Computerized clinical decision support systems for primary preventive care: A decision-maker-researcher partnership systematic review of effects on process of care and patient outcomes.

Souza NM, Sebaldt RJ, Mackay JA, et al. Computerized clinical decision support systems for primary preventive care: A decision-maker-researcher partnership systematic review of effects on process of care and patient outcomes. Implement Sci. 2011 Aug 3;6(1):87. (Review) PMID: 21824381

BACKGROUND: Computerized clinical decision support systems (CCDSSs) are claimed to improve processes and outcomes of primary preventive care (PPC), but their effects, safety, and acceptance must be confirmed. We updated our previous systematic reviews of CCDSSs and integrated a knowledge translation approach in the process. The objective was to review randomized controlled trials (RCTs) assessing the effects of CCDSSs for PPC on process of care, patient outcomes, harms, and costs.
METHODS: We conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid`s EBM Reviews Database, Inspec, and other databases, as well as reference lists through January 2010. We contacted authors to confirm data or provide additional information. We included RCTs that assessed the effect of a CCDSS for PPC on process of care and patient outcomes compared to care provided without a CCDSS. A study was considered to have a positive effect (i.e., CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive.
RESULTS: We added 17 new RCTs to our 2005 review for a total of 41 studies. RCT quality improved over time. CCDSSs improved process of care in 25 of 40 (63%) RCTs. Cumulative scientifically strong evidence supports the effectiveness of CCDSSs for screening and management of dyslipidaemia in primary care. There is mixed evidence for effectiveness in screening for cancer and mental health conditions, multiple preventive care activities, vaccination, and other preventive care interventions. Fourteen (34%) trials assessed patient outcomes, and four (29%) reported improvements with the CCDSS. Most trials were not powered to evaluate patient-important outcomes. CCDSS costs and adverse events were reported in only six (15%) and two (5%) trials, respectively. Information on study duration was often missing, limiting our ability to assess sustainability of CCDSS effects.
CONCLUSIONS: Evidence supports the effectiveness of CCDSSs for screening and treatment of dyslipidaemia in primary care with less consistent evidence for CCDSSs used in screening for cancer and mental health-related conditions, vaccinations, and other preventive care. CCDSS effects on patient outcomes, safety, costs of care, and provider satisfaction remain poorly supported.

Screening for developmental delay

Mackrides PS, Ryherd SJ. Screening for developmental delay. Am Fam Physician. 2011 Sep 1;84(5):544-9. PMID: 21888305 [PubMed - in process] 

According to the literature, 12 to 16 percent of children in the United States have at least one developmental delay, yet as many as one-half of affected children will not be identified by the time they enter kindergarten. If developmental delays are detected too late, opportunities for early intervention may be lost. Empirical literature on clinical recommendations for developmental delay screening in primary care is inconsistent and often insufficient to direct  the family physician. In addition, multiple barriers exist, which often prevent physicians from performing initial screening and completing additional evaluation and referrals. Implementing office-based systems for screening and referrals may  overcome these barriers and improve outcomes. Recent studies support the use of a validated screening tool at regular, repeated intervals, in addition to physician surveillance, at all well-child visits. The literature also supports screening for developmental delay with parent-completed tools rather than directly administered tools. The most extensively evaluated parent-completed tools are the Parents' Evaluation of Developmental Status and the Ages and Stages Questionnaire. Family physicians should be familiar with currently available screening tools, as well as their limitations and strengths. Additional evaluations and referrals are recommended if developmental delay is identified or suspected.

Randomized controlled trial to improve primary care to prevent and manage childhood obesity: the High Five for Kids study.

Taveras EM, Gortmaker SL, Hohman KH, et al. Randomized controlled trial to improve primary care to prevent and manage childhood obesity: the High Five for Kids study. Arch Pediatr Adolesc Med. 2011 Aug;165(8):714-22. Epub 2011 Apr 4. (Original) PMID: 21464376

 

OBJECTIVE: To examine the effectiveness of a primary care-based obesity intervention over the first year (6 intervention contacts) of a planned 2-year study.
DESIGN: Cluster randomized controlled trial.
SETTING: Ten pediatric practices, 5 intervention and 5 usual care.
PARTICIPANTS: Four hundred seventy-five children aged 2 to 6 years with body mass index (BMI) in the 95th percentile or higher or 85th to less than 95th percentile if at least 1 parent was overweight; 445 (93%) had 1-year outcomes.
INTERVENTIONS: Intervention practices received primary care restructuring, and families received motivational interviewing by clinicians and educational modules targeting television viewing and fast food and sugar-sweetened beverage intake. OUTCOME MEASURES: Change in BMI and obesity-related behaviors from baseline to 1 year.
RESULTS: Compared with usual care, intervention participants had a smaller, nonsignificant change in BMI (-0.21; 95% confidence interval [CI], -0.50 to 0.07; P = .15), greater decreases in television viewing (-0.36 h/d; 95% CI, -0.64 to -0.09; P = .01), and slightly greater decreases in fast food (-0.16 serving/wk; 95% CI, -0.33 to 0.01; P = .07) and sugar-sweetened beverage (-0.22 serving/d; 95% CI, -0.52 to 0.08; P = .15) intake. In post hoc analyses, we observed significant effects on BMI among girls (-0.38; 95% CI, -0.73 to -0.03; P = .03) but not boys (0.04; 95% CI, -0.55 to 0.63; P = .89) and among participants in households with annual incomes of $50 000 or less (-0.93; 95% CI, -1.60 to -0.25; P = .01) but not in higher-income households (0.02; 95% CI, -0.30 to 0.33; P = .92).
CONCLUSION: After 1 year, the High Five for Kids intervention was effective in reducing television viewing but did not significantly reduce BMI.

Comments from Clinical Raters

• General Practice(GP)/Family Practice(FP):
  Useful in demonstrating relatively robustly that this intervention in the primary care setting did NOT significantly change children's weight nor most behaviours that would promote obesity. Learning of the negative trials is as important as learning of the trials with positive results.

•  Special Interest - Obesity -- Physician:
  This is a very nice study. A lot of effort was put in the intervention. The results (lack of influence on BMI) are surprising and just shows why you need RCTs. It is noteworthy that positive results were obtained in families who's income was below $50.000, thus, indicating, perhaps, that the intervention is still worthwhile in poorer populations.