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GUideline Implementation with DEcision Support systems

Periodic Reporting for period 1 - GUIDES (GUideline Implementation with DEcision Support systems)

Reporting period: 2015-07-15 to 2017-07-14

Healthcare based on the best available clinical evidence can lead to better quality of care. Evidence-based guidelines are potentially important instruments, but clinicians often do not adhere to them. A computerised decision support system (CDS) is a technology that uses patient-specific data to provide relevant medical knowledge at the point-of-care. It is an important quality improvement intervention, and EU member states are recommended to prioritise investment in it. However, the significant investments do not consistently result in value for money due to content and implementation issues.
The goal of the GUIDES project was to increase the success of guideline-based CDS. Our objectives were to (1) investigate the factors that determine successful CDS implementation, (2) develop tools to address these factors and (3) validate the utility of these tools through the development of a tailored CDS intervention. We also (4) developed a protocol for a cluster randomised controlled trial on the effectiveness of the tailored CDS intervention. We selected the conservative management of knee osteoarthritis as a prototype condition for the pilot.
Ultimately, the better implementation of CDS may lead to better informed decisions and improved care and patient outcomes for a wide range of conditions. The project is a response to the Horizon 2020 health priorities on transferring knowledge to clinical practice, individual empowerment for self-management of health, scalable innovation actions, better use of health data, treating chronic diseases, and active ageing.
The GUIDES project group included experts with a strong commitment to evidence-based medicine and broad expertise related to the development, implementation and evaluation of CDS and to the clinical care of patients with knee osteoarthritis.
We developed the GUIDES tools through an iterative process that involved a systematic review of evidence and frameworks, a synthesis of the success factors identified in the review into a comprehensive checklist, feedback from an international expert panel that evaluated the checklist in relation to a list of desirable framework attributes, consultations with patients and healthcare consumers and pilot testing of the checklist. The final GUIDES checklist is publicly available in multiple formats at www.guidesproject.org. CDS developers, implementers, researchers, funders, clinicians, managers, educators, and policymakers across Europe can use the checklist.
As part of the pilot, we used the GUIDES tools to tailor a guideline-based CDS intervention that facilitates the conservative management of knee osteoarthritis. Experts with backgrounds in clinical medicine, research, implementation and/or health informatics suggested the most important recommendations for implementation, how to develop an implementation strategy, and how to conceptualise a CDS intervention. In focus group sessions, general practitioners and patients from Norway, Belgium and Finland, discussed the suggested CDS intervention and identified factors that would be most critical for the success of the intervention. Within the GUIDES project group, we then developed a protocol for a multi-country cluster randomised trial in which we can evaluate the effect off the tailored CDS intervention. The tailored CDS content for osteoarthritis is the intellectual property of the consortium, but will be available to all licensed users of Duodecim and MAGICorg who were consortium partners in this project.
Any decision to use CDS, other interventions, or additional implementation strategies should be based on an assessment of the determinants of healthcare practice that affect whether the desired changes can be achieved. Furthermore, it is important to be aware of the factors shaping CDS effectiveness. This study has advanced the understanding of such determinants and CDS success factors:

• By developing a checklist, we aimed to assist those involved with the implementation of CDS interventions to consider success factors for guideline-based CDS in a structured way. The expert panel agreed that the final checklist would be potentially beneficial to people implementing guideline-based CDS across a wide range of settings globally.

• Our systematic review identified a substantial number of head-to-head trials that provides important direct evidence about 14 factors that can modify the success of CDS. Unique features of this review include our reporting method which makes it easier for readers to interpret the magnitude of the outcomes and that the review is more explicit than other reviews on the certainty that can be placed in the findings.

• The case study for knee osteoarthritis informs the development and implementation of a tailored CDS intervention. The study participants expressed their support for the CDS intervention as a tool to improve the quality of care and the outcomes for patients with knee osteoarthritis through shared, evidence-based decision-making. The participants also identified multiple barriers and suggested strategies to further improve the intervention. Use of the GUIDES checklist allowed us to identify additional factors that we otherwise would have missed.

• The protocol for a cluster RCT aims to evaluate the effect of the tailored CDS strategy versus usual practice on quality of care and patient outcomes for patients with knee osteoarthritis. This study includes the hypothesis that guideline-based CDS can improve the quality of care for knee osteoarthritis and can lead to benefits for individual patients with mild to severe osteoarthritis. The evidence on the effect of CDS on patient outcomes is very uncertain and only one trial has been done so far on patients with knee osteoarthritis. Doing the actual trial wat outside the scope of this project and we now have to find funding for this trial.

Wider societal implications of the project include:

• Transferring knowledge to clinical practice: implementing the results of this project will likely support shared decision making and better informed decisions by general practitioners and patients;

• Scalable innovation actions: the expertise from this project is scalable to a large spectrum of conditions and to various stages in the care process (e.g. prevention, diagnosis, treatment, monitoring and follow-up);

• Better use of health data: EU member states are recommended to implement CDS. This project promotes better use of CDS, based on actual patient data available in the electronic health record.

• Treatment of chronic diseases: implementation of the results of this project can potentially improve care and reduce the individual and societal burden of knee osteoarthritis;

• Active ageing and empowerment for self-management of health: self-management and exercise are important components of the CDS intervention that we developed.
4 domains that impact on the success of CDS to implement evidence-based recommendations