Design, effectiveness, and economic outcomes of contemporary chronic disease clinical decision support systems: a systematic review and meta-analysis.

OBJECTIVES: Electronic health record-based clinical decision support (CDS) has the potential to improve health outcomes. This systematic review investigates the design, effectiveness, and economic outcomes of CDS targeting several common chronic diseases. MATERIAL AND METHODS: We conducted a search in PubMed (Medline), EBSCOHOST (CINAHL, APA PsychInfo, EconLit), and Web of Science. We limited the search to studies from 2011 to 2021. Studies were included if the CDS was electronic health record-based and targeted one or more of the following chronic diseases: cardiovascular disease, diabetes, chronic kidney disease, hypertension, and hypercholesterolemia. Studies with effectiveness or economic outcomes were considered for inclusion, and a meta-analysis was conducted. RESULTS: The review included 76 studies with effectiveness outcomes and 9 with economic outcomes. Of the effectiveness studies, 63% described a positive outcome that favored the CDS intervention group. However, meta-analysis demonstrated that effect sizes were heterogenous and small, with limited clinical and statistical significance. Of the economic studies, most full economic evaluations (n = 5) used a modeled analysis approach. Cost-effectiveness of CDS varied widely between studies, with an estimated incremental cost-effectiveness ratio ranging between USD$2192 to USD$151 955 per QALY. CONCLUSION: We summarize contemporary chronic disease CDS designs and evaluation results. The effectiveness and cost-effectiveness results for CDS interventions are highly heterogeneous, likely due to differences in implementation context and evaluation methodology. Improved quality of reporting, particularly from modeled economic evaluations, would assist decision makers to better interpret and utilize results from these primary research studies. REGISTRATION: PROSPERO (CRD42020203716).

Barriers and enablers to implementing and using clinical decision support systems for chronic diseases: a qualitative systematic review and meta-aggregation.

BACKGROUND: Clinical decision support (CDS) is increasingly used to facilitate chronic disease care. Despite increased availability of electronic health records and the ongoing development of new CDS technologies, uptake of CDS into routine clinical settings is inconsistent. This qualitative systematic review seeks to synthesise healthcare provider experiences of CDS-exploring the barriers and enablers to implementing, using, evaluating, and sustaining chronic disease CDS systems. METHODS: A search was conducted in Medline, CINAHL, APA PsychInfo, EconLit, and Web of Science from 2011 to 2021. Primary research studies incorporating qualitative findings were included if they targeted healthcare providers and studied a relevant chronic disease CDS intervention. Relevant CDS interventions were electronic health record-based and addressed one or more of the following chronic diseases: cardiovascular disease, diabetes, chronic kidney disease, hypertension, and hypercholesterolaemia. Qualitative findings were synthesised using a meta-aggregative approach. RESULTS: Thirty-three primary research articles were included in this qualitative systematic review. Meta-aggregation of qualitative data revealed 177 findings and 29 categories, which were aggregated into 8 synthesised findings. The synthesised findings related to clinical context, user, external context, and technical factors affecting CDS uptake. Key barriers to uptake included CDS systems that were simplistic, had limited clinical applicability in multimorbidity, and integrated poorly into existing workflows. Enablers to successful CDS interventions included perceived usefulness in providing relevant clinical knowledge and structured chronic disease care; user confidence gained through training and post training follow-up; external contexts comprised of strong clinical champions, allocated personnel, and technical support; and CDS technical features that are both highly functional, and attractive. CONCLUSION: This systematic review explored healthcare provider experiences, focussing on barriers and enablers to CDS use for chronic diseases. The results provide an evidence-base for designing, implementing, and sustaining future CDS systems. Based on the findings from this review, we highlight actionable steps for practice and future research. TRIAL REGISTRATION: PROSPERO CRD42020203716.

Strengthening cardiovascular disease prevention in remote indigenous communities in Australia's Northern Territory.

BACKGROUND: In 2012 the Northern Territory Department of Health commenced the Chronic Conditions Management Model - strengthening cardiovascular disease prevention in remote Indigenous communities. Interventions included providing regular functional reporting and decision support to frontline primary health care teams. METHODS: Longitudinal (three monthly) clinical audits of cardiac prevention services were undertaken between 2012 and 2014. Our primary outcome was population coverage of cardiovascular risk assessment for Indigenous clients aged 20 years and older. Secondary outcomes for those identified at high risk were (i) assessment of modifiable cardiac risk factors, (ii) prescription of risk lowering medications, and (iii) the proportion of high risk clients achieving clinical targets for risk reduction. RESULTS: As of August 2014, 7266 clients have had their cardiovascular risk assessed, improving population coverage from 23% in mid June 2012 to 58.5%. For 2586 high risk clients, 1728 (67%) and 1416 (55%) were prescribed blood pressure and lipid lowering therapy and for those clinically re-assessed, 1366 (57%) and 989 (40%) were achieving clinical targets for risk reduction for blood pressure and lipids respectively. CONCLUSIONS: Functional reporting and decision support was associated with improvement in cardiovascular risk assessment coverage and a sustained proportion of high risk clients achieving clinical targets for cardiovascular risk reduction. Further intervention-based research is required to close the gap between identification of risk and risk reduction.

Health risk assessments for alumina refineries.

OBJECTIVE: To describe contemporary air dispersion modeling and health risk assessment methodologies applied to alumina refineries and to summarize recent results. METHODS: Air dispersion models using emission source and meteorological data have been used to assess ground-level concentrations (GLCs) of refinery emissions. Short-term (1-hour and 24-hour average) GLCs and annual average GLCs have been used to assess acute health, chronic health, and incremental carcinogenic risks. RESULTS: The acute hazard index can exceed 1 close to refineries, but it is typically less than 1 at neighboring residential locations. The chronic hazard index is typically substantially less than 1. The incremental carcinogenic risk is typically less than 10(-6). CONCLUSIONS: The risks of acute health effects are adequately controlled, and the risks of chronic health effects and incremental carcinogenic risks are negligible around referenced alumina refineries.

Improvement of odor intensity measurement using dynamic olfactometry.

Odor intensity reveals a dose-effect relationship between inhaled odor and perceived odor sensation by the receptors, while odor concentration reflects the odor strength at the emission sources. The study reports significant improvements in experimental procedures in establishing the odor concentration-intensity (OCI) relationships using a newly developed digital olfactometer. The improvements in experimental procedures have been made to meet the requirements of both the VDI guideline 3882.1 and the European standard (EN13725). Several areas which could affect the reliability of the results have been identified in some similar studies. The latest digital olfactometer was calibrated automatically to ensure accurate and repeatable dilution ratios. Cross contamination has been eliminated through the instrument design and extensive cleaning procedures, making random presentation possible. Stringent panelist screening and continuous performance monitoring ensures consistent sensitivity of the panel. The extension of odor intensity category to temperature sensation gives a reference to assist judgments of perceived odor sensation. The DynaScent calculation method has simplified odor intensity calculation and can be applied to many odor samples. A total of 38 odor samples from three alumina refinery sites and two sewage treatment plants were collected for analysis. The results have confirmed the efficiency of the olfactometer. Distinct Odor Concentrations (DOCs) were calculated for each sample using both VDI and DynaScent methods. A student t test on two major odor types confirmed that there are no significant differences between two methods. The study has shown the DOCs for refinery odor and wastewater odor are in the range of 3.8-15.4 and 4.2-15.6 odor unit (OU)/m3 respectively. The study demonstrated that the improvements are critical in achieving reliable odor intensity measurement. This can lead to the setup of quantitative odor impact criteria for different industries and sites.

Parallel preparative high-performance liquid chromatography with on-line molecular mass characterization.

High-throughput chemistry (HTC) is now an integral part of the lead discovery process in many pharmaceutical and related chemical companies. As this process becomes refined or improved, with the integration of systems with enhanced capabilities, and the requirement for quality compounds of high purity increases, purification is often considered a bottleneck. Although a wide range of purification techniques is available, high-performance liquid chromatography (HPLC) is usually the preferred method of purification to produce high-purity compounds. Parallel preparative HPLC with robust UV-guided fraction collection has been shown to reduce the bottleneck and complement the parallel synthesis systems. However, despite the success of this technique, post-purification analysis of fractions to identify the target compound adds an additional level of complexity. This paper describes the interfacing of the Biotage Parallex with the MUX interface on a single quadrupole mass spectrometer, thus combining robust UV-guided fractionation with on-line MS characterization.