Review of computerized decision support systems for oral anticoagulation management

Abstract

Summary. Computerized decision support systems (CDSS)are available to assist clinicians in the therapeutic management of oral anticoagulation. We report the findings relating to CDSS for oral anticoagulation management of a primary-care-based systematic review which largely focused on near-patient testing. Seven papers were reviewed which covered four different systems. The methodology of these papers was generally poor, although one randomized controlled trial showed improved therapeutic control associated with computerized management compared with human performance.Keywords: computerized decision support system, oral anticoagulation.Therapeutic monitoring of warfarin therapy requires two key elements to be undertaken if it is to be successful: the measurement of the INR and an interpretation of the result in order to advise on dosage of warfarin and when the next test should be performed. The element of interpretation has traditionally been the consultant haematologist's role, with primary care physicians expressing concern at their perceived lack of clinical knowledge to undertake this service (Taylor et al, 1993).Computerized decision support systems (CDSS) can be defined as 'programmes designed to give advice about significance of results and their implications for subsequent patient management ' (Hobbs et al, 1997). The principle underlying the utilization of CDSS within any clinical environment is that a reproducible decision will be made given a certain set of data. Many clinical situations have been investigated to ascertain the utility of CDSS; however, few have demonstrated enduring effect. One area where success has been reported is the field of oral anticoagulation management.The principle advantages to CDSS are deemed to be reproducibility of interpretation within centres, standardization between centres, and ease of performance assessment. If these features are present, CDSS could enable non-specialist clinicians to undertake tasks which have previously been the domain of the specialist. Anticoagulation CDSS has been reported as enabling non-specialist staff to undertake therapeutic monitoring within hospital clinics, and also to provide accurate data for audit (Hobbs et al, 1997).This paper reports on the literature identified as part of a systematic review which reported on near-patient testing, CDSS and rapid transit systems relevant to or within primary care (Hobbs et al, 1997). METHODSAs part of a systematic review of near-patient tests in primary care (Hobbs et al, 1997), computer searches were undertaken covering the period 1986-95 using the following literature databases: Medline; BIDS (Bath-ISI-DataService); Science Citation Index; Index to Scientific and Technical Proceedings, Department of Health; EMBASE; GP Lit Data Base, Royal College of General Practitioners; and CINHAL. The key words used for CDSS were: computerized decision support, expert systems, electronic data interchange and computer communication networks; in combination with: family practice, primary (health) care, physician...

Pharmacogenetics of warfarin: current status and future challenges

“…Finally, various other strategies have been suggested to improve the safety of anticoagulation therapy including computer decision support systems, 123 the use of patient self-monitoring devices 124 and the use of drugs that inhibit other targets in the anticoagulation pathway, for example the oral thrombin inhibitors. 125 Whether we should use pharmacogenetic-based warfarin therapy in competition or in conjunction with these other approaches is not clear.…”

A Prospective Controlled Study of a Computer-Assisted Acenocoumarol Dosage Program

“…Besides, they may enable non-specialist clinicians or nurses to undertake AO control in primary care centres. Several programs have been developed to generate AO doses with good results [4,[7][8][9][10]. In a multicentre Marco/Sedano/Bermú dez/Ló pez-Duarte/ Ferná ndez-Fontecha/Zubizarreta randomised study of 285 patients, a significant benefit was found in achieving target INR in the group of stable patients when doses were calculated by the computer [11].…”

Decisions about lumping vs. splitting of the scope of systematic reviews of complex interventions are not well justified: A case study in systematic reviews of health care professional reminders

“…Others assessed the effects of CDSSs for a specific clinical outcome, such as oral anticoagulation management but only stated that a review had not been completed in that area without justifying why it might have different results [14]. Authors such as Kawamoto et al [23] conducted specific analyses that had not been done before, such as conducting a meta-analysis; however, given that they did not justify the conduct of a review in their specific topic area, they were still classified as having ''no justification.''…”

“…Condition [9,14,16,20,22,25,28,33,34] 9 Setting [13,19,24] 3 Study design [5,23] 2 Population [27,32] 2 Outcome [31] 1 Total 17 54.8…”