Evaluation of Effectiveness and Cost‐Effectiveness of a Clinical Decision Support System in Managing Hypertension in Resource Constrained Primary Health Care Settings: Results From a Cluster Randomized Trial

This is a review for a study done by Raghupathy Anchala, MD, PhD; Stephen Kaptoge, PhD; Hira Pant, MA; Emanuele Di Angelantonio, MD, PhD; Oscar H. Franco, MD, PhD; and D. Prabhakaran, MD, DM, MSc to assess through randomized control trials from the developed world report whether clinical decision support systems (CDS) could provide an effective means to improve the management of hypertension (HTN).

Research question

Can clinical decision support systems (CDS) provide an effective means to improve the management of hypertension (HTN) in third world countries?

Methods

Design

The authors performed a cluster randomized trial to test the effectiveness and cost‐effectiveness of a CDS among Indian adult hypertensive patients (between 35 and 64 years of age), wherein 16 PHC clusters from a district of Telangana state, India, were randomized to receive either a DSS or a chart‐based support (CBS) system.

Each intervention arm had 8 PHC clusters, with a mean of 102 hypertensive patients per cluster (n=845 in DSS and 783 in CBS groups). Mean change in systolic blood pressure (SBP) from baseline to 12 months was the primary endpoint.

Results

Findings from both studies raised issues with the amount and organization of information in the display, interference with workflow patterns of primary care physicians, and the availability of visual cues and feedback. These findings were then used to recommend user interface design changes.

Main results

The mean difference in SBP change from baseline between the DSS and CBS at the 12th month of follow‐up,and were adjusted for the following parameters as they were identified factors in the study which had significance:

1. Age
2. Sex
3. Height
4. Waist
5. Body mass index (BMI)
6. Alcohol consumption
7. Vegetable intake
8. Pickle intake

The results were the following--using CDS, baseline differences in blood pressure, was −6.59 mm Hg (95% confidence interval: −12.18 to −1.42; P=0.021). The cost‐effective ratio for CBS and CDS groups was $96.01 and $36.57 per mm of SBP reduction, respectively.

Conclusion

CDS embedded with standardized, best-practice clinical practice guidelines aid in the management of HTN even in resource‐limited settings. CDS result in better management of HTN, provided patients adhere to the suggested dietary and lifestyle modifications, and medications and providers adhere to the suggested DSS recommendations. Key features of the DSS include the following:

1. (1) patient‐specific, tailor‐made, and guideline‐based recommendations on risk factors and disease management of HTN

1. (2) counseling on lifestyle modification, both of which aid the end user (clinicians) to decide on the appropriate line of management for the patient.

The CDS was not only effective, but also cost‐effective in management of HTN which would be appropriate in a resource-limited area of the world.

Commentary

Healthcare is a complex activity system of specialized and non-specialized workers, their tools, and their environment. Healthcare work involves continuous interaction among different elements and trade-offs between multiple goals, preferences, values, incentives, and motivations in the course of care processes.

A conceptual model for CPOE was created and had the following elements. The aspects of clinical workflow therefore can be categorized into four elements:

1. Structuring of clinical tasks
2. Coordinating of task performance
3. Enabling of the flow of information to support task performance
4. Monitoring

The resulting model enabled the reviewers to examine the interplay between the social context of healthcare work and CPOE systems. This research study which was a cohort of multiple studies helped create these elements and can create a structure to evaluate CPOE systems.