Objective To report the improvements achieved with clinical decision support systems and examine the heterogeneity from pooling effects across diverse clinical settings and intervention targets. Design Systematic review and meta-analysis. Data sources Medline up to August 2019. Eligibility criteria for selecting studies and methods Randomised or quasi-randomised controlled trials reporting absolute improvements in the percentage of patients receiving care recommended by clinical decision support systems. Multilevel meta-analysis accounted for within study clustering. Meta-regression was used to assess the degree to which the features of clinical decision support systems and study characteristics reduced heterogeneity in effect sizes. Where reported, clinical endpoints were also captured. Results In 108 studies (94 randomised, 14 quasi-randomised), reporting 122 trials that provided analysable data from 1 203 053 patients and 10 790 providers, clinical decision support systems increased the proportion of patients receiving desired care by 5.8% (95% confidence interval 4.0% to 7.6%). This pooled effect exhibited substantial heterogeneity (I 2 =76%), with the top quartile of reported improvements ranging from 10% to 62%. In 30 trials reporting clinical endpoints, clinical decision support systems increased the proportion of patients achieving guideline based targets (eg, blood pressure or lipid control) by a median of 0.3% (interquartile range −0.7% to 1.9%). Two study characteristics (low baseline adherence and paediatric settings) were associated with significantly larger effects. Inclusion of these covariates in the multivariable meta-regression, however, did not reduce heterogeneity. Conclusions Most interventions with clinical decision support systems appear to achieve small to moderate improvements in targeted processes of care, a finding confirmed by the small changes in clinical endpoints found in studies that reported them. A minority of studies achieved substantial increases in the delivery of recommended care, but predictors of these more meaningful improvements remain undefined.
IMPORTANCEThe association of low-value testing with downstream care and clinical outcomes among primary care outpatients is unknown to date.OBJECTIVE To assess the association of low-value testing with subsequent care among low-risk primary care outpatients undergoing an annual health examination (AHE). DESIGN, SETTING, AND PARTICIPANTSThis population-based retrospective cohort study used administrative health care claims from Ontario, Canada, for primary care outpatients undergoing an AHE between April 1, 2012, and March 31, 2016, to identify individuals who could be placed into one (or more) of the following 3 cohorts: adult patients (18 years or older) at low risk for cardiovascular and pulmonary disease, adult patients at low risk for cardiovascular disease, and female patients (aged 13-20 years or older than 69 years) at low risk for cervical cancer. The dates of analysis were June 3 to September 12, 2019.EXPOSURES Low-value screening tests were defined per cohort as (1) a chest radiograph within 7 days, (2) an electrocardiogram (ECG) within 30 days, or (3) a Papanicolaou test within 7 days after an AHE. MAIN OUTCOMES AND MEASURES Subsequent specialist visits, diagnostic tests, and procedures within 90 days after a low-value test (if the patient had a chest radiograph, ECG, or Papanicolaou test) or end of the exposure observation window (if not tested). RESULTS Included in the chest radiograph, ECG, and Papanicolaou test cohorts of propensity score-matched pairs were 43 532 patients (mean [SD] age, 47.5 [14.4] years; 38.5% female), 245 686 patients (mean [SD] age, 49.9 [13.7] years; 51.1% female), and 29 194 patients (mean [SD] age , 45.5 [27.1] years; 100% female), respectively. At 90 days, chest radiographs in low-risk patients were associated with an additional 0.87 (95% CI, 0.69-1.05) and 1.96 (95% CI, 1.71-2.22) patients having an outpatient pulmonology visit or an abdominal or thoracic computed tomography scan per 100 patients, respectively, and ECGs in low-risk patients were associated with an additional 1.92 (95% CI, 1.82-2.02), 5.49 (95% CI, and 4.46 (95% CI, patients having an outpatient cardiologist visit, a transthoracic echocardiogram, or a cardiac stress test per 100 patients, respectively. At 180 days, Papanicolaou testing in low-risk patients was associated with an additional 1.31 (95% CI, 0.84-1.78), 52.8 (95% CI, 51.9-53.6), and 0.84 (95% CI, 0.66-1.01) patients having an outpatient gynecology visit, a follow-up Papanicolaou test, or colposcopy per 100 patients, respectively.CONCLUSIONS AND RELEVANCE Observed associations in this population-based cohort study suggest that testing in low-risk patients as part of an AHE increases the likelihood of subsequent specialist visits, diagnostic tests, and procedures.
Key Points Question Do physicians who order a high frequency of 1 low-value screening test also order a high frequency of other low-value screening tests? Findings In this cohort study of 2394 primary care physicians, 18.4% of the physicians were in the top ordering quintile of at least 2 of 4 low-value screening tests. These physicians ordered 39.2% of all low-value screening tests. Meaning The study findings suggest that efforts to reduce low-value care should consider strategies that focus on physicians who order a high frequency of low-value care.
In this paper, we demonstrated the processing of Li 7 La 3 Zr 0.5 Nb 0.5 Ta 0.5 Hf 0.5 O 12 (LLZNTH) high-entropy Li-garnet with promising properties for lithium batteries. We first synthesized the LLZNTH Li-garnet powders which have a single cubic garnet phase (space group: 𝐼𝑎 3𝑑; No. 230) without any secondary phases as well as uniform elements distributions. The prepared powders were further densified to a relative density of ∼94% with well-crystallized grains and good contact with the neighboring grains. Minimal grain growth can be observed in the sintering time range from 8 to 20 h, which is likely due to the sluggish effects of high-entropy compounds. The sample also maintains the cubic garnet phase along with uniform elements distribution after sintering. Electrochemical characterizations indicate that the densified sample has an adequate ionic conductivity of 4.67 × 10 −4 S cm −1 at room temperature, a low activation energy of 0.25 eV, and a low electronic conductivity in the order of 10 −8 S cm −1 . The significance of designing high-entropy electrolyte is further discussed.
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