To determine the effectiveness of a patient decision aid ( PDA ) to improve decision quality and glycaemic control in people with diabetes making treatment choices using a cluster r and omised controlled trial ( RCT ) . Design A cluster RCT . Setting 49 general practice s in UK r and omised into intervention ( n=25 ) and control ( n=24 ) . Participants General practice s Inclusion criteria : > 4 medical partners ; list size > 7000 ; and a diabetes register with > 1 % of practice population . 191 practice s assessed for eligibility , and 49 practice s r and omised and completed the study . Patients People with type 2 diabetes mellitus ( T2DM ) taking at least two oral glucose-lowering drugs with maximum tolerated dose with a glycosolated haemoglobin ( HbA1c ) greater than 7.4 % ( IFCC HbA1c > 57 mmol/mol ) or advised in the preceeding 6 months to add or consider changing to insulin therapy . Exclusion criteria : currently using insulin therapy ; difficulty reading or underst and ing English ; difficulty in underst and  ing the purpose of the study ; visual or cognitive impairment or mentally ill . A total of 182 assessed for eligibility , 175 r and omised to 95 intervention and 80 controls , and 167 completion and analysis .  Intervention Brief training of clinicians and use of PDA with patients in single consultation . Primary outcomes Decision quality ( Decisional Conflict Scores , knowledge , realistic expectations and autonomy ) and glycaemic control ( glycosolated haemoglobin , HbA1c ) . Secondary outcomes Knowledge and realistic expectations of the risks and benefits of insulin therapy and diabetic complications . Results Intervention group : lower total Decisional Conflict Scores ( 17.4 vs 25.2 , p<0.001 ) ; better knowledge ( 51.6 % vs 28.8 % , p<0.001 ) ; realistic expectations ( risk of ‘ hypo ’ , ‘ weight gain ’ , ‘ complications ’ ; 81.0 % vs 5.2 % , 70.5 % vs 5.3 % , 26.3 % vs 5.0 % respectively , p<0.001 ) ; and were more autonomous in decision-making ( 64.1 % vs 42.9 % , p=0.012 ) . No significant difference in the glycaemic control between the two groups . Conclusions Use of the P AND As decision aid reduces decisional conflict , improves knowledge , promotes realistic expectations and autonomy in people with diabetes making treatment choices in general practice . IS RCT N Trials Register Number 14842077 OBJECTIVES This study aim ed to assess the uptake and effect in primary care of a computerized decision support system ( DSS ) for the management of  hyperlipidaemia .  METHOD A prospect i ve controlled trial was conducted in 25 practice s covering a population of 150,000 in the city of Birmingham . The Primed system , a specialist developed , rule based DSS for general practice , was introduced prospect ively after a 3-month baseline data collection . The main outcome measures were nine months ' data on prescribing of lipid lowering agents ; use of laboratory tests ; and referrals to secondary care for the investigation of hyperlipidaemia . RESULTS System use was lower than expected . A shift was observed towards requests for appropriate follow-up of previously abnormal lipid results and a greater emphasis on full lipid profiles , in line with the DSS guidelines . Referrals showed a 55 % decrease on those expected ( NS ) . The prescribing evaluation revealed a large variation between practice s , but no significant alteration following system use . Views of users favoured decision support as a concept , but criticised technical problems with the system . CONCLUSIONS Greater integration of DSS software and practice based data h and ling systems is needed . The mode of data capture , and hence both the content and form of knowledge representation , in DSS must take greater account of the primary care consultation process if such systems are to be of use to practitioners BACKGROUND Physician adherence to National Cholesterol Education Program clinical practice guidelines has been poor . METHODS We recruited 68 primary care family and internal medicine practice s ; 66 were r and omly allocated to a study arm ; 5 practice s withdrew , result ing in 29 receiving the Third Adult Treatment Panel ( ATP III ) intervention and 32 receiving an alternative intervention focused on the Seventh Report of the Joint National Committee on the Prevention , Detection , Evaluation , and Treatment of High Blood Pressure ( JNC-7 ) . The ATP III providers received a personal digital assistant providing the Framingham risk scores and ATP III-recommended treatment . All practice s received copies of each clinical practice guideline , an introductory lecture , 1 performance feedback report , and 4 visits for intervention-specific academic detailing . Data were abstract ed at 61 practice s from r and om sample s of medical records of patients treated from June 1 , 2001 , through May 31 , 2003 ( baseline ) , and from May 1 , 2004 , through April 30 , 2006 ( follow-up ) . The proportion screened with subsequent appropriate decision making ( primary outcome ) was calculated . Generalized estimating equations were used to compare results by arm , accounting for clustering of patients within practice s. RESULTS We examined 5057 baseline and 3821 follow-up medical records . The screening rate for lipid levels increased from 43.6 % to 49.0 % ( ATP III practice s ) and from 40.1 % to 50.8 % ( control practice s ) ( net difference , -5.3 % [ P = .22 ] ) . Appropriate management of lipid levels decreased slightly ( 73.4 % to 72.3 % ) in ATP III practice s and more markedly ( 79.7 % to 68.9 % ) in control practice s. The net change in appropriate management favored the intervention ( + 9.7 % ; 95 % confidence interval [ CI ] , 2.8%-16.6 % [ P < .01 ] ) . Appropriate drug prescription within 4 months decreased in both arms ( 38.8 % to 24.8 % in ATP III practice s and 45.3 % to 24.1 % in control practice s ; net change , + 7.2 % [ P = .37 ] ) Overtreatment declined from 6.6 % to 3.9 % in ATP III and rose from 4.2 % to 6.4 % in control practice s ( net change , -4.9 % [ P = .01 ] ) . CONCLUSIONS A multifactor intervention including personal digital assistant-based decision support may improve primary care physician adherence to the ATP III guidelines . Trial Registration clinical trials.gov Identifier : NCT00224848 Aims We assessed whether a novel programme to evaluate/communicate predicted coronary heart disease ( CHD ) risk could lower patients ' predicted Framingham CHD risk vs. usual care . Methods The Risk Evaluation and Communication Health Outcomes and Utilization Trial was a prospect i ve , controlled , cluster-r and omised trial in nine European countries , among patients at moderate cardiovascular risk . Following baseline assessment s , physicians in the intervention group calculated patients ' predicted CHD risk and were instructed to advise patients according to a risk evaluation/communication programme . Usual care physicians did not calculate patients ' risk and provided usual care only . The primary end-point was Framingham 10-year CHD risk at 6 months with intervention vs. usual care . Results Of 1103 patients across 100 sites , 524 patients receiving intervention , and 461 receiving usual care , were analysed for efficacy . After 6 months , mean predicted risks were 12.5 % with intervention , and 13.7 % with usual care [ odds ratio = 0.896 ; p = 0.001 , adjusted for risk at baseline ( 17.2 % intervention ; 16.9 % usual care ) and other covariates ] . The proportion of patients achieving both blood pressure and low-density lipoprotein cholesterol targets was significantly higher with intervention ( 25.4 % ) than usual care ( 14.1 % ; p < 0.001 ) , and 29.3 % of smokers in the intervention group quit smoking vs. 21.4 % of those receiving usual care ( p = 0.04 ) . Conclusions A physician-implemented CHD risk evaluation/communication programme improved patients ' modifiable risk factor profile , and lowered predicted CHD risk compared with usual care . By combining this strategy with more intensive treatment to reduce residual modifiable risk , we believe that substantial improvements in cardiovascular disease prevention could be achieved in clinical practice Background R and omized 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 ) setting s. Methods and Results We performed a cluster r and omized 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 r and omized 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 re source ‐constrained PHC setting s. Clinical Trial Registration URL : http://www.ctri.nic.in . Unique identifier : CTRI/2012/03/002476 Background Electronic medical records ( EMRs ) have the potential to facilitate the design of large cluster-r and omized trials ( CRTs ) . Objective To describe the design of a CRT of clinical decision support to improve diabetes care and outcomes . Methods In the Diabetes Improvement Group-Intervention Trial ( DIG-IT ) , we identified and balanced preassignment characteristics of 12,675 diabetic patients cared for by 147 physicians in 24 practice s of 2 systems using the same vendor ’s EMR . EMR-facilitated disease management was system A ’s experimental intervention ; system B interventions involved patient empowerment , with or without disease management . For our sample , we : ( 1 ) identified characteristics associated with response to interventions or outcomes ; ( 2 ) summarized feasible partitions of 10 system A practice s ( 2 groups ) and 14 system B practice s ( 3 groups ) using intra-cluster correlation coefficients ( ICCs ) and st and ardized differences ; ( 3 ) selected ( blinded ) partitions to effectively balance the characteristics ; and ( 4 ) r and omly assigned groups of practice s to interventions . Results In System A , 4,306 patients , were assigned to 2 groups of practice s ; 8,369 patients in system B were assigned to 3 groups of practice s. Nearly all baseline outcome variables and covariates were well-balanced , including several not included in the initial design . DIG-IT ’s balance was superior to alternative partitions based on volume , geography or demographics alone . Conclusions EMRs facilitated rigorous CRT design by identifying large numbers of patients with diabetes and enabling fair comparisons through preassignment balancing of practice sites . Our methods can be replicated in other setting s and for other conditions , enhancing the power of other translational investigations PURPOSE We wanted to determine whether an intervention based on patient activation and a physician decision support tool was more effective than usual care for improving adherence to National Cholesterol Education Program guidelines . METHODS A 1-year cluster r and omized controlled trial was performed using 30 primary care practice s ( 4,105 patients ) in southeastern New Engl and . The main outcome was the percentage of patients screened for hyperlipidemia and treated to their low-density lipoprotein ( LDL ) and non – high-density lipoprotein ( HDL ) cholesterol goals . RESULTS After 1 year of intervention , both r and omized practice groups improved screening ( 89 % screened ) , and 74 % of patients in both groups were at their LDL and non-HDL cholesterol goals ( P < .001 ) . Using intent-to-treat analysis , we found no statistically significant differences between practice groups in screening or percentage of patients who achieved LDL and non-HDL cholesterol goals . Post hoc analysis showed practice s who made high use of the patient activation kiosk were more likely to have patients screened ( odds ratio [ OR ] = 2.54 ; 95 % confidence interval [ CI ] , 1.97–3.27 ) compared with those who made infrequent or no use . Additionally , physicians who made high use of decision support tools were more likely to have their patients at their LDL cholesterol goals ( OR = 1.27 ; 95 % CI , 1.07–1.50 ) and non-HDL goals ( OR = 1.23 ; 95 % CI , 1.04–1.46 ) than low-use or no-use physicians . CONCLUSION This study showed null results with the intent-to-treat analysis regarding the benefits of a patient activation and a decision support tool in improving cholesterol management in primary care practice s. Post hoc analysis showed a potential benefit in practice s that used the e-health tools more frequently in screening and management of dyslipidemia . Further research on how to incorporate and increase adoption of user-friendly , patient-centered e-health tools to improve screening and management of chronic diseases and their risk factors is warranted OBJECTIVE : Suboptimal treatment of hyperlipidemia in patients with coronary artery disease ( CAD ) is well documented . We report the impact of a computer-assisted physician-directed intervention to improve secondary prevention of hyperlipidemia . DESIGN AND SETTING : Two hundred thirty-five patients under the care of 14 primary care physicians in an academically affiliated practice with an electronic health record were enrolled in this proof-of-concept physician-blinded r and omized , controlled trial . Each patient with CAD or risk equivalent above National Cholesterol Education Program-recommended low-density lipoprotein ( LDL ) treatment goal for greater than 6 months was r and omized , stratified by physician and baseline LDL . Physicians received a single e-mail per intervention patient . E-mails were visit independent , provided decision support , and facilitated “ one-click ” order writing . MEASUREMENTS : The primary outcomes were changes in hyperlipidemia prescriptions , time to prescription change , and changes in LDL levels . The time spent using the system was assessed among intervention patients . RESULTS : A greater proportion of intervention patients had prescription changes at 1 month ( 15.3 % vs 2 % , P=.001 ) and 1 year ( 24.6 % vs 17.1 % , P=.14 ) . The median interval to first medication adjustment occurred earlier among intervention patients ( 0 vs 7.1 months , P=.005 ) . Among patients with baseline LDLs > 130 mg/dL , the first postintervention LDLs were substantially lower in the intervention group ( 119.0 vs 138.0 mg/dL , P=.04 ) . Physician processing time was under 60 seconds per e-mail . CONCLUSION : A visit-independent disease management tool result ed in significant improvement in secondary prevention of hyperlipidemia at 1-month postintervention and showed a trend toward improvement at 1 year PURPOSE Clinical guidelines are design ed to assist in the management of specific diseases ; however , these guidelines are often neglected in the delivery of care . The purpose of this study was to determine whether clinician use of an clinical practice guideline would increase in response to having , at the patient visit , a decision support system based on a practice guideline that generates a customized management protocol for the individual patient using data from the patient 's electronic medical record . SUBJECTS AND METHODS In a 6-month controlled trial at a primary care clinic , 58 primary care clinicians were r and omized to receive either a special encounter form with the computer-generated guideline recommendations or a st and ard encounter form . The effect of computer-generated advice on clinician behavior was measured as rate of compliance with guideline recommendations . Data from 30 clinicians were analyzed ; data from 28 clinicians were excluded because these clinicians did not meet predefined criteria for minimum exposure to diabetic patient care . RESULTS Availability of patient management recommendations generated by the decision support system result ed in a two-fold increase in clinician compliance with care guidelines for diabetes mellitus ( P = 0.01 ) . Median compliance for the group receiving the recommendations was 32.0 % versus 15.6 % for the control group . CONCLUSION Decision support based on a clinical practice guideline is an effective tool for assisting clinicians in the management of diabetic patients . This decision support system provides a model for how a clinical practice guideline can be integrated into the care process by computer to assist clinicians in managing a specific disease through helping them comply with care st and ards . Use of decision support systems based on clinical practice guidelines could ultimately improve the quality of medical care Background : Diabetes mellitus is a complex disease with serious complications . Electronic decision support , providing information that is shared and discussed by both patient and physician , encourages timely interventions and may improve the management of this chronic disease . However , it has rarely been tested in community-based primary care . Methods : In this pragmatic r and omized trial , we r and omly assigned adult primary care patients with type 2 diabetes to receive the intervention or usual care .  The intervention involved shared access by the primary care provider and the patient to a Web-based , colour-coded diabetes tracker , which provided sequential monitoring values for 13 diabetes risk factors , their respective targets and brief , prioritized messages of advice . The primary outcome measure was a process composite score . Secondary outcomes included clinical composite scores , quality of life , continuity of care and usability . The outcome assessors were blinded to each patient ’s intervention status . Results : We recruited sequentially 46 primary care providers and then 511 of their patients ( mean age 60.7 [ st and ard deviation 12.5 ] years ) . Mean follow-up was 5.9 months . The process composite score was significantly better for patients in the intervention group than for control patients ( difference 1.27 , 95 % confidence interval [ CI ] 0.79–1.75 , p < 0.001 ) ; 61.7 % ( 156/253 ) of patients in the intervention group , compared with 42.6 % ( 110/258 ) of control patients , showed improvement ( difference 19.1 % , p < 0.001 ) . The clinical composite score also had significantly more variables with improvement for the intervention group ( 0.59 , 95 % CI 0.09–1.10 , p = 0.02 ) , including significantly greater declines in blood pressure ( −3.95 mm Hg systolic and −2.38 mm Hg diastolic ) and glycated hemoglobin ( −0.2 % ) . Patients in the intervention group reported greater satisfaction with their diabetes care . Interpretation : A shared electronic decision-support system to support the primary care of diabetes improved the process of care and some clinical markers of the quality of diabetes care . ( Clinical Trials.gov trial register no. NCT00813085 . In a distributed information search task , data representation and cognitive distribution jointly affect user search performance in terms of response time and accuracy . Guided by UFuRT ( User , Function , Representation , Task ) , a human-centered framework , we proposed a search model and task taxonomy . The model defines its application in the context of healthcare setting . The taxonomy clarifies the legitimate operations for each type of search task of relational data . We then developed experimental prototypes of hyperlipidemia data displays . Based on the displays , we tested the search tasks performance through two experiments . The experiments are of a within-subject design with a r and om sample of 24 participants . The results support our hypotheses and vali date the prediction of the model and task taxonomy . In this study , representation dimensions , data scales , and search task types are the main factors in determining search efficiency and effectiveness . Specifically , the more external representations provided on the interface the better search task performance of users . The results also suggest the ideal search performance occurs when the question type and its corresponding data scale representation match . The implication s of the study lie in contributing to the effective design of search interface for relational data , especially laboratory results , which could be more effectively design ed in electronic medical records Purpose To assess the impact of personalised physician learning ( PPL ) interventions using simulated learning cases on control of  hypertension and dyslipidaemia in primary care setting s. Methods A total of 132 primary care physicians , 4568 eligible patients with uncontrolled hypertension , and 15 392 eligible patients with uncontrolled dyslipidaemia were cluster-r and omised to one of three conditions : ( a ) no intervention , ( b ) PPL-electronic medical record ( EMR ) intervention in which 12 PPL cases were assigned to each physician based on observed patterns of care in the EMR in the previous year , or ( c ) PPL-ASSESS intervention in which 12 PPL cases were assigned to each physician based on their performance on four st and ardised assessment cases . General and generalised linear mixed models were used to account for clustering and to model differences in patient outcomes in the study arms . Results Among patients with uncontrolled hypertension at baseline , 49.1 % , 46.6 % and 47.3 % ( p=0.43 ) achieved blood pressure ( BP ) targets at follow-up . Among patients with uncontrolled dyslipidaemia at baseline , 37.5 % , 37.3 % and 38.1 % ( p=0.72 ) achieved low density lipoprotein cholesterol targets at follow-up in PPL-EMR , PPL-ASSESS and the control group , respectively . Although systolic ( BP ) ( p<0.001 ) and lipid ( p<0.001 ) values significantly improved during the study , the group-by-time interaction term showed no differential change in systolic BP values ( p=0.51 ) or lipid values ( p=0.61 ) among the three study arms . No difference in intervention effect was noted when comparing the PPL-EMR with the PPL-ASSESS intervention ( p=0.47 ) . Conclusions The two PPL interventions tested in this study did not lead to improved control of hypertension or dyslipidaemia in primary care clinics during a mean 14-month follow-up period . This null result may have been due in part to substantial overall improvement in BP and lipid control at the study sites during the study . Trial registration number NCT00903071 Computerized reminder systems have been shown to be effective in improving physician compliance with preventive services guidelines . Very little has been published about the use of computerized reminders for preventive care in diabetes . We implemented a computer-generated reminder system for diabetes care guidelines in a r and omized controlled study in the outpatient clinics of 35 internal medicine residents at the University of Utah and Salt Lake Veterans Affairs Hospitals . After a six month study period , compliance with the recommended care significantly improved in both the intervention group that received patient-specific reminders about the guidelines ( 38.0 % at baseline , 54.9 % at follow-up ) and the control group that received a nonspecific report ( 34.6 % at baseline , 51.0 % at follow-up ) . There was no significant difference between the two groups . Both clinic sites showed similar improvement over baseline levels of compliance .  Residents who completed encounter forms used by the system showed a significantly greater improvement in compliance than those who did not complete encounter forms ( 19.7 % vs. 7.6 % , p = 0.006 ) . The improvements in guideline compliance were seen in all areas of diabetes preventive care studied , and significant improvements were seen with recommended items from the medical history , physical exam , laboratory testing , referrals , and patient education . The use of encounter forms by the providers significantly improved documented compliance with the guidelines in almost all categories of preventive care . These results suggest that computerized reminder systems improve compliance with recommended care more by facilitating the documentation of clinical findings and the ordering of recommended procedures than by providing the clinician with patient-specific information about guideline compliance status . Further study is needed to underst and the implication s of these findings to the development of future computerized reminder systems for chronic diseases such as diabetes BACKGROUND Achievement of diabetes care goals is suboptimal globally . Diabetes-focused quality improvement ( QI ) is effective but remains untested in South Asia . OBJECTIVE To compare the effect of a multicomponent QI strategy versus usual care on cardiometabolic profiles in patients with poorly controlled diabetes . DESIGN Parallel , open-label , pragmatic r and omized , controlled trial . ( Clinical Trials.gov : NCT01212328 ) . SETTING Diabetes clinics in India and Pakistan . PATIENTS 1146 patients ( 575 in the intervention group and 571 in the usual care group ) with type 2 diabetes and poor cardiometabolic profiles ( glycated hemoglobin [ HbA1c ] level ≥8 % plus systolic blood pressure [ BP ] ≥140 mm Hg and /or low-density lipoprotein cholesterol [ LDLc ] level ≥130 mg/dL ) .  INTERVENTION Multicomponent QI strategy comprising nonphysician care coordinators and decision-support electronic health records . MEASUREMENTS Proportions achieving HbA1c level less than 7 % plus BP less than 130/80 mm Hg and /or LDLc level less than 100 mg/dL ( primary outcome ) ; mean risk factor reductions , health-related quality of life ( HRQL ) , and treatment satisfaction ( secondary outcomes ) . RESULTS Baseline characteristics were similar between groups . Median diabetes duration was 7.0 years ; 6.8 % and 39.4 % of participants had preexisting cardiovascular and microvascular disease , respectively ; mean HbA1c level was 9.9 % ; mean BP was 143.3/81.7 mm Hg ; and mean LDLc level was 122.4 mg/dL. Over a median of 28 months , a greater percentage of intervention participants achieved the primary outcome ( 18.2 % vs. 8.1 % ; relative risk , 2.24 [ 95 % CI , 1.71 to 2.92 ] ) . Compared with usual care , intervention participants achieved larger reductions in HbA1c level ( -0.50 % [ CI , -0.69 % to -0.32 % ] ) , systolic BP ( -4.04 mm Hg [ CI , -5.85 to -2.22 mm Hg ] ) , diastolic BP ( -2.03 mm Hg [ CI , -3.00 to -1.05 mm Hg ] ) , and LDLc level ( -7.86 mg/dL [ CI , -10.90 to -4.81 mg/dL ] ) and reported higher HRQL and treatment satisfaction . LIMITATION Findings were confined to urban specialist diabetes clinics . CONCLUSION Multicomponent QI improves achievement of diabetes care goals , even in re source -challenged clinics . PRIMARY FUNDING SOURCE National Heart , Lung , and Blood Institute and UnitedHealth Group PURPOSE Recent efforts to encourage meaningful use of electronic health records ( EHRs ) assume that widespread adoption will improve the quality of ambulatory care , especially for complex clinical conditions such as diabetes . Cross-sectional studies of typical uses of commercially available ambulatory EHRs provide conflicting evidence for an association between EHR use and improved care , and effects of longer-term EHR use in community-based primary care setting s on the quality of care are not well understood . METHODS We analyzed data from 16 EHR-using and 26 non – EHR-using practice s in 2 northeastern states participating in a group-r and omized quality improvement trial . Measures of care were assessed for 798 patients with diabetes . We used hierarchical linear models to examine the relationship between EHR use and adherence to evidence -based diabetes care guidelines , and hierarchical logistic models to compare rates of improvement over 3 years . RESULTS EHR use was not associated with better adherence to care guidelines or a more rapid improvement in adherence . In fact , patients in practice s that did not use an EHR were more likely than those in practice s that used an EHR to meet all of 3 intermediate outcomes targets for hemoglobin A1c , low-density lipoprotein cholesterol , and blood pressure at the 2-year follow-up ( odds ratio = 1.67 ; 95 % CI , 1.12–2.51 ) . Although the quality of care improved across all practice s , rates of improvement did not differ between the 2 groups . CONCLUSIONS Consistent use of an EHR over 3 years does not ensure successful use for improving the quality of diabetes care . Ongoing efforts to encourage adoption and meaningful use of EHRs in primary care should focus on ensuring that use succeeds in improving care . These efforts will need to include provision of assistance to longer-term EHR users AIMS To evaluate the effectiveness of a multifaceted intervention to improve the clinical decision making of general practitioners ( GPs ) for patients with diabetes . To identify practice characteristics which predict success . METHODS Cluster r and omized controlled trial with 124 practice s and 185 GPs in The Netherl and s. The intervention group received feedback reports and support from a facilitator ; the control group received no special attention . Outcome measures were the  compliance rates with evidence -based recommendations pertaining to discussion of body weight control , discussion of problems with medication , blood pressure measurement , foot examination , eye examination , initiating anti-diabetic medication or increasing the dosage in cases of uncontrolled blood glucose , and scheduling a follow-up appointment .  RESULTS The GPs reported on their clinical decision making in 1410 consultations with Type 2 diabetic patients at baseline and 1449 consultations after the intervention period . The intervention result ed in statistically significant improvement for two of the seven outcome measures : foot examination ( odds ratio 1.68 ; 95 % confidence interval 1.19 - 2.39 ) and eye examination ( 1.52 ; 1.07 - 2.16 ) . Discussion of problems with medication showed a near significant trend towards increased benefit for the intervention group ( 1.52 ; 0.99 - 2.32 ) . Practice characteristics were not found to be related to the success of the intervention . CONCLUSIONS Feedback reports with support from facilitators appear to increase rates of foot examination and eye examination in general practice . Alternative interventions should be explored to improve the pursuit of metabolic control by GPs Background : Achieving optimum blood glucose control in patients with type 2 diabetes mellitus ( T2DM ) is difficult . Some primary care physicians ( PCPs ) delay the start of insulin use because of the uncertainty in intensifying insulin therapy . The objective was to develop and vali date a computer application ( CA ) that helps PCPs to make decisions about insulin therapy in order to achieve a significant improvement in glycated hemoglobin ( HbA1c ) . Methods : This was a cluster-r and omized clinical trial . Fourteen primary care centers ( PCCs ) in Madrid with 66 PCPs and 697 T2DM patients on insulin therapy were r and omly divided into two groups of seven PCCs each . In the intervention group , seven PCCs included 39 PCPs and 365 T2DM patients on insulin therapy . These PCPs were free to use the CA . A further seven PCCs were assigned to the control group with 27 PCPs and 332 T2DM patients on insulin therapy . The control group did not use the CA . The duration of the trial was 18 months to vali date the CA . The outcome was a change in HbA1c from baseline . Results : In the intervention group , the final HbA1c was 7.19 % ( st and ard deviation [ SD ] ± 0.93 ) , with a difference from the start of −0.69 % ( p = .001 ) . In the control group , it was 7.71 % ( SD ± 1.37 ) , with a difference from the start of −0.09 % ( p not significant ) . Conclusions : This CA helps to improve HbA1c figures of T2DM patients with insulin when it is used by PCPs to make decisions when starting , continuing , or changing insulin and its dosage OBJECTIVE To evaluate whether a new documentation-based clinical decision support system ( CDSS ) is effective in addressing deficiencies in the care of patients with coronary artery disease ( CAD ) and diabetes mellitus ( DM ) . STUDY DESIGN Controlled trial r and omized by physician . METHODS We assigned primary care physicians ( PCPs ) in 10 ambulatory practice s to usual care or the CAD/DM Smart Form for 9 months . The primary outcome was the proportion of deficiencies in care that were addressed within 30 days after a patient visit . RESULTS The Smart Form was used for 5.6 % of eligible patients . In the intention-to-treat analysis , patients of intervention PCPs had a greater proportion of deficiencies addressed within 30 days of a visit compared with controls ( 11.4 % vs 10.1 % , adjusted and clustered odds ratio = 1.14 ; 95 % confidence interval , 1.02 - 1.28 ; P = .02 ) . Differences were more pronounced in the " on-treatment " analysis : 17.0 % of deficiencies were addressed after visits in which the Smart Form was used compared with 10.6 % of deficiencies after visits in which it was not used ( P < .001 ) . Measures that improved included documentation of smoking status and prescription of antiplatelet agents when appropriate . CONCLUSIONS Overall use of the CAD/DM Smart Form was low , and improvements in management were modest . When used , documentation-based decision support shows promise , and future studies should focus on refining such tools , integrating them into current electronic health record platforms , and promoting their use , perhaps through organizational changes to primary care practice OBJECTIVE There is a well-documented gap between diabetes care guidelines and the services received by patients in most health care setting s. This report presents 12-month follow-up results from a computer-assisted , patient-centered intervention to improve the level of recommended services patients received from a variety of primary care setting s. RESEARCH DESIGN AND METHODS A total of 886 patients with type 2 diabetes under the care of 52 primary care physicians participated in the Diabetes Priority Program . Physicians were stratified and r and omized to intervention or control conditions and evaluated on two primary outcomes : number of recommended laboratory screenings and recommended patient-centered care activities completed from the National Committee on Quality Assurance/American Diabetes Association Provider Recognition Program ( PRP ) . Secondary outcomes were evaluated using the Problem Areas in Diabetes 2 quality of life scale , lipid and HbA1c levels , and the Patient Health Question naire-9 depression scale . RESULTS The program was well implemented and significantly improved both the number of laboratory assays and patient-centered aspects of diabetes care patients received compared with those in the control condition . There was overall improvement on secondary outcomes of lipids , HbA1c , quality of life , and depression scores ; between-condition differences were not significant . CONCLUSIONS Staff in small , mixed-payer primary care offices can consistently implement a patient-centered intervention to improve PRP measures of quality of diabetes care . Alternative explanations for why these process improvements did not lead to improved outcomes , and suggested directions for future research are discussed BACKGROUND Web-based personal health records ( PHRs ) have been advocated as a means to improve type 2 diabetes mellitus ( DM ) care . However , few Web-based systems are linked directly to the electronic medical record ( EMR ) used by physicians . METHODS We r and omized 11 primary care practice s. Intervention practice s received access to a DM-specific PHR that imported clinical and medications data , provided patient-tailored decision support , and enabled the patient to author a " Diabetes Care Plan " for electronic su bmi ssion to their physician prior to upcoming appointments . Active control practice s received a PHR to up date and su bmi t family history and health maintenance information . All patients attending these practice s were encouraged to sign up for online access . RESULTS We enrolled 244 patients with DM ( 37 % of the eligible population with registered online access , 4 % of the overall population of patients with DM ) . Study participants were younger ( mean age , 56.1 years vs 60.3 years ; P < .001 ) and lived in higher-income neighborhoods ( median income , $ 53,784 vs $ 49,713 ; P < .001 ) but had similar baseline glycemic control compared with non participants . More patients in the intervention arm had their DM treatment regimens adjusted ( 53 % vs 15 % ; P < .001 ) compared with active controls . However , there were no significant differences in risk factor control between study arms after 1 year ( P = .53 ) . CONCLUSIONS Previsit use of online PHR linked to the EMR increased rates of DM-related medication adjustment . Low rates of online patient account registration and good baseline control among participants limited the intervention 's impact on overall risk factor control . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00251875 BACKGROUND : Electronic information systems have been proposed as one means to reduce medical errors of commission ( doing the wrong thing ) and omission ( not providing indicated care ) . OBJECTIVE : To assess the effects of computer-based cardiac care suggestions . DESIGN : A r and omized , controlled trial targeting primary care physicians and pharmacists . SUBJECTS : A total of 706 out patients with heart failure and /or ischemic heart disease . INTERVENTIONS : Evidence -based cardiac care suggestions , approved by a panel of local cardiologists and general internists , were displayed to physicians and pharmacists as they cared for enrolled patients . MEASUREMENTS : Adherence with the care suggestions , generic and condition-specific quality of life , acute exacerbations of their cardiac disease , medication compliance , health care costs , satisfaction with care , and physicians ’ attitudes toward guidelines . RESULTS : Subjects were followed for 1 year during which they made 3,419 primary care visits and were eligible for 2,609 separate cardiac care suggestions . The intervention had no effect on physicians ’ adherence to the care suggestions ( 23 % for intervention patients vs 22 % for controls ) . There were no intervention-control differences in quality of life , medication compliance , health care utilization , costs , or satisfaction with care . Physicians viewed guidelines as providing helpful information but constraining their practice and not helpful in making decisions for individual patients . CONCLUSIONS : Care suggestions generated by a sophisticated electronic medical record system failed to improve adherence to accepted practice guidelines or outcomes for patients with heart disease . Future studies must weigh the benefits and costs of different ( and perhaps more Draconian ) methods of affecting clinician behavior BACKGROUND We conducted a cluster r and omized controlled trial to examine the effectiveness of computerized decision support ( CDS ) design ed to improve hypertension care and outcomes in a racially diverse sample of primary care patients . METHODS We r and omized 2,027 adult patients receiving hypertension care in 14 primary care practice s to either 18 months of their physicians receiving CDS for each hypertensive patient or to usual care without computerized support for the control group .  We assessed prescribing of guideline -recommended drug therapy and levels of blood pressure control for patients in each group and examined if the effects of the intervention differed by patients ’ race/ethnicity using interaction terms . MEASUREMENTS AND MAIN RESULTS Rates of blood pressure control were 42 % at baseline and 46 % at the outcome visit with no significant differences between groups . After adjustment for patients ’ demographic and clinical characteristics , number of prior visits , and levels of baseline blood pressure control , there were no differences between intervention groups in the odds of outcome blood pressure control . The use of CDS to providers significantly improved Joint National Committee ( JNC ) guideline adherent medication prescribing compared to usual care ( 7 % versus 5 % , P < 0.001 ) ; the effects of the intervention remained after multivariable adjustment ( odds ratio [ OR ] 1.39 [ CI , 1.13–1.72 ] ) and the effects of the intervention did not differ by patients ’ race and ethnicity . CONCLUSIONS CDS improved appropriate medication prescribing with no improvement in disparities in care and overall blood pressure control . Future work focusing on improvement of these interventions and the study of other practical interventions to reduce disparities in hypertension-related outcomes is needed OBJECTIVE : To describe the effect of the Vermont Diabetes Information System ( VDIS ) on hospital and emergency room use DATA SOURCE : Statewide discharge data base STUDY DESIGN : R and omized controlled trial of a decision support system for 7,412 adults with diabetes and their 64 primary care providers . DATA COLLECTION / DATA EXTRACTION : Charges and date s for hospital admissions and emergency room care in Vermont during an average of 32 months of observation . Data from New York hospitals were not available . PRINCIPAL FINDINGS : Patients r and omized to VDIS were admitted to the hospital less often than control subjects ( 0.17 admissions vs. 0.20 ; P=0.01 ) and generated lower hospital charges ( $ 3,113 vs. $ 3,480 ; P=0.019 ) . VDIS patients also had lower emergency room utilization ( 0.27 visits vs. 0.36 ; P<0.0001 ) and charges ( $ 304 vs. $ 414 ; P<0.0001 ) . The intervention was particularly effective in men and in older subjects . CONCLUSIONS : In spite of data limitations that tended to reduce the apparent effect of the system ; this r and omized , controlled trial showed that VDIS reduces hospitalization and emergency room utilization and expenses BACKGROUND The success of guidelines depends largely on effective implementation and uptake in clinical practice . The Optimal Renal Anemia Management Assessment ( ORAMA ) study investigated the impact of European Best Practice Guideline ( EBPG ) prompting on patient outcomes . METHODS ORAMA was a prospect i ve , international , multicenter , cluster-r and omized study . Fifty-three centers in eight European countries enrolled patients with chronic kidney disease stage V receiving chronic dialysis . Patients were either anemic ( hemoglobin [ Hb ] < 11 g/dL [ 110 g/L ] ) or treated with erythropoiesis stimulating agents and /or iron supplementation .  Centers were r and omized to two groups , with or without access to a computerized clinical decision support ( CDS ) system . In a post hoc analysis , patients were further subdivided into adherence or non-adherence of investigators to the EBPG regardless of CDS usage . Primary endpoint was the proportion of patients with Hb > 11 g/ dL ( 110 g/L ) , reflecting hematological targets in the revised EPBG . RESULTS In this population of 599 dialysis patients , hematological targets did not differ in the presence or absence of a CDS system . There was a general shift towards improved patient distribution by Hb categories while the width of the distribution curves remained unchanged . The proportion of patients with Hb > 11 g/dL ( 110 g/L ) was higher among adherers ( 79 % and 84 % with or without CDS use , respectively ) than non-adherers ( 59 % and 57 % , respectively ) . CONCLUSIONS ORAMA is the first international study to show that adherence to EBPG improved attainment of anemia indices . The availability of a CDS system did not affect anemia management STUDY OBJECTIVE To assess the effects of evidence -based treatment suggestions for hypertension made to physicians and pharmacists using a comprehensive electronic medical record system . DESIGN R and omized controlled trial with a 2 x 2 factorial design of physician and pharmacist interventions , which result ed in four groups of patients :  physician intervention only , pharmacist intervention only , intervention by physician and pharmacist , and intervention by neither physician nor pharmacist ( control ) . SETTING Academic primary care internal medicine practice . SUBJECTS Seven hundred twelve patients with uncomplicated hypertension . MEASUREMENTS AND MAIN RESULTS Suggestions were displayed to physicians on computer workstations used to write outpatient orders and to pharmacists when filling prescriptions . The primary end point was generic health-related quality of life . Secondary end points were symptom profile and side effects from antihypertensive drugs , number of emergency department visits and hospitalizations , blood pressure measurements , patient satisfaction with physicians and pharmacists , drug therapy compliance , and health care charges . In the control group , implementation of care changes in accordance with treatment suggestions was observed in 26 % of patients . In the intervention groups , compliance with suggestions was poor , with treatment suggestions implemented in 25 % of patients for whom suggestions were displayed only to pharmacists , 29 % of those for whom suggestions were displayed only to physicians , and 35 % of the group for whom both physicians and pharmacists received suggestions ( p=0.13 ) . Intergroup differences were neither statistically significant nor clinical ly relevant for generic health-related quality of life , symptom and side-effect profiles , number of emergency department visits and hospitalizations , blood pressure measurements , charges , or drug therapy compliance . CONCLUSION Computer-based intervention using a sophisticated electronic physician order-entry system failed to improve compliance with treatment suggestions or outcomes of patients with uncomplicated hypertension Electronic decision-support tools may help to improve management of hyperlipidemia and other chronic diseases . This study examined the impact of lipid management tools integrated into an electronic medical record ( EMR ) in primary care practice s. This r and omized controlled trial was conducted in a national network of physicians who use an outpatient EMR . Adult primary care physicians were r and omized by office to receive an electronic form that was embedded in the EMR . The form contained prompts regarding suboptimal care based on Adult Treatment Panel-III ( ATP-III ) guidelines , as well as reporting tools to identify patients outside of office visits whose lipid management was suboptimal . All active patients , ages 20 - 79 years , whose physicians participated in the study , were categorized as high , moderate , or low cardiovascular risk , and the proportion who were tested for hyperlipidemia , at lipid goal , and on lipid-lowering medications if not at goal were measured according to ATP-III guidelines . A total of 105 physicians from 25 offices and 64,150 patients were included in the study . Outcomes improved for most measures from before to 1 year after the intervention ( November 1 , 2005 to October 31 , 2006 ) . However , after controlling for confounding variables and for clustering in multilevel modeling , only up-to- date lipid testing for high-risk patients was statistically better in the intervention group as compared to the control group ( adjusted odds ratio 15.0 , P < 0.05 ) . This study showed few differences in quality of lipid management after implementing an EMR-based disease management intervention in primary care setting s. Future studies may need to examine more comprehensive interventions that include office staff in a team approach to care OBJECTIVES To explore changes in mortality and hospital usage for chronically ill seniors enrolled in a multidisease care management program , Care Management Plus ( CMP ) .  DESIGN Controlled clinical trial with seven intervention and six control clinics with additional patient-level matching . SETTING Intermountain Health Care , a large health system in Utah ; seven intervention and six control clinics . PARTICIPANTS Three thous and four hundred thirty-two senior patients ( > or=65 ) enrolled in Medicare . INTERVENTION The intervention employed nurse care managers supported by specialized information technology in primary care to manage chronically ill patients ( 2002 - 2005 ) . MEASUREMENTS Mortality and hospitalization data were collected from clinical records and Medicare billing . RESULTS One thous and one hundred forty-four intervention patients were matched to 2,288 controls . Average age was 76.2 ; average comorbidity score was 2.3+/-1.1 ; 75 % of patients had two or more chronic diseases . Survival analyses showed lower mortality and slightly more emergency department visits for care managed patients than for controls . In patients with diabetes mellitus , the intervention result ed in significantly lower mortality at 1 year ( 6.2 % , vs 10.6 % for controls ) and at 2 years ( 12.9 % vs 18.2 % ) . Hospitalization rate was lower ( 21.0 % , vs. 24.2 % for controls ) at 1 year and substantially more so at the 2-year follow-up . CONCLUSION CMP was successful in reducing death for all patients . For complex patients with diabetes mellitus in the intervention group , death and hospital usage were lower . Per clinic , hypothesized savings from decreased hospitalizations was $ 17,384 to $ 70,349 PURPOSE We wanted to assess the impact of an electronic health record – based diabetes clinical decision support system on control of hemoglobin A1c ( glycated hemoglobin ) , blood pressure , and low-density lipoprotein ( LDL ) cholesterol levels in adults with diabetes . METHODS We conducted a clinic-r and omized trial conducted from October 2006 to May 2007 in Minnesota . Included were 11 clinics with 41 consenting primary care physicians and the physicians ’ 2,556 patients with diabetes . Patients were r and omized either to receive or not to receive an electronic health record (EHR)–based clinical decision support system design ed to improve care for those patients whose hemoglobin A1c , blood pressure , or LDL cholesterol levels were higher than goal at any office visit . Analysis used general and generalized linear mixed models with repeated time measurements to accommo date the nested data structure . RESULTS The intervention group physicians used the EHR-based decision support system at 62.6 % of all office visits made by adults with diabetes . The intervention group diabetes patients had significantly better hemoglobin A1c ( intervention effect −0.26 % ; 95 % confidence interval , −0.06 % to −0.47 % ; P=.01 ) , and better maintenance of systolic blood pressure control ( 80.2 % vs 75.1 % , P=.03 ) and borderline better maintenance of diastolic blood pressure control ( 85.6 % vs 81.7 % , P = .07 ) , but not improved low-density lipoprotein cholesterol levels ( P = .62 ) than patients of physicians r and omized to the control arm of the study . Among intervention group physicians , 94 % were satisfied or very satisfied with the intervention , and moderate use of the support system persisted for more than 1 year after feedback and incentives to encourage its use were discontinued . CONCLUSIONS EHR-based diabetes clinical decision support  significantly improved glucose control and some aspects of blood pressure control in adults with type 2 diabetes
target: Among CVRM patients , the results tended towards a beneficial effect of CDSS , but only LDL-c target attainment in diabetes patients reached statistical significance .
  Prompting , integration into the electronical health record , patient empowerment , and medication support were related to more effective CVRM .
  Conclusion We did not find a clear clinical benefit from CDSS in cardiovascular risk factor levels and target attainment .
  Some features of CDSS seem more promising than others .
  Clinical relevance of CDSS in CVRM might additionally be sought in the improvement of shared decision making and patient empowerment
background: Background Cardiovascular risk management ( CVRM ) is notoriously difficult because of multi-morbidity and the different phenotypes and severities of cardiovascular disease .
  Computerized decision support systems ( CDSS ) enable the clinician to integrate the latest scientific evidence and patient information into tailored strategies .
  The effect on cardiovascular risk factor management is yet to be confirmed .