A Randomized Trial of Population-Based Clinical Decision Support to Manage Health and Resource Use for Medicaid Beneficiaries

Abstract

To determine whether a clinical decision support system can favorably impact the delivery of emergency department and hospital services. Randomized clinical trial of three clinical decision support delivery modalities: email messages to care managers (email), printed reports to clinic administrators (report) and letters to patients (letter) conducted among 20,180 Medicaid beneficiaries in Durham County, North Carolina with follow-up through 9 months. Patients in the email group had fewer low-severity emergency department encounters vs. controls (8.1 vs. 10.6/100 enrollees, p < 0.001) with no increase in outpatient encounters or medical costs. Patients in the letter group had more outpatient encounters and greater outpatient and total medical costs. There were no treatment-related differences for patients in the reports group. Among patients <18 years, those in the email group had fewer low severity (7.6 vs. 10.6/100 enrollees, p < 0.001) and total emergency department encounters (18.3 vs. 23.5/100 enrollees, p < 0.001), and lower emergency department ($63 vs. $89, p = 0.002) and total medical costs ($1,736 vs. $2,207, p = 0.009). Patients who were ≥18 years in the letter group had greater outpatient medical costs. There were no intervention-related differences in patient-reported assessments of quality of life and medical care received. The effectiveness of clinical decision support messaging depended upon the delivery modality and patient age. Health IT interventions must be carefully evaluated to ensure that the resultant outcomes are aligned with expectations as interventions can have differing effects on clinical and economic outcomes.

Effects of Computerized Decision Support Systems on Practitioner Performance and Patient Outcomes: Systematic Review

“…As illustrated, 61% (22/36) of occurrences of themes identified 7 positive patient medical outcomes as a result of using CDSSs [ 15 , 17 , 20 , 21 , 23 , 26 , 27 , 31 , 32 , 34 , 35 , 37 , 39 , 41 - 48 , 50 ]. Patients experienced improved symptoms [ 20 , 23 , 26 , 41 , 43 , 46 - 48 , 50 ], improved feedback from provider [ 17 , 31 , 42 , 45 ], improved disease management [ 21 , 35 , 37 ], improved efficacy of treatment [ 32 , 39 ], improved screening [ 15 , 27 ], and improved safety [ 34 ], and one study even reported improved mortality [ 44 ]. Although 11 articles did not discuss patient medical outcomes [ 16 , 18 , 19 , 24 , 25 , 28 - 30 , 33 , 40 , 49 ], only 3 reported no statistically significant difference in outcomes between control and intervention groups [ 22 , 36 , 38 ].…”

“…Commensurate with previous reviews on this topic [ 6 , 7 ], a majority of articles analyzed reported improvement in practitioner performance [ 16 - 18 , 21 , 23 - 25 , 28 - 31 , 33 - 35 , 37 , 38 , 40 , 44 , 45 , 47 - 50 ], but contrary to the previous reviews, our review found articles that reported patient outcomes, and a majority were positive outcomes [ 15 , 17 , 20 , 21 , 23 , 26 , 27 , 31 , 32 , 34 , 35 , 37 , 39 , 41 - 48 , 50 ]. Although 9 articles did not discuss practitioner performance [ 15 , 20 , 26 , 27 , 32 , 39 , 41 , 43 ], only 5 articles reported no difference in productivity [ 19 , 22 , 36 , 42 , 46 ].…”

“…Overall , the research generally supports the efficiency of CDSS technologies for practitioner performance [ 16 - 18 , 21 , 23 - 25 , 28 - 31 , 33 - 35 , 37 , 38 , 40 , 44 , 45 , 47 - 50 ] and effectiveness in patient medical outcomes [ 15 , 17 , 20 , 21 , 23 , 26 , 27 , 31 , 32 , 34 , 35 , 37 , 39 , 41 - 48 , 50 ]; however, a further in-depth review of their effectiveness, in particular for aspects such as the avoidance of alert fatigue and extension of CDSS utility, is important. Decision-support tools extend beyond the practitioner to the patient, and some tools are not software-based but based on patient-reported data [ 46 ]. The implementation of CDSSs can mutually benefit the practitioner and patient, and they show great promise for health care in the future.…”

A systematic review of trials evaluating success factors of interventions with computerised clinical decision support

“…risk factors, patient concerns). For the factor CDS to patients versus CDS aimed at the healthcare provider, we point at the findings from one study that found a 14.7% relative increase in the emergency department encounters when computer generated information was directed at the patient versus directed at a healthcare provider [ 31 ].…”

Effects of Computerized Decision Support Systems on Practitioner Performance and Patient Outcomes: Systematic Review (Preprint)

“…As illustrated, 61% (22/36) of occurrences of themes identified 7 positive patient medical outcomes as a result of using CDSSs [15,17,20,21,23,26,27,31,32,34,35,37,39,[41][42][43][44][45][46][47][48]50]. Patients experienced improved symptoms [20,23,26,41,43,[46][47][48]50], improved feedback from provider [17,31,42,45], improved disease management [21,35,37], improved efficacy of treatment [32,39], improved screening [15,27], and improved safety [34], and one study even reported improved mortality [44]. Although 11 articles did not discuss patient medical outcomes [16,18,19,24,…”