Evaluating the impact of an integrated computer-based decision support with person-centered analytics for the management of asthma in primary care: a randomized controlled trial
Robyn Tamblyn, Pierre Ernst, Nancy Winslade, Allen Huang, Roland Grad, Robert W Platt, Sara Ahmed, Teresa Moraga, Tewodros Eguale, Robyn Tamblyn, Pierre Ernst, Nancy Winslade, Allen Huang, Roland Grad, Robert W Platt, Sara Ahmed, Teresa Moraga, Tewodros Eguale
Abstract
Background: Computer-based decision support has been effective in providing alerts for preventive care. Our objective was to determine whether a personalized asthma management computer-based decision support increases the quality of asthma management and reduces the rate of out-of-control episodes.
Methods: A cluster-randomized trial was conducted in Quebec, Canada among 81 primary care physicians and 4447 of their asthmatic patients. Patients were followed from the first visit for 3-33 months. The physician control group used the Medical Office of the 21st century (MOXXI) system, an integrated electronic health record. A custom-developed asthma decision support system was integrated within MOXXI and was activated for physicians in the intervention group.
Results: At the first visit, 9.8% (intervention) to 12.9% (control) of patients had out-of-control asthma, which was defined as a patient having had an emergency room visit or hospitalization for respiratory-related problems and/or more than 250 doses of fast-acting β-agonist (FABA) dispensed in the past 3 months. By the end of the trial, there was a significant increase in the ratio of doses of inhaled corticosteroid use to fast-acting β-agonist (0.93 vs. 0.69: difference: 0.27; 95% CI: 0.02-0.51; P = 0.03) in the intervention group. The overall out-of-control asthma rate was 54.7 (control) and 46.2 (intervention) per 100 patients per year (100 PY), a non-significant rate difference of -8.7 (95% CI: -24.7, 7.3; P = 0.29). The intervention's effect was greater for patients with out-of-control asthma at the beginning of the study, a group who accounted for 44.7% of the 5597 out-of-control asthma events during follow-up, as there was a reduction in the event rate of -28.4 per 100 PY (95% CI: -55.6, -1.2; P = 0.04) compared to patients with in-control asthma at the beginning of the study (-0.08 [95% CI: -10.3, 8.6; P = 0.86]).
Discussion: This study evaluated the effectiveness of a novel computer-assisted ADS system that facilitates systematic monitoring of asthma control status, follow-up of patients with out of control asthma, and evidence-based, patient-specific treatment recommendations. We found that physicians were more likely to use ADS for out-of-control patients, that in the majority of these patients, they were advised to add an inhaled corticosteroid or a leukotriene inhibitor to the patient s treatment regimen, and the intervention significantly increased the mean ratio of inhaled corticosteroids to FABA during follow-up. It also reduced the rate of out-of-control episodes during follow up among patients whose asthma was out-of-control at the time of study entry. Future research should assess whether coupling patient-specific treatment recommendations, automated follow-up, and home care with comparative feedback on quality and outcomes of care can improve guideline adoption and care outcomes.
Conclusions: A primary care-personalized asthma management system reduced the rate of out-of-control asthma episodes among patients whose asthma was poorly controlled at the study's onset.
Trial registration: ClinicalTrials.gov NCT00170248.
Keywords: MOXXI; RCT; asthma; computer decision support; out-of-control; personalized medicine.
© The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association.
Figures
References
- Vinicor F. Diabetes mellitus and asthma: “twin” challenges for public health and managed care systems. Am J Prev Med. 1998;14 (Suppl 3):87–92.
- Wilkins K, Mao Y. Trends in rates of admission to hospital and death from asthma among children and young adults in Canada during the 1980s. Can Med Assoc J. 1993;148 (2):185–190.
- Kelloway JS. A United States approach to the management of asthma in a managed care environment. Eur Respir Rev. 1996;6 (33):50–53.
- Braman SS. The Global Burden of Asthma*. Chest. 2006;130:4S–12S.
- The Conference Board of Canada. Lung Disease Imposes Major Costs on Canada's Economy. News Release, March 15. 2012:12–96.
- Krahn MD, Berka C, Langlois P, Detsky AS. Direct and Indirect Costs of Asthma in Canada, 1990. Can Med Assoc J. 1996;154 (6):821–831.
- Booth A. Benefits of an individual asthma action plan. Pract Nurs. 2012;23:592–604.
- Zemek RL, Bhogal SK, Ducharme FM. Systematic review of randomized controlled trials examining written action plans in children: what is the plan? Arch Pediatr Adolesc Med. 2008;162:157.
- Bhogal S, Zemek R, Ducharme FM. Written action plans for asthma in children. Cochrane Database Syst Rev. 2006;3.
- Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax. 2004;59:94–99.
- Boulet LP, Becker A, Berube D, Beveridge R, Ernst P; on behalf of the Canadian Asthma Consensus Group Summary of recommendations from the Canadian Asthma Consensus Report, 1999. CMAJ Suppl. 2003;161.
- Fitzgerald JM, Ernst P, Boulet LP, O'Byrne P. Measures of outcome. Evidence-Based Asthma Management. Hamilton, London: BC Decker Inc.; 2001:307–322.
- Boulet LP, Bai TR, Becker A, et al. What is new since the last (1999) Canadian Asthma Consensus Guidelines? [comment]. Can Respir J. 2001;8 (Suppl A):3A–27A.
- Gibson PG. Monitoring the patient with asthma: an evidence-based approach. [see comments.]. [Review] [72 refs]. J Allergy Clin Immunol. 2000;106:t–26.
- Lougheed MD, Lemiere C, Ducharme FM, et al. Canadian Thoracic Society 2012 guideline update: diagnosis and management of asthma in preschoolers, children and adults. Can Respir J. 2012;19:127–164.
- Blais L, Suissa S, Boivin JF, Ernst P. First treatment with inhaled corticosteroids and the prevention of admissions to hospital for asthma. Thorax. 1998;53:1025–1029.
- Blais L, Ernst P, Boivin JF, Suissa S. Inhaled corticosteroids and the prevention of readmission to hospital for asthma. Am J Respir Crit Care Med. 1998;158:126–132.
- Suissa S, Ernst P, Kezouh A. Regular use of inhaled corticosteroids and the long term prevention of hospitalisation for asthma. Thorax. 2002;57:880–884.
- Suissa S, Ernst P, Benayoun S, Baltzan M, Cai B. Low-dose inhaled corticosteroids and the prevention of death from asthma. New Engl J Med. 2000;343:332–336.
- Licskai C, Sands T, Ong M, Paolatto L, Nicoletti I. Using a knowledge translation framework to implement asthma clinical practice guidelines in primary care. Int J Qual Health Care. 2012;24:538–546.
- Chapman KR, Ernst P, Grenville A, Dewland P, Zimmerman S. Control of asthma in Canada: failure to achieve guideline targets. Can Respir J. 2001;8 (Suppl A):35A–40A.
- Bateman ED, Boushey HA, Bousquet J, et al. Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma ControL study. Am J Respir Crit Care Med. 2004;170:836–844.
- Wechsler ME. Managing asthma in primary care: putting new guideline recommendations into context. Mayo Clin Proc. 2009;84:707–717.
- Yawn BP. The role of the primary care physician in helping adolescent and adult patients improve asthma control. Mayo Clin Proc. 2011;86:894–902.
- Crim C. Clinical practice guidelines vs actual clinical practice: the asthma paradigm. Chest. 2000;118 (Suppl S):62S–64S.
- Hunt DL, Haynes B, Hanna SE, Smith K. Effects of computer-based clinical decision support systems on physician performance and patient outcomes. A systematic review. JAMA. 1998;280:1339–1346.
- Burack RC, Gimotty PA, George J, et al. Promoting screening mammography in inner-city settings: a randomized controlled trial of computerized reminders as a component of a program to facilitate mammography. Med Care. 1994;32:609–624.
- Frame PS, Zimmer JG, Werth PL, Hall WJ, Eberly SW. Computer-based vs manual health maintenance tracking. A controlled trial. Arch Fam Med. 1994;3:581–588.
- McPhee SJ, Bird JA, Fordham D, Rodnick JE, Osborn EH. Promoting cancer prevention activities by primary care physicians. Results of a randomized, controlled trial. JAMA. 1991;266:538–544.
- Turner RC, Peden JG, Jr, O'Brien K. Patient-carried card prompts vs computer-generated prompts to remind private practice physicians to perform health maintenance measures. Arch Intern Med. 1994;154:1957–1960.
- Rind DM, Safran C, Phillips RS, et al. Effect of computer-based alerts on the treatment and outcomes of hospitalized patients. Arch Intern Med. 1994;154:1511–1517.
- Montgomery AA, Fahey T, Peters TJ, MacIntosh C, Sharp DJ. Evaluation of computer based clinical decision support system and risk chart for management of hypertension in primary care: randomised controlled trial. Br Med J. 2000;320:686–690.
- Shegog R, Bartholomew LK, Sockrider MM, et al. Computer-based decision support for pediatric asthma management: description and feasibility of the Stop Asthma Clinical System. Health Informatics J. 2006;12:259–273.
- Roshanov PS, Misra S, Gerstein HC, et al. Computerized clinical decision support systems for chronic disease management: a decision-maker-researcher partnership systematic review. Implement Sci. 2011;6:92.
- Eccles M, McColl E, Steen N, et al. Effect of computerised evidence based guidelines on management of asthma and angina in primary care: cluster randomised controlled trial. Br Med J. 2002;325:941–947.
- Tierney WM, Overhage JM, Murray MD, et al. Can computer-generated evidence-based care suggestions enhance evidence-based management of asthma and chronic obstructive pulmonary disease? A randomized, controlled trial. Health Serv Res. 2005;40:477–498.
- Kattan M, Crain EF, Steinbach S, et al. A randomized clinical trial of clinician feedback to improve quality of care for inner-city children with asthma. Pediatrics. 2006;117:e1095–e1103.
- Bell LM, Grundmeier R, Localio R, et al. Electronic health record-based decision support to improve asthma care: a cluster-randomized trial. Pediatrics. 2010;125:e770–e777.
- Tamblyn R, Huang A, Perreault R, et al. The medical office of the 21st century (MOXXI): effectiveness of computerized decision-making support in reducing inappropriate prescribing in primary care. CMAJ. 2003;169:549–556.
- Boulet LP, Becker A, Berube D, Beveridge R, Ernst P. Canadian Asthma Consensus Report, 1999. Canadian Asthma Consensus Group. Can Med Assoc J. 1999;161:S1–S61.
- Ernst P. Education of asthmatic patients. The Quebec experience. Revue Francaise D Allergologie et d Immunologie Clinique. 1998;38:784–788.
- Spitzer WO, Suissa S, Ernst P, et al. The use of B-agonists and the risk of death and near death from asthma. N Engl J Med. 1992;326:501–506.
- Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2014. . Accessed August 26, 2014.
- Sin DD, Tu JV. Inhaled corticosteroids and the risk of mortality and readmission in elderly patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2001;164:580–584.
- Chuang JH, Hripcsak G, Jenders RA. Considering Clustering: A Methodological Review of Clinical Decision Support System Studies. Proc AMIA Symp. 2000;146–150.
- Plaza V, Cobos A, Ignacio-Garcia JM, et al. [Cost-effectiveness of an intervention based on the Global INitiative for Asthma (GINA) recommendations using a computerized clinical decision support system: a physicians randomized trial]. Med Clin. 2005;124:201–206.
- McCowan RGN. Lessons from a randomized controlled trial designed to evaluate computer decision support software to improve the management of asthma. Inform Health Soc Care. 2001;26:191–201.
- Peters TE, Bhavaraju NC, Frei MG, Osorio I. Network system for automated seizure detection and contingent delivery of therapy. J Clin Neurophysiol. 2001;18:545–549.
- Skledar SJ, Niccolai CS, Schilling D, et al. Quality-improvement analytics for intravenous infusion pumps. Am J Health Syst Pharm. 2013;70:680–686.
- Institute of Medicine, Committee on the National Quality Report on Health Care Delivery, Corrigan J, et al. Envisioning the National Health Care Quality Report. Washington, DC: National Academy Press; 2001.
- Institute of Medicine of the National Academies. Digital Data Improvement Priorities for Continuous Learning in Health and Health Care. Washington, D.C: The National Academies Press; 2013.
- Hutchison B, Levesque JF, Strumpf E, Coyle N. Primary health care in Canada: systems in motion. Milbank Q. 2011;89:256–288.
- Hutchison B, Glazier R. Ontario’s primary care reforms have transformed the local care landscape, but a plan is needed for ongoing improvement. Health Aff. 2013;32:695–703.
- Hutchison B, Abelson J, Lavis J. Primary care in Canada: so much innovation, so little change. Health Aff. 2001;20:116–131.
- Pham HH, Ginsburg PB. Unhealthy trends: the future of physician services. Health Aff. 2007;26:1586–1598.
- Walker S, Mason AR, Claxton K, et al. Value for money and the quality and outcomes framework in primary care in the UK NHS. Br J Gen Pract. 2010;60:e213–e220.
- NHS Employers. Quality and Outcomes Framework guidance for GMS contract 2013/14. 1-3-2013. The NHS Confederation (Employers) Company. . Accessed August 26, 2014.
- Pomey MP, Martin E, Forest PG. Quebec's Family Medicine Groups: Innovation and Compromise in the Reform of Front. Can Polit Sci Rev. 2009;4:31–46.
- Berenson RA, Hammons T, Gans DN, et al. A house is not a home: keeping patients at the center of practice redesign. Health Aff. 2008;27:1219–1230.
- McMillan SS, Kendall E, Sav A, et al. Patient-centered approaches to health care: A systematic review of randomized controlled trials. Med Care Res Rev. 2013;6:567–596.
- Stange KC, Nutting PA, Miller WL, et al. Defining and measuring the patient-centered medical home. J Gen Intern Med. 2010;25:601–612.
- Taylor EF, Machta RM, Meyers DS, Genevro J, Peikes DN. Enhancing the primary care team to provide redesigned care: the roles of practice facilitators and care managers. Ann Fam Med. 2013;11:80–83.
- British Columbia Pharmacy Association. British Columbia Pharmacy Association (BCPhA) Clinical Service Proposal Asthma Consultation Service. British Columbia: British Columbia Pharmacy (BCPhA); 2013.
- Buckley KN, Ryder SA. Asthma management in the community pharmacy setting in Ireland. Int J Clin Pharm. 2012;34:186.
- Monheit AC. Persistence in health expenditures in the short run: prevalence and consequences. Med Care. 2003;41:III53–III64.
Source: PubMed