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Cardiovascular Disease: Clinical Decision-Support Systems (CDSS)


What the Task Force Found

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.

Summary of 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).

Summary of 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.


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

Evidence Gaps

Each Community Preventive Services Task Force (Task Force) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the Task Force finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the Task Force recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the Task Force recommendation is based.

Identified Evidence Gaps

  • Most studies evaluated outcomes at a relatively short follow-up period of 12 months. More evidence is needed on longer term evaluations of CDSS to account for issues associated with initial integration of CDSS with clinical workflow.
  • More evidence is needed from established CDSS in healthcare systems combined with information about implementation in real-world settings to increase understanding of the potential CDSS has to prevent cardiovascular disease.
  • Only a small proportion of studies collected data on the impact of CDSS on cardiovascular disease risk factor outcomes (e.g., blood pressure, cholesterol, and diabetes outcomes) and morbidity and mortality.
  • Most studies developed CDSS for physician use. More evidence is needed to assess the effectiveness of CDSS with other providers on the healthcare team such as nurses and pharmacists.
  • Patient-centered outcomes and processes to involve patients in decision-making were rarely examined. More assessments of the impact of CDSS in reducing health disparities and improving patient satisfaction with care are needed.
  • Only a small proportion of studies examined CDSS in combination with other interventions to overcome barriers at the patient, provider, organizational, and community levels. More evidence is needed on the impact of CDSS when employed as a tool within a multicomponent approach to improve the efficiency of healthcare delivery.
  • More evidence is needed on the effectiveness of CDSS that includes public health recommendations.

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.