Heart Disease and Stroke Prevention: Clinical Decision-Support Systems (CDSS)
Findings and Recommendations
The Community Preventive Services Task Force (CPSTF) recommends clinical decision-support systems (CDSS) for prevention of cardiovascular disease (CVD). Evidence shows CDSS increase screening for CVD risk factors and improve practices for CVD-related preventive care services, clinical tests, and treatments.
Most of the included studies looked at CDSS when used alone in healthcare systems. More research is needed on using CDSS as part of a comprehensive healthcare service delivery system designed to address barriers at the patient, provider, organizational, and community levels.
The full CPSTF Finding and Rationale Statement and supporting documents for Heart Disease and Stroke Prevention: Clinical Decision-Support Systems (CDSS) are available in The Community Guide Collection on CDC Stacks.
Intervention
Clinical decision-support systems (CDSS) are computer-based information systems designed to help healthcare providers implement clinical guidelines at the point of care. CDSS use patient data to generate 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 (e.g., 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 (e.g., quitting smoking, increasing physical activity, reducing excessive salt intake)
- Alerts when indicators for CVD risk factors are not at goal
About The Systematic Review
The CPSTF 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. 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).
Study Characteristics
- CDSS were added to pre-existing EHRs in about one-third of included studies.
- In most studies, CDSS were designed to do the following:
- Prompt providers without user requests for information, meaning the prompts were ‘system-initiated’ (82% of included studies)
- Deliver decision support during patient visits ‘synchronously,’ as part of the clinical workflow (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.
Summary of Results
- CDSS led to modest improvements for three CVD-related quality-of-care outcomes associated with provider practices. When compared with usual care
- Screening and preventive care services completed or ordered increased by a median of 3.8 percentage points (17 studies)
- Clinical tests completed or ordered increased by a median of 4.0 percentage points (7 studies)
- Treatments prescribed increased by a median of 2.0 percentage points (11 studies)
- Eight studies implemented CDSS in combination with other approaches such as team-based care and patient-reminders. When compared with usual care, large improvements were reported for quality-of-care outcomes.
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.
Applicability
Based on the settings and populations from included studies, the CPSTF finding should be applicable to the following:
- U.S. healthcare system
- Outpatient, primary care settings
- Patients with multiple CVD risk factors
Evidence Gaps
- How effective are longer-term programs that account for issues associated with initial integration of CDSS with clinical workflow?
- How effective are CDSS in real-world settings?
- What is the impact of CDSS on cardiovascular disease risk factor outcomes (e.g., blood pressure, cholesterol, and diabetes outcomes) and morbidity and mortality?
- Are CDSS effective with different healthcare providers (i.e., other than physicians), including nurses and pharmacists?
- How do CDSS effect patient-centered outcomes and patient involvement in decision-making?
- Do CDSS reduce health disparities and improve patient satisfaction with care?
- How well do CDSS, used in combination with other interventions, overcome barriers at the patient, provider, organizational, and community levels?
- What is the impact of CDSS when used within a multicomponent approach to improve the efficiency of healthcare delivery?
- How effective are CDSS that include public health recommendations?
Implementation Considerations and Resources
- Barriers to efficient healthcare delivery exist at multiple levels including patient-related barriers, provider-related barriers, community-related barriers, and organizational barriers. CDSS addresses provider-related barriers mainly ‘clinical inertia’, which is the failure to modify treatment when necessary. To address all barriers, CDSS may need to be used with other effective strategies such as culturally competent healthcare, team-based care, or other infrastructural improvements.
- Successful CDSS typically do the following (Bright et al., 2012):
- Provide patient assessments and treatment recommendations automatically
- Deliver assessments and recommendations at the time and location of decision-making
- Give a recommendation, not just an assessment
- Automatically incorporate patient data from electronic health records
- Link with electronic patient charts to support workflow integration
- Promote action rather than inaction
- Provide research evidence to justify assessments and recommendations
- Engage local users during system development
- Give decision-support results to patients and providers
- The Centers for Medicare & Medicaid Services has developed a set of standards for ‘meaningful use‘ of EHR technology and offers financial incentives to individual providers and healthcare systems that adhere to the standards.
- Healthcare providers may be more accepting of CDSS if they are encouraged to provide input during system development and offered training and orientation.
- Use of CDSS changes the way patients and providers traditionally interact during a visit. 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.
Crosswalks
Healthy People 2030 includes the following objectives related to this CPSTF recommendation.