Key result
The introduction of a computerized clinical decision support system for new onset chest pain did not substantially change the proportion of appropriate diagnostic investigations (59% after vs 50% before) and was rarely used to guide real-time decision making.
Why the study?
Does a computerised clinical decision support system improve appropriate investigation and management in patients with suspected new onset stable angina?
Observational (n=285)
Yes
Does a computerised clinical decision support system improve appropriate investigation and management in patients with suspected new onset stable angina?
A computerised clinical decision support system for new onset chest pain was not feasible in its current form and did not significantly change real-time clinical decision making due to structural and practical barriers.
Answers are grounded in this paper and cite their sources.
CDSS for chest pain should not yet change diagnostic pathways; hypothesis-generating for usability and integration barriers in future studies.
BACKGROUND: Clinical decision support systems (CDSS) can modify clinician behaviour, yet the factors influencing their effect remain poorly understood. This study assesses the feasibility and acceptability of a CDSS supporting diagnostic and treatment decisions for patients with suspected stable angina. METHODS: Intervention The Optimising Management of Angina (OMA) programme includes a CDSS guiding investigation and medication decisions for clinicians managing patients with new onset stable angina, based on English national guidelines, introduced through an educational intervention. Design and participants A mixed methods study i. A study of outcomes among patients presenting with suspected angina in three chest pain clinics in England before and after introduction of the OMA programme. ii. Observations of clinic processes, interviews and a focus group with health professionals at two chest pain clinics after delivery of the OMA programme. OUTCOMES: Medication and cardiovascular imaging investigations undertaken within six months of presentation, and concordance of these with the recommendations of the CDSS. Thematic analysis of qualitative data to understand how the CDSS was used. RESULTS: Data were analysed for 285 patients attending chest pain clinics: 106 before and 179 after delivery of the OMA programme. 40 consultations were observed, 5 clinicians interviewed, and a focus group held after the intervention. The proportion of patients appropriate for diagnostic investigation who received one was 50 % (95 CI 34-66 %) of those before OMA and 59 % (95 CI 48-70 %) of those after OMA. Despite high use of the CDSS (84 % of consultations), observations and interviews revealed difficulty with data entry into the CDSS, and structural and practical barriers to its use. In the majority of cases the CDSS was not used to guide real-time decision making, only being consulted after the patient had left the room. CONCLUSIONS: The OMA CDSS for the management of chest pain is not feasible in its current form. The CDSS was not used to support decisions about the care of individual patients. A range of barriers to the use of the CDSS were identified, some are easily removed, such as insufficient capture of cardiovascular risk, while others are more deeply embedded in current practice, such as unavailability of some investigations or no prescribing privileges for nurses.
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Johnson et al. (2015) conducted an observational in Suspected stable angina / new onset chest pain (n=285). Computerised clinical decision support system (CDSS) vs. Usual care (before CDSS implementation) was evaluated on Proportion of patients appropriate for diagnostic investigation who received one. The introduction of a computerized clinical decision support system for new onset chest pain did not substantially change the proportion of appropriate diagnostic investigations (59% after vs 50% before) and was rarely used to guide real-time decision making.
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