E-drug: Effect of Computerised Evidence Based Guidelines
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[Some time ago we had a discussion on the effectiveness of
treatment guidelines. The most recent INRUD News (April 2003)
published the abstract below and a comment from Dennis Ross-
Degnan. The main outcome of this study was that "computerized
decision support system had no significant effect on consultation
rates, process of care measures (including prescribing), or any
patient-reported outcomes for either condition. Levels of use of the
software were low". That is worrisome. What experiences do E-
druggers have with the use of treatment guidelines? With thanks to
INRUD News (www.msh.org/INRUD). Copied as fair use. HH]
Effect of Computerised Evidence Based Guidelines on Management
of Asthma and Angina in Adults in Primary Care: Cluster Randomised
Controlled Trial
M. Eccles, E. McColl, N. Steen, N. Rousseau, J. Grimshaw, D.
Parkin, and I. Purves
British Medical Journal 2002; 325:941-7
Objective: To evaluate the use of a computerized support system for
decision making for implementing evidence-based clinical guidelines
for the management of asthma and angina in adults in primary care.
Design: A before-and-after pragmatic, cluster, randomized controlled
trial utilizing a two-by-two incomplete block design
Setting: Sixty general practices in northeast England
Participants: General practitioners and practice nurses in the study
practices and their patients aged 18 or over with angina or asthma
Main Outcome Measures: Adherence to the guidelines, based on
review of case notes and patient-reported generic and
condition-specific outcome measures
Results: The computerized decision support system had no
significant effect on consultation rates, process of care measures
(including prescribing), or any patient-reported outcomes for either
condition. Levels of use of the software were low.
Conclusions: No effect was found of computerized evidencebased
guidelines on the management of asthma or angina in adults in
primary care. This was probably due to low levels of use of the
software, despite the system being optimized as far as was
technically possible. Even if the technical problems of producing a
system that fully supports the management of chronic disease were
solved, there remains the challenge of integrating the systems into
clinical encounters where busy practitioners manage patients with
complex, multiple conditions. Recent systematic review of 68
controlled trials examined the effectiveness of such systems. They
were shown to be beneficial in 9 of 15 trials of systems to improve
drug dosing; 1 of 5 trials evaluating diagnostic aids; 14 of 19 trials
evaluating systems to improve preventive care; and 19 of 26 trials
evaluating "other" medical care such as the management of disease
in hospitals and ordering tests. Improvements were found in 6 of the
14 studies measuring patient outcomes. However, the authors
reported that most of the studies had flaws in design or analysis, so
the findings should be interpreted with caution. Moreover, no studies
were identified in the management of chronic disease in primary care
or in computerized decision support systems integrated into routine
computer systems in primary care.
Comment
This very carefully designed and implemented study, conducted by
several leading researchers on physician behaviour change in the
UK, amply demonstrates that technology is not a panacea. As the
authors note in their discussion, previous work showing the positive
effects of computerized guidelines has been criticized on
methodological grounds. As frequently happens with behaviour
change interventions, this carefully controlled study of an intervention
method that appears to be successful in less well-designed trials
shows no effect. The work demonstrates that simply making
guidelines easily and immediately available to clinicians in whatever
form does not mean that they will be used or actively incorporated
into daily practice. All of the medical practices in this study involved
groups of physicians, and it would be interesting to see if some of the
more behaviourally engaging, peer-oriented strategies, such as group
norm development or self-assessment, tested in the previous two
studies could have been combined with the computerized guidelines
to achieve positive behavior change.
Dennis Ross-Degnan
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