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The Guide to Clinical Preventive Services

Together, the Community Guide and the Clinical Guide provide evidence-based recommendations across the prevention spectrum.

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Cardiovascular Disease Prevention and Control: Clinical Decision-Support Systems (CDSS)

Task Force Finding

The Community Preventive Services Task Force recommends clinical decision-support systems (CDSS) for prevention of cardiovascular disease (CVD) based on sufficient evidence of effectiveness in improving screening for CVD risk factors and practices for CVD-related preventive care services, clinical tests, and treatments.

Most of the available evidence is from studies on the effectiveness of CDSS when implemented alone in the healthcare system rather than as part of a coordinated service delivery effort that is intended to address barriers at the patient, provider, organizational, and community levels. More evidence is needed about implementation of CDSS as one part of a comprehensive service delivery system designed to improve outcomes for CVD risk factors and reduce CVD-related morbidity and mortality.

Read the full Task Force Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

Intervention Definition

CDSS are computer-based information systems designed to assist healthcare providers in implementing clinical guidelines at the point of care. CDSS use patient data to provide tailored patient assessments and evidence-based treatment recommendations for healthcare providers to consider. Patient information is entered manually or automatically through an electronic health record (EHR) system. CDSS for cardiovascular disease prevention (CVD) include one or more of the following:

  • Reminders for overdue CVD preventive services including screening for risk factors such as high blood pressure, diabetes, and high cholesterol
  • Assessments of patients' risk for developing CVD based on their medical history, symptoms, and clinical test results
  • Recommendations for evidence-based treatments to prevent CVD, including intensification of treatment
  • Recommendations for health behavior changes to discuss with patients such as quitting smoking, increasing physical activity, and reducing excessive salt intake
  • Alerts when indicators for CVD risk factors are not at goal

CDSS are often incorporated within EHR systems and integrated with other computer-based functions that offer patient-care summary reports, feedback on quality indicators, and benchmarking. Knowledge management systems providing access to scientific literature and strategies for CVD prevention may also be linked with CDSS.

About the Systematic Review

The Task Force finding is based on evidence from a broad systematic review (Bright et al. 2012, search period January 1976-January 2011) that examined the effectiveness of CDSS in improving quality of care and clinical outcomes for a variety of conditions (e.g., CVD prevention, cancer screening, immunization, antenatal care). From this broad review, CDSS studies focused on CVD prevention were identified (39 studies) and combined with evidence from an updated search (6 studies, search period January 2011-October 2012). The systematic review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice and policy related to cardiovascular disease prevention.

Results

  • CDSS led to modest improvements for three quality-of-care outcomes for provider practices related to CVD prevention - compared to usual care:
    1. Screening and preventive care services completed or ordered: median increase of 3.8 percentage points (Interquartile interval [IQI]: -0.08 to 10.6; 17 studies)
    2. Clinical tests completed or ordered: median increase of 4.0 percentage points (IQI: 0.7 to 7.0; 7 studies)
    3. Treatments prescribed: median increase of 2.0 percentage points (IQI: -0.75 to 8.55, 11 studies)
  • Eight studies implemented CDSS in combination with other approaches such as team-based care and patient-reminders compared to usual care. Large improvements in the following quality-of-care outcomes were reported in these studies:
    • CDSS-prompted screening and preventive care services ordered
    • CDSS-prompted clinical tests completed or ordered by providers
  • Results from the broad systematic review (Bright et al., 2012), which examined the effectiveness of CDSS across a variety of conditions and related risk factors, found improvements for all three quality-of-care outcomes (e.g., cardiovascular disease prevention, cancer screening, immunization).

Study Characteristics

  • CDSS were added to pre-existing EHRs in about one-third of included studies.
  • In most studies, CDSS were designed to:
    • Prompt providers without user requests for information, meaning the prompts were 'system-initiated' (82% of included studies)
    • Deliver decision support as part of the clinical workflow at the patient visit (i.e., 'synchronously') (84% of included studies)
  • Most studies (95%) evaluated CDSS in outpatient, primary care settings, many of which were run by group practices that had multiple primary care centers.
  • Many studies had large patient populations (median: 1,189).
  • Studies evaluated CDSS that were targeted at a variety of CVD risk factors such as high blood pressure, diabetes and high cholesterol.

Applicability

  • Based on the settings and populations from included studies, results are applicable to:
    • U.S. healthcare system
    • Outpatient, primary care settings
    • Patients with multiple CVD risk factors

Economic Evidence

An overall conclusion about the economic effectiveness of CDSS cannot be reached due to limited evidence on cost and economic benefit. In addition, studies evaluated a range of CDSS functions implemented for diverse CVD risk factors.

The economic review is based on evidence from 17 studies (search period January 1976–October 2012). Included studies reported the cost of CDSS (10 studies), benefits of CDSS measured as estimated changes in healthcare cost (15 studies), cost-benefit analyses (4 studies), and cost-effectiveness (3 studies).

  • Cost of CDSS: Most of the studies that reported program costs did not provide complete costs of developing, implementing, and operating CDSS.
  • Benefits of CDSS: Most of the studies that reported on benefits did not account for all major components of healthcare cost.
  • Cost-benefit and cost-effectiveness: The incomplete assessments of costs and benefits led to inconsistent results.

The economic evidence is based on a systematic review of all available studies, conducted on behalf of the Task Force by a team of specialists in systematic review and economic methods, and in research, practice, and policy related to CDSS for cardiovascular disease prevention.

Considerations for Implementation

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion. This information was emphasized by the Task Force and may provide context for the delivery of the intervention.

  • Barriers to efficient healthcare delivery exist at multiple levels including patient-related barriers, provider-related barriers, community-related barriers, and organizational barriers. CDSS serves as a tool to address provider-related barriers—mainly 'clinical inertia', which is the failure to modify treatment when necessary. However, to address all barriers CDSS might need to be combined with other effective strategies such as culturally competent healthcare, team-based care, or other infrastructural improvements.
  • Bright et al. identified the following as features of a successful CDSS:
    • Provides patient assessments and treatment recommendations automatically
    • Delivers assessments and recommendations at the time and location of decision-making
    • Gives a recommendation, not just an assessment
    • Automatically incorporates patient data from electronic health records
    • Links with electronic patient charts to support workflow integration
    • Promotes action rather than inaction
    • Provides research evidence to justify assessments and recommendations
    • Engages local users during system development
    • Gives decision-support results to patients as well as providers
  • The Centers for Medicare & Medicaid Services has developed a set of standards for 'meaningful use' External Web Site Icon of EHR technology and offers financial incentives to individual providers and healthcare systems adhering to the standards.
  • Encouraging provider input during CDSS development and offering training and orientation may increase provider acceptance of these systems.
  • Use of CDSS changes the way patients and providers traditionally interact during a visit, and it is important that new CDSS are designed in a way that fosters productive patient-provider interaction.
  • Health systems should consider additional interventions that could be integrated with CDSS such as provider performance feedback reports or system-level interventions such as team-based care.

Supporting Materials

Publication Status

Full peer-reviewed articles of this systematic review will be posted on the Community Guide website when published. Subscribe External Web Site Icon to be notified when we post these publications or other materials. See our library for Community Guide publications on other topics.

Promotional Materials

Community Guide News

More promotional materials for Community Guide reviews about Cardiovascular Disease Prevention and Control.

References

Bright TJ, Wong A, Dhurjati R, Bristow E, Bastian L, et al. Effect of clinical decision-support systems: a systematic review. Ann Intern Med 2012;157(1):29-43.




Disclaimer

The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC. Task Force evidence-based recommendations are not mandates for compliance or spending. Instead, they provide information and options for decision makers and stakeholders to consider when determining which programs, services, and policies best meet the needs, preferences, available resources, and constraints of their constituents.

Sample Citation

The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services. . Cardiovascular disease prevention and control: clinical decision-support systems (CDSS). www.thecommunityguide.org/cvd/CDSS.html. Last updated: MM/DD/YYYY.

Review Completed: April 2013