Table 5 Detailed description of findings
Study | Risk of bias | CDSS use | Process outcomes of interest | Clinical outcomes of interest | Interpretation |
|---|---|---|---|---|---|
McCowan et al.28 | High | Not reported | No between-group difference in number of patients prescribed maintenance therapy based on British asthma guidelines step; p = 0.51. No between-group difference in the number of patients attending practice initiated asthma reviews OR 0.69 (CI 0.21–2.21). | Fewer exacerbations were reported in the intervention group; 12/147 (8%) in comparison to the control group 57/330 (17%); OR 0.43 (CI 0.21–0.85). Fewer patients were prescribed oral steroids for an exacerbation; 7/147 (5%) of the intervention group compared to 35/330 (11%) of the control group OR 0.42 (CI 0.14–1.29). Fewer primary care consultations were initiated by patients; 22% intervention group compared to 34% control group, OR 0.59 (0.37–0.95). No between-group difference in hospital admissions; OR 0 (CI 0–3.44); or emergency department visits; OR 0 (CI 0–9.16). | Of the 46 practices registered to participate, 21 were randomised but only 5 completed the trial due to software problems. Patients treated with CDSS initiated less asthma consultations and were less likely to experience an exacerbation. However it was not clear how exacerbation was defined. The CDSS was not integrated and usage rate was not captured. |
Eccles et al. 29 | Low | Median number of active interactions between groups was zero. | No between-group difference in numbers of SABA prescribed; OR 1.04 (CI 0.83–1.31).No between-group difference in numbers of ICS prescribed; OR 0.95 (CI 0.78–1.16). | No between-group difference in number of consultations for asthma OR 0.94 (CI 0.81–1.08). No between-group difference in number of patients prescribed oral steroids before and after OR 1.0 (CI 0.82–1.22). | This cluster study design with practices as the unit of randomisation, consisted of two arms, asthma and angina each acting as control for the opposite arm e.g., CDSS care for angina acted as control data for asthma CDSS care. Data analysed 12 months before and after. A high number of practices participated (62); prescribing data was obtained from 1139 patients treated with the intervention and 1385 controls. Process of care data was obtained from 1200 patients treated with the intervention and 1163 controls. The intervention had no effect on process or clinical outcomes. Median intervention usage was zero. Data was analysed on an intention to treat basis. |
Zeiger et al.30 | Low | Not reported | aLess patients in the intervention group dispensed excessive SABA: 50.7% vs 57.1% control group; RR 0.89, p = 0.007 (CI 0.82-0.97) and increased time to be dispensed SABA excessively; HR 0.80; p = < 0.001 (CI 0.71–0.91). Greatest effects seen in those with no prior asthma specialist care. Reduction in SABA inhalers dispensed to intervention group at 3 months p = 0.002, 6 months p = < 0.001, 12 months p = < 0.001. Increase in ICS-LABA inhalers dispensed to intervention patients without prior asthma specialist care; 3 months p = 0.004, 6 months p = < 0.001, 12 months p = 0.03. | No between group difference in number of patients with an exacerbation requiring oral steroids; p = 0.71, either with or without prior specialist asthma care; p = 0.38 vs. p = 0.83. No between group difference in number of patients with an asthma exacerbation requiring > = two oral steroid courses; p = 0.55, either with or without prior specialist asthma care; p = 0.89 vs. p = 0.50. No between group difference in number of asthma ED visits and/or hospitalisation; p = 0.96, either with or without prior specialist asthma care; p = 0.55 vs p = 0.66. | Real-time outreach intervention in the Kaiser Permanente Southern California (KPSC) managed healthcare system. Usual care included KSPC extensive integrated asthma care management. The intervention reduced excessive SABA use, and ICS/LABA use. Greatest effect were seen in the subgroup of patients without prior asthma specialist care. Physician engagement was not captured as electronic message presented automatically and did not require physician action. Multicomponent intervention included a clinician message, patient letter and allergy referral. |
Tamblyn et al.31 | Low | Physicians did not use the CDSS intervention ‘Asthma Decision Support’ in 60.5% of consultations for patients with out-of-control asthma | Increased ICS-SABAb mean ratio in the intervention group; mean difference = 0.27 p = 0.034 (CI 0.02–0.51); | Reduction in out of control asthma events in the intervention group rate difference −8.7/100 PY; p = 0.29 (CI −24.7, 7.3). Greatest effects were seen in the sub-group of patients with out-of-control asthma when beginning the study. Rate difference: −28.4, p = 0.04 (CI −55.6,−1.2); The greatest reduction was seen in the subgroup with out-of-control asthma at beginning of the study when treated with CDS alone had Rate difference: −36.9/100 PY; p = 0.01. | 81 physicians were randomised to ‘asthma decision support;’ 2273 patients treated with the intervention and 2174 controls. This intervention increased the mean ratio ICS-SABA use and reduced the rate of out-of-control asthma episodes. Greatest effect were seen in the subgroup of patients with out-of-control asthma at study entry as treated by CDS alone. In 60% of out-of-control visits the decision support was not accessed by clinicians. No data was available on use over time. |
