Improving diabetes care: multi-component cardiovascular disease risk reduction strategies for people with diabetes in South Asia--the CARRS multi-center translation trial. Cholgate - A Randomized Controlled Trial Comparing The Effect Of Automated And On-Demand Decision Support On The Management Of Cardiovascular Disease Factors In Primary Care Effectiveness of a tailored intervention to improve cardiovascular risk management in primary care: study protocol for a randomised controlled trial Effects of a computerized decision support system in improving pharmacological management in high-risk cardiovascular patients: A cluster-randomized open-label controlled trial Pilot study to validate a computer-based clinical decision support system for dyslipidemia treatment (HTE-DLP). The impact of a decision aid about heart disease prevention on patients' discussions with their doctor and their plans for prevention: a pilot randomized trial Effect of a Computer-Guided, Quality Improvement Program for Cardiovascular Disease Risk Management in Primary Health Care: The Treatment of Cardiovascular Risk Using Electronic Decision Support Cluster-Randomized Trial A Cluster-Randomized, Controlled Trial of a Simplified Multifaceted Management Program for Individuals at High Cardiovascular Risk (SimCard Trial) in Rural Tibet, China, and Haryana, India A simple computer program for guiding management of cardiovascular risk factors and prescribing A randomised controlled trial of a consumer-focused e-health strategy for cardiovascular risk management in primary care: the Consumer Navigation of Electronic Cardiovascular Tools (CONNECT) study protocol A cluster-randomized controlled trial to evaluate the effects of a simplified cardiovascular management program in Tibet, China and Haryana, India: study design and rationale Rational Prescribing in Primary Care (RaPP): A Cluster Randomized Trial of a Tailored Intervention Exposure to and experiences with a computerized decision support intervention in primary care: results from a process evaluation The Treatment of cardiovascular Risk in Primary care using Electronic Decision suppOrt (TORPEDO) study: intervention development and protocol for a cluster randomised, controlled trial of an electronic decision support and quality improvement intervention in Australian primary healthcare Improving cardiovascular risk management: a randomized, controlled trial on the effect of a decision support tool for patients and physicians Clinical decision support implemented with academic detailing improves prescribing of key renally cleared drugs in the hospital setting Controlled trial of effect of documented cardiovascular risk scores on prescribing Rationale, design, and conduct of the PEPI Trial. Postmenopausal Estrogen/Progestin Interventions. A computer decision aid for medical prevention: a pilot qualitative study of the Personalized Estimate of Risks (EsPeR) system Effectiveness of general practice nurse interventions in cardiac risk factor reduction among adults Rationale, design, methods and baseline characteristics of the Asklepios Study Combined Task Delegation, Computerized Decision Support, and Feedback Improve Cardiovascular Risk for Type 2 Diabetic Patients Effectiveness of an mHealth-Based Electronic Decision Support System for Integrated Management of Chronic Conditions in Primary Care: The mWellcare Cluster-Randomized Controlled Trial Implementation and evaluation of an integrated computerized asthma management system in a pediatric emergency department: A randomized clinical trial Cost-Effectiveness of the Diabetes Care Protocol, a Multifaceted Computerized Decision Support Diabetes Management Intervention That Reduces Cardiovascular Risk Focus on health information technology, electronic health records and their financial impact: Cost-effectiveness of a shared computerized decision support system for diabetes linked to electronic medical records A case-management program of medium intensity does not improve cardiovascular risk factor control in coronary artery disease patients: the Heartcare I trial. A multifaceted quality improvement intervention for CVD risk management in Australian primary healthcare: a protocol for a process evaluation Computerized decision support based on a clinical practice guideline improves compliance with care standards. Clinician-specific episiotomy rates: impact on perineal outcomes. Cluster-randomized, controlled trial of computer-based decision support for selecting long-term anti-thrombotic therapy after acute ischaemic stroke. Improved delivery of cardiovascular care (IDOCC) through outreach facilitation: study protocol and implementation details of a cluster randomized controlled trial in primary care Comparison of oral anticoagulant control by a nurse-practitioner using a computer decision-support system with that by clinicians. A multifaceted strategy using mobile technology to assist rural primary healthcare doctors and frontline health workers in cardiovascular disease risk management: protocol for the SMARTHealth India cluster randomised controlled trial A randomized trial of an intervention to improve use and adherence to effective coronary heart disease prevention strategies A cardiac rehabilitation program to improve psychosocial outcomes of women with heart disease. [The PreFord Study. A prospective cohort study to evaluate the risk of a cardiovascular event (overall-collective) as well as a prospective, randomized, controlled, multicentre clinical intervention study (high-risk-collective) on primary prevention of cardiovascular diseases in the Ford Motor Compa Evaluation of computer based clinical decision support system and risk chart for management of hypertension in primary care: randomised controlled trial Understanding Keys to Successful Implementation of Electronic Decision Support in Rural Hospitals: Analysis of a Pilot Study for Antimicrobial Prescribing Rationale and design of the Investigation of Motivational Interviewing and Prevention Consults to Achieve Cardiovascular Targets (IMPACT) trial. Clinical utility of family history for cancer screening and referral in primary care: A report from the Family Healthware Impact Trial
AIMS Cardiovascular disease ( CVD ) is the leading cause of morbidity and mortality in people with diabetes in South Asia . The CARRS Translation Trial tests the effectiveness , cost-effectiveness , and sustainability of a clinic-based multi-component CVD risk reduction intervention among people with diabetes in India and Pakistan . METHODS We r and omly assigned 1146 adults with diabetes recruited from 10 urban clinic sites , to receive usual care by physicians or to receive an integrated multi-component CVD risk reduction intervention . The intervention involves electronic health record management , decision-support prompts to the healthcare team , and the support of a care coordinator to actively facilitate patient and provider adherence to evidence -based guidelines . The primary outcome is a composite of multiple CVD risk factor control ( blood glucose and either blood pressure or cholesterol , or all three ) . Other outcomes include control of the individual CVD risk factors , process and patient-centered measures , cost-effectiveness , and acceptability/feasibility . CONCLUSION The CARRS Translation Trial tests a low-cost diabetes care delivery model in urban South Asia to achieve comprehensive cardio-metabolic disease case-management of high-risk patients ( clinical trials.gov number : NCT01212328 ) Automated and on-dem and decision support systems integrated into an electronic medical record have proven to be an effective implementation strategy for guidelines . Cholgate is a r and omized controlled trial comparing the effect of automated and on-dem and decision support on the management of cardiovascular disease factors in primary care Abstract Background Cardiovascular disease ( CVD ) is an important worldwide cause of mortality . In The Netherl and s , CVD is the leading cause of death for women and the second cause of death for men . Recommendations for diagnosis and treatment of CVD are not well implemented in primary care . In this study , we aim to examine the effectiveness of a tailored implementation program targeted at practice nurses to improve healthcare for patients with ( high risk for ) CVD . Methods / design A two-arm cluster r and omized trial is planned . We offer practice nurses a tailored program to improve adherence to six specific recommendations related to blood pressure and cholesterol target values , risk profiling and lifestyle advice . Practice nurses are offered training and feedback on their motivational interviewing technique and an e-learning program on cardiovascular risk management ( CVRM ) . They are also advised to screen for the presence and severity of depressive symptoms in patients . We also advise practice nurses to use selected E-health options ( selected websites and Twitter-consult ) in patients without symptoms of depression . Patients with mild depressive symptoms are referred to a physical exercise group . We recommend referring patients with major depressive symptoms for assessment and treatment of depressive symptoms if appropriate before starting CVRM .  Data from 900 patients at high risk of CVD or with established CVD will be collected in 30 general practice s in several geographical areas in The Netherl and s. The primary outcome measure is performance of practice nurses in CVRM and reflects application of recommendations for personalized counselling and education of CVRM patients . Patients ’ health-related lifestyles ( physical exercise , diet and smoking status ) will be measured with vali date d question naires and medical record audit will be performed to document estimated CVD risk . Additionally , we will survey and interview participating healthcare professionals for exploration of processes of change . The control practice s will provide usual care . Discussion Tailored interventions can improve healthcare . An underst and ing of the methods to reach the improved healthcare can be improved . This research contributes a share of it . Identification of the determinants of practice and developing implementation interventions were two steps which were completed . The subsequent step was implementation of the tailored intervention program . Trial registration Name trial register : Nederl and s trial registerWeb address of trial register : http://www.trialregister.nl Data of registration : 11 July 2013Number of registration : This study was aim ed to investigate the effects of computerized decision support system in improving the prescription of drugs for cardiovascular prevention . A total of 197 Italian general practitioners were r and omly allocated to receive either the alerting computerized decision support system integrated into st and ard software ( intervention arm ) or the st and ard software alone ( control arm ) . Data on 21230 patients with diabetes , 3956 with acute myocardial infa rct ion , and 2158 with stroke were analysed . The proportion of patients prescribed with cardiovascular drugs and days of drug – drug interaction exposure were evaluated . Computerized decision support system significantly increased the proportion of patients with diabetes prescribed with antiplatelet drugs ( intervention : + 2.7 % vs. control : + 0.15 % ; p < 0.001 ) or lipidlowering drugs ( + 4.2 % vs. + 2.8 % ; p = 0.001 ) . A statistically significant decrease in days of potential interactions has been observed only among patients with stroke ( −1.2 vs. −0.5 days/person-year ; p = 0.001 ) . In conclusion , computerized decision support system  significantly increased the use of recommended cardiovascular drugs in diabetic patients , but it did not influence the exposure to potential UNLABELLED Pilot study to vali date a Computerized Decision Support Systems ( CDS ) ( HTE-DLP ) for improving treatment of hyperlipidemia . METHODS HTE-DLP was programmed to offer automatic specific reminders for lipid treatment .  Seventy-seven patients with high cardiovascular risk were r and omized . 10 expert physicians in cardiovascular-risk management were recruited . We assessed number of patients at LDL < 70 mg/dl after 12 weeks of treatment . RESULTS A greater proportion of intervention group reached the LDL-C < 70 mg/ml [ 55.0 % vs 12.5 % , p = 0.003 ; OR : 3.26 IC ( 1.16 - 9.15 ) ] .  " High potency statins " and combined therapy  were used more frequently in the intervention group than the control group ( p = 0.001 ) . Seven adverse effects were documented in the intervention group and two in the control group . An acceptable relationship was observed with regard to costeffectiveness in the intervention group . Physicians expressed good agreement with HTE-DLP ( 86.1 % ) and comfortable ease-of-use ( 85 % ) . CONCLUSIONS Use of a CDSS in high-risk cardiovascular patients result ed in a significant reduction in LDL-C levels Abstract Background Low utilization of effective coronary heart disease ( CHD ) prevention strategies may be due to many factors , but chief among them is the lack of patient involvement in prevention decisions . We undertook this study to test the effectiveness of an individually-tailored , computerized decision aid about CHD on patients ' discussion s with their doctor and their plans for CHD prevention . Methods We conducted a pilot r and omized trial in a convenience sample of adults with no previous history of cardiovascular disease to test the effectiveness of an individually-tailored , computerized decision aid about CHD prevention against a risk factor list that patients could present to their doctor . Results We enrolled 75 adults . Mean age was 53 . 59 % were female , 73 % white , and 23 % African-American . 66 % had some college education . 43 % had a 10-year CHD risk of 0–5 % , 25 % a risk of 6–10 % , 24 % a risk of 11–20 % , and 5 % a risk of > 20 % . 78 % had at least one option to reduce their CHD risk , but only 45 % accurately identified the strategies best supported by evidence . 41 patients received the decision aid  , 34 received  usual care . In unadjusted analysis , the decision aid increased the proportion of patients who discussed CHD risk reduction with their doctor from 24 % to 40 % ( absolute difference 16 % ; 95 % CI -4 % to + 37 % ) and increased the proportion who had a specific plan to reduce their risk from 24 % to 37 % ( absolute difference 13 % ; 95 % CI -7 % to + 34 % ) . In pre-post testing , the decision aid also appeared to increase the proportion of patients with plans to intervene on their CHD risk ( absolute increase ranging from 21 % to 47 % for planned medication use and 5 % to 16 % for planned behavioral interventions ) . Conclusion Our study confirms patients ' limited knowledge about their CHD risk and effective risk reduction options and provides preliminary evidence that an individually-tailored decision aid about CHD prevention might be expected to increase patients ' discussion s about CHD prevention with their doctor and their plans for CHD risk reduction . These findings should be replicated in studies with a larger sample size and patients at overall higher risk of CHD . Trial Registration : Clinical Trials.gov Background — Despite effective treatments to reduce cardiovascular disease risk , their translation into practice is limited . Methods and Results — Using a parallel arm cluster-r and omized controlled trial in 60 Australian primary healthcare centers , we tested whether a multifaceted quality improvement intervention comprising computerized decision support , audit/feedback tools , and staff training improved ( 1 ) guideline -indicated risk factor measurements and ( 2 ) guideline -indicated medications for those at high cardiovascular disease risk . Centers had to use a compatible software system , and eligible patients were regular attendees ( Aboriginal and Torres Strait Isl and er people aged ≥35 years and others aged ≥45 years ) . Patient-level analyses were conducted using generalized estimating equations to account for clustering . Median follow-up for 38 725 patients ( mean age , 61.0 years ; 42 % men ) was 17.5 months . Mean monthly staff support was < 1 hour/site . For the co primary outcomes , the intervention was associated with improved overall risk factor measurements ( 62.8 % versus 53.4 % risk ratio ; 1.25 ; 95 % confidence interval , 1.04–1.50 ; P=0.02 ) , but there was no significant differences in recommended prescriptions for the high-risk cohort ( n=10 308 ; 56.8 % versus 51.2 % ; P=0.12 ) . There were significant treatment escalations ( new prescriptions or increased numbers of medicines ) for antiplatelet ( 4.3 % versus 2.7 % ; P=0.01 ) , and BP lowering ( 18.2 % versus 11.0 % ; P=0.02 ) but not lipid-lowering medications . Conclusions — In Australian primary healthcare setting s , a computer-guided quality improvement intervention , requiring minimal support , improved cardiovascular disease risk measurement but did not increase prescription rates in the high-risk group . Computerized quality improvement tools offer an important , albeit partial , solution to improving primary healthcare system capacity for cardiovascular disease risk management . Clinical Trial Registration — URL : https://www.anzctr.org.au/Trial/ Registration /Trial Review .aspx?id=336630 . Australian New Zeal and Clinical Trials Registry No. 12611000478910 Background — In rural areas in China and India , the cardiovascular disease burden is high but economic and healthcare re sources are limited . This study ( the Simplified Cardiovascular Management Study [ SimCard ] ) aims to develop and evaluate a simplified cardiovascular management program delivered by community health workers with the aid of a smartphone-based electronic decision support system . Methods and Results — The SimCard study was a yearlong cluster-r and omized , controlled trial conducted in 47 villages ( 27 in China and 20 in India ) . Recruited for the study were 2086 individuals with high cardiovascular risk ( aged ≥40 years with self-reported history of coronary heart disease , stroke , diabetes mellitus , and /or measured systolic blood pressure ≥160 mm Hg ) . Participants in the intervention villages were managed by community health workers through an And roid-powered app on a monthly basis focusing on 2 medication use and 2 lifestyle modifications . In comparison with the control group , the intervention group had a 25.5 % ( P<0.001 ) higher net increase in the primary outcome of the proportion of patient-reported antihypertensive medication use pre- and post-intervention . There were also significant differences in certain secondary outcomes : aspirin use ( net difference : 17.1 % ; P<0.001 ) and systolic blood pressure ( –2.7 mm Hg ; P=0.04 ) . However , no significant changes were observed in the lifestyle factors . The intervention was culturally tailored , and country-specific results revealed important differences between the regions . Conclusions — The results indicate that the simplified cardiovascular management program improved quality of primary care and clinical outcomes in re source -poor setting s in China and India . Larger trials in more places are needed to ascertain the potential impacts on mortality and morbidity outcomes . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT01503814 Abstract Objective : To describe , and to test against trial data , a simple and flexible computer program for calculating cardiovascular risk in individual patients as an aid to managing risk factors and prescribing drugs to lower cholesterol concentration and blood pressure . Design : Descriptive comparison of actual cardiovascular risk in r and omised controlled trials of cholesterol reduction  with risk predicted by a computer program based on the Framingham risk equation . Comparison of the program 's performance with that of tables and guidelines by means of hypothetical case examples . Main outcome measures : Average risk of coronary heart disease and myocardial infa rct ion . Results : The computer program accurately predicted baseline absolute risk in a UK population as well as the relative and absolute reduction in risk from cholesterol lowering for primary prevention of coronary heart disease . The program also allowed a more refined estimate of absolute risk of coronary heart disease than some existing tables and enabled the impact of prescribing decisions to be quantified and costed . Conclusions : This simple computer program to estimate individuals ' cardiovascular disease risk and display the benefits of intervention should help clinicians and patients decide on the most effective packages of risk reduction and identify those most likely to benefit from modulation of risk factors Introduction Fewer than half of all people at highest risk of a cardiovascular event are receiving and adhering to best practice recommendations to lower their risk . In this project , we examine the role of an e-health-assisted consumer-focused strategy as a means of overcoming these gaps between evidence and practice . Consumer Navigation of Electronic Cardiovascular Tools ( CONNECT ) aims to test whether a consumer-focused e-health strategy provided to Aboriginal and Torres Strait Isl and er and non-indigenous adults , recruited through primary care , at moderate-to-high risk of a cardiovascular disease event will improve risk factor control when compared with usual care . Methods and analysis R and omised controlled trial of 2000 participants with an average of 18 months of follow-up to evaluate the effectiveness of an integrated consumer-directed e-health portal on cardiovascular risk compared with usual care in patients with cardiovascular disease or who are at moderate-to-high cardiovascular disease risk . The trial will be augmented by formal economic and process evaluations to assess acceptability , equity and cost-effectiveness of the intervention . The intervention group will participate in a consumer-directed e-health strategy for cardiovascular risk management . The programme is electronically integrated with the primary care provider 's software and will include interactive smart phone and Internet platforms . The primary outcome is a composite endpoint of the proportion of people meeting the Australian guideline -recommended blood pressure ( BP ) and cholesterol targets . Secondary outcomes include change in mean BP and fasting cholesterol levels , proportion meeting BP and cholesterol targets separately , self-efficacy , health literacy , self-reported point prevalence abstinence in smoking , body mass index and waist circumference , self-reported physical activity and self-reported medication adherence . Ethics and dissemination Primary ethics approval was received from the University of Sydney Human Research Ethics Committee and the Aboriginal Health and Medical Research Council . Results will be disseminated via the usual scientific forums including peer- review ed publications and presentations at international conferences Clinical Trials registration number ACTRN12613000715774 Background In re source -poor areas of China and India , the cardiovascular disease burden is high , but availability of and access to quality healthcare is limited . Establishing a management scheme that utilizes the local infrastructure and builds healthcare capacity is essential for cardiovascular disease prevention and management . The study aims to develop , implement , and evaluate the feasibility and effectiveness of a simplified , evidence -based cardiovascular management program delivered by community healthcare workers in re source -constrained areas in Tibet , China and Haryana , India . Methods / design This yearlong cluster-r and omized controlled trial will be conducted in 20 villages in Tibet and 20 villages in Haryana . R and omization of villages to usual care or intervention will be stratified by country . High cardiovascular disease risk individuals ( aged 40 years or older , history of heart disease , stroke , diabetes , or measured systolic blood pressure of 160 mmHg or higher ) will be screened at baseline . Community health workers in the intervention villages will be trained to manage and follow up high-risk patients on a monthly basis following a simplified ‘ 2 + 2 ’ intervention model involving two lifestyle recommendations and the appropriate prescription of two medications . A customized electronic decision support system based on the intervention strategy will be developed to assist the community health workers with patient management . Baseline and follow-up surveys will be conducted in a st and ardized fashion in all villages . The primary outcome will be the net difference between-group in the proportion of high-risk patients taking antihypertensive medication pre- and post-intervention . Secondary outcomes will include the proportion of patients taking aspirin and changes in blood pressure . Process and economic evaluations will also be conducted . Discussion To our knowledge , this will be the first study to evaluate the effect of a simplified management program delivered by community health workers with the help of electronic decision support system on improving the health of high cardiovascular disease risk patients . If effective , this intervention strategy can serve as a model that can be implemented , where applicable , in rural China , India , and other re source -constrained areas .Trial registration The trial was registered in the clinical trials.gov data base on 30 December , 2011 and the registration number is NCT01503814 Background A gap exists between evidence and practice regarding the management of cardiovascular risk factors . This gap could be narrowed if systematic ally developed clinical practice guidelines were effectively implemented in clinical practice . We evaluated the effects of a tailored intervention to support the implementation of systematic ally developed guidelines for the use of antihypertensive and cholesterol-lowering drugs for the primary prevention of cardiovascular disease . Methods and Findings We conducted a cluster-r and omized trial comparing a tailored intervention to passive dissemination of guidelines in 146 general practice s in two geographical areas in Norway . Each practice was r and omized to either the tailored intervention ( 70 practice s ; 257 physicians ) or control group ( 69 practice s ; 244 physicians ) . Patients started on medication for hypertension or hypercholesterolemia during the study period and all patients already on treatment that consulted their physician during the trial were included . A multifaceted intervention was tailored to address identified barriers to change . Key components were an educational outreach visit with audit and feedback , and computerized reminders linked to the medical record system . Pharmacists conducted the visits . Outcomes were measured for all eligible patients seen in the participating practice s during 1 y before and after the intervention . The main outcomes were the proportions of ( 1 ) first-time prescriptions for hypertension where thiazides were prescribed , ( 2 ) patients assessed for cardiovascular risk before prescribing antihypertensive or cholesterol-lowering drugs , and ( 3 ) patients treated for hypertension or hypercholesterolemia for 3 mo or more who had achieved recommended treatment goals . The intervention led to an increase in adherence to guideline recommendations on choice of antihypertensive drug . Thiazides were prescribed to 17 % of patients in the intervention group versus 11 % in the control group ( relative risk 1.94 ; 95 % confidence interval 1.49–2.49 , adjusted for baseline differences and clustering effect ) . Little or no differences were found for risk assessment prior to prescribing and for achievement of treatment goals . Conclusions Our tailored intervention had a significant impact on prescribing of antihypertensive drugs , but was ineffective in improving the quality of other aspects of managing hypertension and hypercholesterolemia in primary care Background Trials evaluating the effects of interventions usually provide little insight into the factors responsible for ( lack of ) changes in desired outcomes . A process evaluation alongside a trial can shed light on the mechanisms responsible for the outcomes of a trial . The aim of this study was to investigate exposure to and experiences with a computerized decision support system ( CDSS ) intervention , in order to gain insight into the intervention ’s impact and to provide suggestions for improvement . Methods A process evaluation was conducted as part of a large-scale cluster-r and omized controlled trial investigating the effects of the CDSS NHGDoc on quality of care . Data on exposure to and experiences with the intervention were collected during the trial period among participants in both the intervention and control group - whenever applicable - by means of the NHGDoc server and an electronic question naire . Multiple data were analyzed using descriptive statistics . Results Ninety-nine percent ( n = 229 ) of the included practice s generated data for the NHGDoc  server and 50 % ( n = 116 ) responded to the question naire : both general practitioners ( GPs ; n = 112 ; 49 % ) and practice nurses ( PNs ; n = 52 ; 37 % ) participated . The actual exposure to the NHGDoc system and specific heart failure module was limited with 52 % of the GPs and 42 % of the PNs reporting to either never or rarely use the system . Overall , users had a positive attitude towards CDSSs . The most perceived barriers to using NHGDoc were a lack of learning capacity of the system , the additional time and work it requires to use the CDSS , irrelevant alerts , too high intensity of alerts and insufficient knowledge regarding the system . Conclusions Several types of barriers may have negatively affected the impact of the intervention . Although users are generally positive about CDSSs , a large share of them is insufficiently aware of the functions of NHGDoc and , finds the decision support not always useful or relevant and difficult to integrate into daily practice . In design ing CDSS interventions we suggest to more intensely involve the end-users and increase the system ’s flexibility and learning capacity . To improve implementation a proper introduction of a CDSS among its target group including adequate training is advocated . Trial registration Clinical trials NCT01773057 Background Large gaps exist in the implementation of guideline recommendations for cardiovascular disease ( CVD ) risk management .  Electronic decision support ( EDS ) systems are promising interventions to close these gaps but few have undergone clinical trial evaluation in Australia . We have developed HealthTracker , a multifaceted EDS and quality improvement intervention to improve the management of CVD risk . Methods / design It is hypothesised that the use of HealthTracker over a 12-month period will result in : ( 1 ) an increased proportion of patients receiving guideline -indicated measurements of CVD risk factors and ( 2 ) an increased proportion of patients at high risk will receive guideline -indicated prescriptions for lowering their CVD risk . Sixty health services ( 40 general practice s and 20 Aboriginal Community Controlled Health Services ( ACCHSs ) will be r and omised in a 1:1 allocation to receive either the intervention package or continue with usual care , stratified by service type , size and participation in existing quality improvement initiatives . The intervention consists of point-of-care decision support ; a risk communication interface ; a clinical audit tool to assess performance on CVD-related indicators ; a quality improvement component comprising peer-ranked data feedback and support to develop strategies to improve performance .  The control arm will continue with usual care without access to these intervention components . Quantitative data will be derived from cross-sectional sample s at baseline and end of study via automated data extraction . Detailed process and economic evaluations will also be conducted . Ethics and dissemination The general practice component of the study is approved by the University of Sydney Human Research Ethics Committee ( HREC ) and the ACCHS component is approved by the Aboriginal Health and Medical Research Council HREC . Formal agreements with each of the participating sites have been signed . In addition to the usual scientific forums , results will be disseminated via newsletters , study websites , face-to-face feedback forums and workshops . Trial registration The trial is registered with the Australian Clinical Trials Registry ACTRN 12611000478910 Background There is nonoptimal adherence of general practitioners ( GPs ) and patients to cardiovascular risk reducing interventions . GPs find it difficult to assimilate multiple risk factors into an accurate assessment of cardiovascular risk . In addition , communicating cardiovascular risk to patients has proved to be difficult . Aims Improving primary prevention of cardiovascular disease ( CVD ) in primary care by enhancing patient involvement in the use of a decision support tool . Design Cluster r and omized trial . Methods Thirty-four GPs included patients ( 40 - 75 years old ) without CVD . In an interactive , small group training session lasting 4h , the GPs in the intervention group were trained to use the guidelines on cardiovascular risk and a decision support tool . The control group received educational material s about the guidelines on paper .  GPs ’ clinical performance and patients ’ risk perception and self-reported lifestyles were measured at baseline and after 6 months . Results Thirty-four GPs recorded 490 consultations , 276 in the intervention and 214 in the control group . After 6 months , no significant effect of the intervention on the GPs ’ performance or the patients ’ risk perception was found . There was only an effect on self-reported lifestyle , in that more men in the intervention group than in the control group increased their physical activity ( odds ratio 3.8 , 95 % confidence interval 1.7–8.7 ) . Conclusion The 4-h interactive , small group training did not guarantee correct application of the decision support tool and as such failed to improve GPs ’ performance or correct patients ’ risk perception . The positive effect on physical activity justifies further research on patient involvement . Eur J Cardiovasc Prev Rehabil 14 : 44 - 50 © 2007 The European Society of OBJECTIVE Lack of dose adjustment for renally cleared drugs in the presence of poor renal function is a common problem in the hospital setting . The absence of a clinical decision support system ( CDSS ) from direct clinician workflows such as computerized provider order entry ( CPOE ) hinders the uptake of CDSS . This study implemented CDSS in an environment independent of CPOE , introduced to prescribers via academic detailing , to address the dosing of renally cleared drugs . DESIGN GFR+ was design ed to automatically calculate and up date renal function , doses of key drugs adjusted for renal function , and highlight clinical ly significant decreases in renal function . Prescribers were made aware of GFR+ , its navigation , and surrounding clinical issues , using academic detailing . MEASUREMENT The rate of dosing conformity and management for key renally cleared drugs in hospitalized patients , before and after GFR+ implementation . RESULTS Improvements were seen in dosing conformity for enoxaparin ( from 68 % to 86 % , p=0.03 ) , gentamicin ( 63 - 87 % , p=0.01 ) , and vancomycin ( 47 - 77 % , p=0.07 ) , as well as the appropriate use of gentamicin therapeutic drug monitoring ( 70 - 90 % , p=0.02 ) . During episodes of acute renal impairment , renally cleared drugs were held on 38 % of instances in the pre-intervention period compared with 62 % post-intervention ( p=0.01 ) . CONCLUSION Clinical decision support implemented with academic detailing improved dosing conformity and management of key renally cleared drugs in a hospitalized population . Academic detailing should be strongly considered to facilitate the introduction of CDSS systems that can not be placed directly into the clinician workflow Cardiovascular disease causes the death of around 80 % of patients with type 2 diabetes.1 However , risk factors for cardiovascular disease in such patients are often untreated2 despite the proved benefits of intervention . 3 4 One way to help clinicians identify patients at high risk of cardiovascular disease is to use cardiovascular primary prevention risk tables . These tables integrate the multiple risk factors into a single score . We did a pilot study to test the hypothesis that documentation of a  cardiovascular risk score in the case notes would improve the management of cardiovascular risk factors . We recruited patients with type 2 diabetes who had no history of cardiovascular disease or renal disease . All patients were aged 35–75 years and attending a hospital There is growing and consistent evidence that estrogen use in postmenopausal women is associated with a substantial reduction in the occurrence of cardiovascular disease . However , remarkably little is known about the biological mechanisms by which estrogen therapy may influence risk . Even less information is available on the cardiovascular effects of combined estrogen-progestin use . PEPI was not design ed to test whether estrogen and estrogen-progestin therapy is efficacious in the prevention of cardiovascular disease , as a much larger trial with clinical disease outcomes is needed to answer that question . However , PEPI will provide critical evidence regarding the potential effectiveness of the various estrogen and estrogen/progestin regimens ni altering risk factors for cardiovascular disease in women . Detailed information on factors such as adherence , side effects , and general patient acceptability will also be ascertained . The main results from PEPI will provide the scientific community with information on the basic actions of estrogen and estrogen/progestin therapy  on four biological systems believed to be causally associated with cardiovascular disease occurrence . Further , since the trial is design ed to continue for 3 years , PEPI will be able to provide information on longer term as well as short-term effects on these systems . Finally , the results from PEPI should enable women and their physicians to select an optimal hormonal regimen , i.e. , one that is acceptable , safe , and provides the most beneficial and least deleterious changes in cardiovascular and other risk factors Background Many preventable diseases such as ischemic heart diseases and breast cancer prevail at a large scale in the general population .  Computerized decision support systems are one of the solutions for improving the quality of prevention strategies . Methods The system called EsPeR ( Personalised Estimate of Risks ) combines calculation of several risks with computerisation of guidelines ( cardiovascular prevention , screening for breast cancer , colorectal cancer , uterine cervix cancer , and prostate cancer , diagnosis of depression and suicide risk ) . We present a qualitative evaluation of its ergonomics , as well as it 's underst and ing and acceptance by a group of general practitioners . We organised four focus groups each including 6–11 general practitioners . Physicians worked on several structured clinical scenari os with the help of EsPeR , and three senior investigators leaded structured discussion sessions . Results The initial sessions identified several ergonomic flaws of the system that were easily corrected . Both clinical scenarios and discussion sessions identified several problems related to the insufficient comprehension ( expression of risks , definition of familial history of disease ) , and difficulty for the physicians to accept some of the recommendations . Conclusion Educational , socio-professional and organisational components ( i.e. time constraints for training and use of the EsPeR system during consultation ) as well as acceptance of evidence -based decision-making should be taken into account before launching computerised decision support systems , or their application in r and omised trials Background Cardiovascular disease is the leading cause of death for adults in Australia . In recent years there has been a shift in health service delivery from institutional to community‐based care for chronic conditions , including cardiovascular disease . The general practice setting is seen to offer greater flexibility , higher levels of efficiency and more client focused healthcare delivery than is possible in the acute care sector . It has been suggested that practice nurses represent a useful adjunct to current models of cardiovascular disease management . To date , significant descriptive research has been conducted exploring the demographics , roles , educational needs and issues facing practice nurses . However , there is a need to evaluate the effectiveness of practice nurse interventions in terms of patient outcomes , clinician satisfaction and cost‐effectiveness . Objectives This review seeks to present the best available evidence regarding the efficacy of general practice nurse interventions for cardiac risk factor reduction in healthy adults , as well as those with established cardiovascular disease or known cardiac risk factors . Search Strategy A systematic literature search was performed using Medline ( 1966 ‐ 2005 ) , CINAHL ( 1982 −2005 ) , Cochrane Controlled Trials Register ( Issue 4 , 2005 ) and the Joanna Briggs Institute Evidence Library . In addition , the reference lists of retrieved papers , conference proceedings and the Internet , were scrutinised for additional trials . Selection Criteria This review considered any English language r and omised trials that investigated interventions conducted by the practice nurse for cardiovascular disease management or reduction of cardiac risk factors . Interventions conducted by specialist cardiac nurses in general practice were excluded . Outcomes measured included blood pressure , smoking cessation , total cholesterol , exercise , body weight/body mass index and cost‐effectiveness . Results Eighteen trials , reported in 33 papers , were included in the review . Ten trials investigated multifaceted interventions , while the remaining eight trials reported targeted interventions . Of the trials that reported multifaceted interventions , three trials investigated risk reduction in those with established cardiovascular disease , four trials focused on those with known cardiovascular disease risk factors and three trials included the general community . The eight trials which examined the efficacy of targeted interventions focused upon dietary intake ( two trials ) , smoking cessation ( three trials ) , weight reduction ( one trial ) and physical activity ( two trials ) . The effect of both the multifaceted and targeted interventions on patient outcomes was variable . However , both the multifaceted and targeted interventions demonstrated similar outcome trends for specific variables . Improvements were demonstrated by most studies in blood pressure , cholesterol level , dietary intake and physical activity . The variation in outcome measures and contradictory findings between some studies makes it difficult to draw definitive conclusions . Conclusions While interventions to reduce cardiovascular disease risk factors have produced variable results , they offer significant potential to assist patients in modifying their personal risk profile and should be developed . The public health importance of these changes is dependant upon the sustainability of the change and its effect on the health outcomes of these individuals . Further well‐ design ed research is required to establish the effectiveness of practice nurse interventions for cardiovascular disease management and risk factor reduction in terms of patient outcomes and cost‐effectiveness The Asklepios Study is a longitudinal population study focusing on the interplay between ageing , cardiovascular haemodynamics and inflammation in ( pre clinical ) cardiovascular disease . The 2524 participants ( 1301 women ) are a representative cohort of 35–55-year-old individuals , free from overt cardiovascular disease at study initiation , r and omly sample d from the twinned Belgian communities of Erpe – Mere and Nieuwerkerken . Baseline examinations ( all single-observer , single-device , single-site , single 2-year consecutive timeframe ) include : question naires , conventional risk factors and biochemistry . Additional phenotypes under study include : ( a ) vascular structure and function : carotid and femoral atherosclerosis ( intima – media thickness , plaque ) , arterial distension and pressure curves ( brachial , carotid , femoral ; wall-tracking and applanation tonometry ) ; ( b ) cardiac structure and function . A novel aspect of the study is ‘ integrated ’ noninvasive biomechanical assessment of cardiac , arterial and ventriculovascular function through a combination of modeling , fundamental hydraulical measurements and system identification techniques . Integrated phenotypes result from combining at least two sets of curves ( flow/pressure/distension ) . The value of this ‘ integrated ’ haemodynamic phenotype in the detection , prediction and prevention of clinical cardiovascular pathology ( atherosclerosis progression , atherothrombosis , development of heart failure ) will be tested . A second novel aspect is the systematic determination of peripheral blood leukocyte telomere length as a marker for biological ageing . During follow-up , baseline examinations will be repeated and the incidence of cardiovascular events will be monitored . Sex-specific baseline risk factor and biochemical data are provided in the current analyses . The primary aim is to build a combined data set that will act as a tool to answer a cluster of questions about ageing , haemodynamics and the emergence of cardiovascular disease , especially the incidence of atherothrombotic events and the development of adverse haemodynamic profiles ( arterial stiffening , heart failure ) . The study will reassess current risk factors and provide a long-term base for the detection of novel (epi)genetic and non-genetic risk factors and for more performant risk stratification modalities . Within these broader goals , a constant will be to strive towards more fundamental mechanistic-haemodynamic insights into cardiovascular disease processes OBJECTIVE —The Diabetes Care Protocol combines task delegation ( a practice nurse ) , computerized decision support , and feedback every 3 months . We studied the effect of the Diabetes Care Protocol on A1C and cardiovascular risk factors in type 2 diabetic patients in primary care . RESEARCH DESIGN AND METHODS —In a cluster r and omized trial , mean changes in cardiovascular risk factors between the intervention and control groups after 1 year were calculated by generalized linear models . RESULTS —Throughout the Netherl and s , 26 intervention practice s included 1,699 patients and 29 control practice s 1,692 patients . The difference in A1C change was not significant , whereas total cholesterol , LDL cholesterol , and blood pressure improved significantly more in the intervention group . The 10-year coronary heart disease risk estimate of the UK Prospect i ve Diabetes Study improved 1.4 % more in the intervention group . CONCLUSIONS —Delegation of routine diabetes care to a practice nurse combined with computerized decision support and feedback did not improve A1C but reduced cardiovascular risk in type 2 diabetes patients Background : The burden of noncommunicable diseases and their risk factors has rapidly increased worldwide , including in India .  Innovative management strategies with electronic decision support and task sharing have been assessed for hypertension , diabetes mellitus , and depression individually , but an integrated package for multiple chronic condition management in primary care has not been evaluated . Methods : In a prospect i ve , multicenter , open-label , cluster-r and omized controlled trial involving 40 community health centers , using hypertension and diabetes mellitus as entry points , we evaluated the effectiveness of mWellcare , an mHealth system consisting of electronic health record storage and an electronic decision support for the integrated management of 5 chronic conditions ( hypertension , diabetes mellitus , current tobacco and alcohol use , and depression ) versus enhanced usual care among patients with hypertension and diabetes mellitus in India . At trial end ( 12-month follow-up ) , using intention-to-treat analysis , we examined the mean difference between arms in change in systolic blood pressure and glycated hemoglobin as primary outcomes and fasting blood glucose , total cholesterol , predicted 10-year risk of cardiovascular disease , depression score , and proportions reporting tobacco and alcohol use as secondary outcomes . Mixed-effects regression models were used to account for clustering and other confounding variables . Results : Among 3698 enrolled participants across 40 clusters ( mean age , 55.1 years ; SD , 11 years ; 55.2 % men ) , 3324 completed the trial . There was no evidence of difference between the 2 arms for systolic blood pressure ( & Dgr;=−0.98 ; 95 % CI , −4.64 to 2.67 ) and glycated hemoglobin ( & Dgr;=0.11 ; 95 % CI , −0.24 to 0.45 ) even after adjustment of several key variables ( adjusted differences for systolic blood pressure : – 0.31 [ 95 % CI , −3.91 to 3.29 ] ; for glycated hemoglobin : 0.08 [ 95 % CI , −0.27 to 0.44 ] ) . The mean within-group changes in systolic blood pressure in mWellcare and enhanced usual care were −13.65 mm Hg versus −12.66 mm Hg , respectively , and for glycated hemoglobin were −0.48 % and −0.58 % , respectively . Similarly , there were no differences in the changes between the 2 groups for tobacco and alcohol use or other secondary outcomes . Conclusions : We did not find an incremental benefit of mWellcare over enhanced usual care in the management of the chronic conditions studied . Clinical Trial Registration : URL : https://www . clinical trials.gov . Unique identifier : NCT02480062 OBJECTIVE The use of evidence -based guidelines can improve the care for asthma patients . We implemented a computerized asthma management system in a pediatric emergency department ( ED ) to integrate national guidelines . Our objective was to determine whether patient eligibility identification by a probabilistic disease detection system ( Bayesian network ) combined with an asthma management system embedded in the workflow decreases time to disposition decision . METHODS We performed a prospect i ve , r and omized controlled trial in an urban , tertiary care pediatric ED . All patients 2 - 18 years of age presenting to the ED between October 2010 and February 2011 were screened for inclusion by the disease detection system . Patients identified to have an asthma exacerbation were r and omized to intervention or control . For intervention patients , asthma management was computer-driven and workflow-integrated including computer-based asthma scoring in triage , and time-driven display of asthma-related reminders for re-scoring on the electronic patient status board combined with guideline -compliant order sets . Control patients received st and ard asthma management . The primary outcome measure was the time from triage to disposition decision . RESULTS The Bayesian network identified 1339 patients with asthma exacerbations , of which 788 had an asthma diagnosis determined by an ED physician-established reference st and ard ( positive predictive value 69.9 % ) . The median time to disposition decision did not differ among the intervention ( 228 min ; IQR=(141 , 326 ) ) and control group ( 223 min ; IQR=(129 , 316 ) ) ; ( p=0.362 ) . The hospital admission rate was unchanged between intervention ( 25 % ) and control groups ( 26 % ) ; ( p=0.867 ) . ED length of stay did not differ among intervention ( 262 min ; IQR=(165 , 410 ) ) and control group ( 247 min ; IQR=(163 , 379 ) ) ; ( p=0.818 ) . CONCLUSIONS The control and intervention groups were similar in regards to time to disposition ; the computerized management system did not add additional wait time . The time to disposition decision did not change ; however the management system integrated several different information systems to support clinicians ' communication OBJECTIVE The Diabetes Care Protocol ( DCP ) , a multifaceted computerized decision support diabetes management intervention , reduces cardiovascular risk of type 2 diabetic patients . We performed a cost-effectiveness analysis of DCP from a Dutch health care perspective . RESEARCH DESIGN AND METHODS A cluster r and omized trial provided data of DCP versus usual care . The 1-year follow-up patient data were extrapolated using a modified Dutch microsimulation diabetes model , computing individual lifetime health-related costs , and health effects . Incremental costs and effectiveness ( quality -adjusted life-years [ QALYs ] ) were estimated using multivariate generalized estimating equations to correct for practice -level clustering and confounding . Incremental cost-effectiveness ratios ( ICERs ) were calculated and cost-effectiveness acceptability curves were created . Stroke costs were calculated separately . Subgroup analyses examined patients with and without cardiovascular disease ( CVD+ or CVD− patients , respectively ) . RESULTS Excluding stroke  , DCP patients lived longer ( 0.14 life-years , P = NS ) , experienced more QALYs ( 0.037 , P = NS ) , and incurred higher total costs ( € 1,415 , P = NS ) , result ing in an ICER of € 38,243 per QALY gained . The likelihood of cost-effectiveness given a willingness-to-pay threshold of € 20,000 per QALY gained is 30 % . DCP had a more favorable effect on CVD+ patients ( ICER = € 14,814 ) than for CVD− patients ( ICER = € 121,285 ) . Coronary heart disease costs were reduced ( € −587 , P < 0.05 ) . CONCLUSIONS DCP  reduces cardiovascular risk , result ing in only a slight improvement in QALYs , lower CVD costs , but higher total costs , with a high cost-effectiveness ratio . Cost-effective care can be achieved by focusing on cardiovascular risk factors in type 2 diabetic patients with a history of CVD BACKGROUND Computerized decision support systems ( CDSSs ) are believed to enhance patient care and reduce healthcare costs ; however the current evidence is limited and the cost-effectiveness remains unknown . OBJECTIVE To estimate the long-term cost-effectiveness of a CDSS linked to evidence -based treatment recommendations for type 2 diabetes . METHODS Using the Ontario Diabetes Economic Model , changes in factors ( eg , HbA1c ) from a r and omized controlled trial were used to estimate cost-effectiveness . The cost of implementation , development , and maintenance of the core data set , and projected diabetes-related complications were included . The base case assumed a 1-year treatment effect , 5 % discount rate , and 40-year time horizon . Univariate , one-way sensitivity analyses were carried out by altering different parameter values . The perspective was the Ontario Ministry of Health and costs were in 2010 Canadian dollars . RESULTS The cost of implementing the intervention was $ 483,699 . The one-year intervention reduced HbA1c by 0.2 and systolic blood pressure by 3.95 mm Hg , but increased body mass index by 0.02 kg/m² , result ing in a relative risk reduction of 14 % in the occurrence of amputation . The model estimated that the intervention result ed in an additional 0.0117 quality -adjusted life year ; the incremental cost-effectiveness ratio was $ 160,845 per quality -adjusted life-year . CONCLUSION The web-based prototype decision support system slightly improved short-term risk factors . The model predicted moderate improvements in long-term health outcomes . This disease management program will need to develop considerable efficiencies in terms of costs and processes or improved effectiveness to be considered a cost-effective intervention for treating patients with type 2 diabetes BACKGROUND Case-management programs for secondary prevention of coronary artery disease that utilize extensive re sources can reduce cardiovascular risk factors , but less intensive approaches have failed to show benefits . This r and omized trial evaluated whether a medium intensity case-management program improves risk factor control in patients with coronary artery disease . METHODS We assigned 201 consecutive patients hospitalized for acute coronary events in the intensive care unit of University Hospital , Basel , Switzerl and , to either a risk factor case-management program ( n = 99 ) or care as usual ( n = 102 ) using the patients ' primary care physicians as the unit of r and omization ( cluster r and omization ) . The case-management program consisted of an hour of counseling by a clinician during hospitalization and two short reminders by phone and mail 3 and 6 months later . Treatment decisions were left to patients and their primary care physicians . RESULTS After 9 and 18 months of follow-up , there were no significant differences in lipid values , blood pressure control , fasting blood glucose , body-mass index , or number of smokers between the two groups . However , significantly more patients in the intervention group than in the care as usual group achieved target cholesterol values after 18 months ( 48 % versus 27 % , P = 0.002 and remained significant after Bonferroni-Holms correction ) but not after 9 months of follow-up ( 31 % versus 27 % , P > 0.2 ) . CONCLUSION This hospital-based case-management and outreach program , limited to counseling by a clinician , did not substantially improve cardiovascular risk factor control among patients hospitalized for coronary events Background Cardiovascular disease ( CVD ) is the leading cause of death and disability worldwide . Despite the widespread availability of evidence -based clinical guidelines and vali date d risk predication equations for prevention and management of CVD , their translation into routine practice is limited . We developed a multifaceted quality improvement intervention for CVD risk management which incorporates electronic decision support , patient risk communication tools , computerised audit and feedback tools , and monthly , peer-ranked performance feedback via a web portal . The intervention was implemented in a cluster r and omised controlled trial in 60 primary healthcare services in Australia . Overall , there were improvements in risk factor recording and in prescribing of recommended treatments among under-treated individuals , but it is unclear how this intervention was used in practice and what factors promoted or hindered its use . This information is necessary to optimise intervention impact and maximally implement it in a post-trial context . In this study protocol , we outline our methods to conduct a theory-based , process evaluation of the intervention . Our aims are to underst and how , why , and for whom the intervention produced the observed outcomes and to develop effective strategies for translation and dissemination . Methods / Design We will conduct four discrete but inter-related studies taking a mixed methods approach . Our quantitative studies will examine ( 1 ) the longer term effectiveness of the intervention post-trial , ( 2 ) patient and health service level correlates with trial outcomes , and ( 3 ) the health economic impact of implementing the intervention at scale . The qualitative studies will ( 1 ) identify healthcare provider perspectives on implementation barriers and enablers and ( 2 ) use video ethnography and patient semi-structured interviews to underst and how cardiovascular risk is communicated in the doctor/patient interaction both with and without the use of intervention . We will also assess the costs of implementing the intervention in Australian primary healthcare setting s which will inform scale-up considerations . Discussion This mixed methods evaluation will provide a detailed underst and ing of the process of implementing a  quality improvement intervention and identify the factors that might influence scalability and sustainability . Trials registration 12611000478910 PURPOSE Clinical guidelines are design ed to assist in the management of specific diseases ; however , these guidelines are often neglected in the delivery of care . The purpose of this study was to determine whether clinician use of an clinical practice guideline would increase in response to having , at the patient visit , a decision support system based on a practice guideline that generates a customized management protocol for the individual patient using data from the patient 's electronic medical record . SUBJECTS AND METHODS In a 6-month controlled trial at a primary care clinic , 58 primary care clinicians were r and omized to receive either a special encounter form with the computer-generated guideline recommendations or a st and ard encounter form . The effect of computer-generated advice on clinician behavior was measured as rate of compliance with guideline recommendations . Data from 30 clinicians were analyzed ; data from 28 clinicians were excluded because these clinicians did not meet predefined criteria for minimum exposure to diabetic patient care . RESULTS Availability of patient management recommendations generated by the decision support system result ed in a two-fold increase in clinician compliance with care guidelines for diabetes mellitus ( P = 0.01 ) . Median compliance for the group receiving the recommendations was 32.0 % versus 15.6 % for the control group . CONCLUSION Decision support based on a clinical practice guideline is an effective tool for assisting clinicians in the management of diabetic patients . This decision support system provides a model for how a clinical practice guideline can be integrated into the care process by computer to assist clinicians in managing a specific disease through helping them comply with care st and ards . Use of decision support systems based on clinical practice guidelines could ultimately improve the quality of medical care Recent , large , r and omized , controlled trials of the effects of episiotomy on perineal damage have confirmed that episiotomy is associated with an increased risk of damage to the perineum . Yet episiotomy remains the most common surgical procedure women undergo . This article examines if clinician experience , rather than scientific evidence , forms the basis for continuing this practice . Perineal outcome data are analyzed for 865 low-risk women who were attended at birth by the staff nurse-midwives or faculty obstetricians at a university-based , tertiary-care hospital . Data were collected under routine , nonexperimental conditions such that the circumstances of the labor and the clinician 's preferences were allowed to determine management decisions regarding the use of episiotomy or other techniques of perineal management . Multivariate findings indicate that in the absence of episiotomy , rates of perineal integrity were highest among clinicians who usually had the lowest rate of episiotomy use . When an episiotomy was done , rates of third- and fourth-degree extensions were highest among clinicians who used episiotomy most frequently . This finding challenges the idea that clinicians who were very experienced with the use of episiotomy would avoid complications such as extensions . Future research should explore the use of nonsurgical techniques such as those employed by midwives to promote perineal integrity . Then interdisciplinary research and evidence -based education regarding these techniques can occur to improve perineal outcomes for all women BACKGROUND Identifying the appropriate long-term anti-thrombotic therapy following acute ischaemic stroke is a challenging area in which computer-based decision support may provide assistance . AIM To evaluate the influence on prescribing practice of a computer-based decision support system ( CDSS ) that provided patient-specific estimates of the expected ischaemic and haemorrhagic vascular event rates under each potential anti-thrombotic therapy . DESIGN Cluster-r and omized controlled trial . METHODS We recruited patients who presented for a first investigation of ischaemic stroke or TIA symptoms , excluding those with a poor prognosis or major contraindication to anticoagulation . After observation of routine prescribing practice ( 6 months ) in each hospital , centres were r and omized for 6 months to either control ( routine practice observed ) or intervention ( practice observed while the CDSS provided patient-specific information ) . We compared , between control and intervention centres , the risk reduction ( estimated by the CDSS ) in ischaemic and haemorrhagic vascular events achieved by long-term anti-thrombotic therapy , and the proportions of subjects prescribed the optimal therapy identified by the CDSS . RESULTS Sixteen hospitals recruited 1952 subjects . When the CDSS provided information , the mean relative risk reduction attained by prescribing increased by 2.7 percentage units ( 95%CI -0.3 to 5.7 ) and the odds ratio for the optimal therapy being prescribed was 1.32 ( 0.83 to 1.80 ) . Some 55 % ( 5/9 ) of clinicians believed the CDSS had influenced their prescribing . CONCLUSIONS Cluster-r and omized trials provide excellent frameworks for evaluating novel clinical management methods . Our CDSS was feasible to implement and acceptable to clinicians , but did not substantially influence prescribing practice for anti-thrombotic drugs after acute ischaemic stroke Background There is a need to find innovative approaches for translating best practice s for chronic disease care into daily primary care practice routines . Primary care plays a crucial role in the prevention and management of cardiovascular disease . There is , however , a substantive care gap , and many challenges exist in implementing evidence -based care . The Improved Delivery of Cardiovascular Care ( IDOCC ) project is a pragmatic trial design ed to improve the delivery of evidence -based care for the prevention and management of cardiovascular disease in primary care practice s using practice outreach facilitation . Methods The IDOCC project is a stepped-wedge cluster r and omized control trial in which Practice Outreach Facilitators work with primary care practice s to improve cardiovascular disease prevention and management for patients at highest risk . Primary care practice s in a large health region in Eastern Ontario , Canada , were eligible to participate . The intervention consists of regular monthly meetings with the Practice Outreach Facilitator over a one- to two-year period . Starting with audit and feedback , consensus building , and goal setting , the practice s are supported in changing practice behavior by incorporating chronic care model elements . These elements include ( a ) evidence -based decision support for providers , ( b ) delivery system re design for practice s , ( c ) enhanced self-management support tools provided to practice s to help them engage patients , and ( d ) increased community re source linkages for practice s to enhance referral of patients . The primary outcome is a composite score measured at the level of the patient to represent each practice 's adherence to evidence -based guidelines for cardiovascular care . Qualitative analysis of the Practice Outreach Facilitators ' written narratives of their ongoing practice interactions will be done . These textual analyses will add further insight into underst and ing critical factors impacting project implementation . Discussion This pragmatic , stepped-wedge r and omized controlled trial with both quantitative and process evaluations demonstrates innovative methods of implementing large-scale quality improvement and evidence -based approaches to care delivery . This is the first Canadian study to examine the impact of a large-scale multifaceted cardiovascular quality -improvement program in primary care . It is anticipated that through the evaluation of IDOCC , we will demonstrate an effective , practical , and sustainable means of improving the cardiovascular health of patients across Canada . Trial Registration Clinical Trials.gov : With increasing work-loads in anticoagulant clinics different methods of service delivery need evaluation . The quality of anticoagulant control achieved by a  nurse-practitioner  using a computer decision-support system ( CDSS ) was compared with that achieved by trainee doctors without CDSS . Eighty-one out- patients ( group A , therapeutic range 2 - 3 ) and 96 out- patients ( group B , therapeutic range 3 - 4.5 ) were r and omized to management by a nurse-practitioner or by trainee doctors ( clinicians ) . Thirty-seven patients in group A and 50 patients in group B were r and omized to be managed by the nurse-practitioner .  In group A , patients in the nurse-practitioner group spent a longer time in the therapeutic range than those in the clinician group ( 60.7 % compared with 51.6 % ) . Dose suggestion acceptance in the nurse-practitioner group ( 88 % ) was higher compared with agreement between the CDSS and the clinicians ( 60 % ) . In group B , patients in the clinician group spent a slightly longer time in the therapeutic range ( 70 % compared with 67.6 % ) . Acceptance of dose suggestion was lower in the nurse-practitioner group ( 67 % ) compared with agreement between the CDSS and the clinicians ( 73 % ) . In conclusion , the CDSS can improve the quality of control of warfarin therapy by a nurse-practitioner over that by trainee doctors for the therapeutic range 2 - 3 . Similar quality of control is achieved for the therapeutic range 3 - 4.5 . The CDSS may be used by nurse-practitioners to achieve safe and effective anticoagulation in hospital-based or out-reach anticoagulant clinics Background Blood Pressure related disease affected 118 million people in India in the year 2000 ; this figure will double by 2025 . Around one in four adults in rural India have hypertension , and of those , only a minority are accessing appropriate care . Health systems in India face substantial challenges to meet these gaps in care , and innovative solutions are needed . Methods We hypothesise that a multifaceted intervention involving capacity strengthening of primary healthcare doctors and non-physician healthcare workers through use of a mobile device-based clinical decision support system will result in improved blood pressure control for individuals at high risk of a cardiovascular disease event when compared with usual healthcare . This intervention will be implemented as a stepped wedge , cluster r and omised controlled trial in 18 primary health centres and 54 villages in rural And hra Pradesh involving adults aged ≥40 years at high cardiovascular disease event risk ( approximately 15,000 people ) . Cardiovascular disease event risk will be calculated based on World Health Organisation/International Society of Hypertension ’s region-specific risk charts . Cluster r and omisation will occur at the level of the primary health centres . Outcome analyses will be conducted blinded to intervention allocation . Expected outcomes The primary study outcome is the difference in the proportion of people meeting guideline -recommended blood pressure targets in the intervention period vs. the control period . Secondary outcomes include mean reduction in blood pressure levels ; change in other cardiovascular disease risk factors , including body mass index , current smoking , reported healthy eating habits , and reported physical activity levels ; self-reported use of blood pressure and other cardiovascular medicines ; quality of life ( using the EQ-5D ) ; and cardiovascular disease events ( using hospitalisation data ) . Trial outcomes will be accompanied by detailed process and economic evaluations . Significance The findings are likely to inform policy on a scalable strategy to overcome entrenched inequities in access to effective healthcare for under-served population s in low and middle income country setting s . Trial registration Clinical Trial Registry India CTRI/2013/06/003753 Background Efficacious strategies for the primary prevention of coronary heart disease ( CHD ) are underused , and , when used , have low adherence . Existing efforts to improve use and adherence to these efficacious strategies have been so intensive that they are impractical for clinical practice . Methods We conducted a r and omized trial of a CHD prevention intervention ( including a computerized decision aid and automated tailored adherence messages ) at one university general internal medicine practice . After obtaining informed consent and collecting baseline data , we r and omized patients ( men and women age 40 - 79 with no prior history of cardiovascular disease ) to either the intervention or usual care . We then saw them for two additional study visits over 3 months . For intervention participants , we administered the decision aid at the primary study visit ( 1 week after baseline visit ) and then mailed 3 tailored adherence reminders at 2 , 4 , and 6 weeks . We assessed our outcomes ( including the predicted likelihood of angina , myocardial infa rct ion , and CHD death over 10 years ( CHD risk ) and self-reported adherence ) between groups at 3 month follow-up . Data collection occurred from June 2007 through December 2009 . All study procedures were IRB approved . Results We r and omized 160 eligible patients ( 81 intervention ; 79 control ) and followed 96 % to study conclusion . Mean predicted CHD risk at baseline was 11.3 % . The intervention increased self-reported adherence to chosen risk reducing strategies by 25 percentage points ( 95 % CI 8 % to 42 % ) , with the biggest effect for aspirin . It also changed predicted CHD risk by -1.1 % ( 95 % CI -0.16 % to -2 % ) , with a larger effect in a pre-specified subgroup of high risk patients . Conclusion A computerized intervention that involves patients in CHD decision making and supports adherence to effective prevention strategies can improve adherence and reduce predicted CHD risk . Clinical trials registration number Clinical Trials.gov : BACKGROUND AND AIMS Heart disease in women is characterised by greater disability and a higher rate of morbidity and early death after an acute coronary event compared with men . Women also have lower participation rates than men in cardiac rehabilitation . This study sought to describe development of a nurse-directed cardiac rehabilitation program tailored to the needs of women following an acute cardiac event to address their psychological and social needs . METHODS The Heart Awareness for Women program ( HAFW ) commenced in 2003 with phase I involving development of program elements and seeking validation through consumers and clinical experts . The program was then trialed in an 8-week program in a convenience sample of 6 women . Phase II applied the revised program using action research principles focusing on enabling clinical staff to implement the ongoing program . A total of 54 women participated in this phase , 48 of whom completed baseline question naires . A mixed- method evaluation , using question naires , interviews , and observation , assessed the impact of the intervention on psychological and social aspects of women 's recovery following an acute coronary event . RESULTS Women welcomed the opportunity to discuss their individual stories , fears , and challenges and to derive support from contact with other women . Via health professional facilitation , women were able to develop strategies collectively to address risk factor modification and achieve optimal cardiovascular health . No statistically significant changes in depression , anxiety , stress , cardiac control , role integration , or perceived social support were found ; however , descriptive and qualitative findings revealed decreases in anxiety and an increased sense of social support . CONCLUSIONS On the basis of this study , a cardiac rehabilitation program tailored to the needs of women appears to be feasible and acceptable . The efficacy of this intervention to improve health-related outcomes needs to be tested in a r and omized , controlled trial The PreFord Study is a multicenter prospect i ve cohort study to evaluate guideline based risk management on primary prevention of cardiovascular diseases . Furthermore a r and omised controlled trial ( RCT ) will be design ed to analyse the effect of a special intervention program . 40,000 employees of the Ford Motor Company , Visteon Company and Deutz Company in Germany will be included , monitored for ten years and the following primary endpoints will be investigated : 1 . evaluation and comparison of established and newly developed risk-scores , 2 . the relative impact of single and combined cardiovascular risk factors on cardiovascular diseases , 3 . the influence of a novel occupationally integrated ambulant rehabilitation program in combination with a guideline oriented optimal drug therapy within a high risk group on the primary endpoint : risk reduction by , 4 . the influence of this intervention on secondary endpoints : death , myocardial infa rct ion and stroke , combined appearance of angina pectoris and hospitalisation , occurrence of cerebral circulatory disorder and hospitalisation , occurrence of peripheral occlusive arterial disease and hospitalisation and single cardiovascular risk factors and cost-benefit- analysis . Beginning with an cross sectional study there will be a systemic screening of cardiovascular risk profiles , of anthropometric data and different lifestyle-factors . Based on these data participants will be differentiated into three risk-groups according to the risk score of the European Society of Cardiology ( risk of a lethal primary acute cardiovascular event : I < or = 1 % ; II > 1- < 5 % and III > or = 5 % ) . In the following longitudinal study different strategies will be applied : Group I : low risk ( < 0.5 % per year ) : repetition of the investigation after five and ten years . Group II : middle risk , ( 0.6 % to 1.4 % per year ) , repetition of the investigation every two years , instruction of the patients general practitioner ( GP ) with respect to a risk factor oriented and evidence based treatment . Group III : high risk , ( > 1.5 % per year or > 15 % within the next 10 years ) will be r and omised into two interventional groups . The first one , the intervention-group " PreFord " will perform an occupational integrated rehabilitation program ( 2,5 - 3 hours twice a week , for 15 weeks according to the BAR guidelines ) with a following engagement in heart-groups and an annual repetition of the check-ups . The second group , the " classic " intervention-group will be treated evidence based in cooperation with their GP . As a result of this long term interventional study efficient , area wide implementable and economically feasible prevention concepts with special regards to operational healthcare will be developed and evaluated . Core elements will be exercise- and lifestyle-oriented concepts as well as guideline -based pharmacotherapy Abstract Objectives : To investigate the effect of a computer based clinical decision support system and a risk chart on absolute cardiovascular risk , blood pressure , and prescribing of cardiovascular drugs in hypertensive patients . Design : Cluster r and omised controlled trial . Setting : 27 general practice s in Avon . Participants : 614 patients aged between 60 and 79 years with high blood pressure . Interventions : Patients were r and omised to computer based clinical decision support system plus cardiovascular risk chart ; cardiovascular risk chart alone ; or usual care . Main outcome measures : Percentage of patients in each group with a five year cardiovascular risk≥10 % , systolic blood pressure , diastolic blood pressure , prescribing of cardiovascular drugs . Results : Patients in the computer based clinical decision support system and chart only groups were no more likely to have cardiovascular risk reduced to below 10 % than patients receiving usual care . Patients in the computer based clinical decision support group were more likely to have a cardiovascular risk≥10 % than chart only patients , odds ratio 2.3 ( 95 % confidence interval 1.1 to 4.8 ) . The chart only group had significantly lower systolic blood pressure compared with the usual care group ( difference in means−4.6 mm Hg ( 95 % confidence interval−8.4 to−0.8 ) . Reduction of diastolic blood pressure did not differ between the three groups . The chart only group were twice as likely to be prescribed two classes of cardiovascular drugs and over three times as likely to be prescribed three or more classes of drugs compared with the other groups . Conclusions : The computer based clinical decision support system did not confer any benefit in absolute risk reduction or blood pressure control and requires further development and evaluation before use in clinical care can be recommended . Use of chart guidelines are associated with a potentially important reduction in systolic blood pressure Electronic clinical decision support systems ( CDSS ) have been hailed for their potential to improve clinical outcomes . Using a pretest/posttest design , an Internet-based CDSS design ed to optimize antimicrobial prescribing was pilot tested for community-acquired pneumonia in 5 rural hospitals in southwestern Idaho . An antimicrobial management team was created in each hospital to address clinicians ’ perception of excessive time required for direct use of the CDSS . In pooled hospital data , agreement with CDSS recommendations improved to a statistically significant level . However , inspection of data at the individual hospital level demonstrated that almost all improvement occurred in a single hospital . Failure in the other hospitals appeared to be primarily a consequence of organizational and cultural barriers . These barriers are discussed to underst and keys for successful future implementation of CDSS in rural hospitals , drawing on experience with cultural barriers from other industries , specifically aviation BACKGROUND Patients undergoing cardiovascular procedures remain at increased risk for myocardial infa rct ion , stroke , and cardiovascular death . Risk factor control in this patient population remains suboptimal and would likely benefit from strategies targeting education , lifestyle , and healthy behaviors . DESIGN The IMPACT trial is a 400-subject prospect i ve r and omized trial design ed to compare different cardiovascular prevention strategies in subjects following a cardiovascular intervention . The trial began enrollment in the Spring of 2012 and is r and omizing subjects in a 1:1:1 manner to usual care , a one-time cardiovascular prevention consult , or a one-time cardiovascular prevention consult plus behavioral intervention program ( telephone-based motivational interviewing and tailored text messages ) over a 6-month period . The primary end point is non-high-density lipoprotein cholesterol . Secondary end points include other plasma lipid values , metabolic risk , smoking cessation , physical activity , dietary intake , medication use and adherence , and quality of life . CONCLUSIONS The IMPACT trial provides data on different management strategies for risk factor optimization in subjects following cardiovascular procedures . The results will provide a platform for the continued development of novel multidisciplinary interventions in this high-risk population Purpose : To assess the effectiveness of computerized familial risk assessment and tailored messages for identifying individuals for targeted cancer prevention strategies and motivating behavior change . Methods : We conducted a r and omized clinical trial in primary care patients aged 35–65 years using Family Healthware  , a self-administered , internet-based tool that collects family history for six common diseases including breast cancer , colon cancer , and ovarian cancer , stratifies risk into three tiers , and provides tailored prevention messages .  Cancer screening adherence and consultation were measured at baseline and 6-month follow-up . Results : Of 3283 participants , 34 % were at strong or moderate risk of at least one of the cancers . Family Healthware identified additional participants for whom earlier screening ( colon cancer , 4.4 % ; breast cancer , women ages : 35–39 years , 9 % ) or genetic assessment ( colon cancer , 2.5 % ; breast cancer , 10 % ; and ovarian cancer , 4 % ) may be indicated . Fewer than half were already adherent with risk-based screening . Screening adherence improved for all risk categories with no difference between intervention and control groups . Consultation with specialists did not differ between groups . Conclusion : Family Healthware identified patients for intensified cancer prevention . Engagement of clinicians and patients , integration with clinical decision support , and inclusion of nonfamilial risk factors may be necessary to achieve the full potential of computerized risk assessment
Among CVRM patients , the results tended towards a beneficial effect of CDSS , but only LDL-c target attainment in diabetes patients reached statistical significance .
Prompting , integration into the electronical health record , patient empowerment , and medication support were related to more effective CVRM .
Conclusion We did not find a clear clinical benefit from CDSS in cardiovascular risk factor levels and target attainment .
Some features of CDSS seem more promising than others .
Clinical relevance of CDSS in CVRM might additionally be sought in the improvement of shared decision making and patient empowerment
Background Cardiovascular risk management ( CVRM ) is notoriously difficult because of multi-morbidity and the different phenotypes and severities of cardiovascular disease .
Computerized decision support systems ( CDSS ) enable the clinician to integrate the latest scientific evidence and patient information into tailored strategies .
The effect on cardiovascular risk factor management is yet to be confirmed .