Desarrollo e impacto de los sistemas informatizados de apoyo a las decisiones en el manejo clínico de la depresión: revisión sistemática / Development and impact of computerised decision support systems for clinical management of depression: a systematic review

Una de las propuestas para conseguir mejorar la práctica clínica es la incorporación de sistemas informatizados de apoyo a las decisiones (SADC) y su integración con los registros clínicos electrónicos. El objetivo de este trabajo es revisar de forma sistemática la evidencia sobre la eficacia de los SADC en el manejo de la depresión. Para ello se realizó una búsqueda bibliográfica en Medline, EMBASE y PsycInfo. La calidad de los estudios cuantitativos se evaluó mediante el método SIGN y los estudios cualitativos mediante el checklist de CASPe. Se identificaron 7 estudios (3 ensayos clínicos aleatorizados, 3 ensayos no aleatorizados y un estudio cualitativo). Los SADC evaluados incorporaron contenidos derivados de guías u otros productos basados en la evidencia. En líneas generales, los SADC mostraron un impacto positivo sobre diferentes aspectos como el cribado y diagnóstico, tratamiento, mejora de síntomas depresivos y calidad de vida y derivación de pacientes a asistencia especializada. El empleo de SADC podría optimizar la atención de la depresión en diversos escenarios mediante la provisión de recomendaciones basadas en la mejor evidencia disponible y la facilitación de la toma de decisiones de los profesionales en la práctica clínica (AU)

One of the proposals for improving clinical practice is to introduce computerised decision support systems (CDSS) and integrate these with electronic medical records. Accordingly, this study sought to systematically review evidence on the effectiveness of CDSS in the management of depression. A search was performed in Medline, EMBASE and PsycInfo, in order to do this. The quality of quantitative studies was assessed using the SIGN method, and qualitative studies using the CASPe checklist. Seven studies were identified (3 randomised clinical trials, 3 non-randomised trials, and one qualitative study). The CDSS assessed incorporated content drawn from guidelines and other evidence-based products. In general, the CDSS had a positive impact on different aspects, such as the screening and diagnosis, treatment, improvement in depressive symptoms and quality of life, and referral of patients. The use of CDSS could thus serve to optimise care of depression in various scenarios by providing recommendations based on the best evidence available and facilitating decision-making in clinical practice (AU)

Development and impact of computerised decision support systems for clinical management of depression: A systematic review.

One of the proposals for improving clinical practice is to introduce computerised decision support systems (CDSS) and integrate these with electronic medical records. Accordingly, this study sought to systematically review evidence on the effectiveness of CDSS in the management of depression. A search was performed in Medline, EMBASE and PsycInfo, in order to do this. The quality of quantitative studies was assessed using the SIGN method, and qualitative studies using the CASPe checklist. Seven studies were identified (3 randomised clinical trials, 3 non-randomised trials, and one qualitative study). The CDSS assessed incorporated content drawn from guidelines and other evidence-based products. In general, the CDSS had a positive impact on different aspects, such as the screening and diagnosis, treatment, improvement in depressive symptoms and quality of life, and referral of patients. The use of CDSS could thus serve to optimise care of depression in various scenarios by providing recommendations based on the best evidence available and facilitating decision-making in clinical practice.

The validity of recommendations from clinical guidelines: a survival analysis.

BACKGROUND: Clinical guidelines should be updated to maintain their validity. Our aim was to estimate the length of time before recommendations become outdated. METHODS: We used a retrospective cohort design and included recommendations from clinical guidelines developed in the Spanish National Health System clinical guideline program since 2008. We performed a descriptive analysis of references, recommendations and resources used, and a survival analysis of recommendations using the Kaplan-Meier method. RESULTS: We included 113 recommendations from 4 clinical guidelines with a median of 4 years since the most recent search (range 3.9-4.4 yr). We retrieved 39 136 references (range 3343-14 787) using an exhaustive literature search, 668 of which were related to the recommendations in our sample. We identified 69 (10.3%) key references, corresponding to 25 (22.1%) recommendations that required updating. Ninety-two percent (95% confidence interval 86.9-97.0) of the recommendations were valid 1 year after their development. This probability decreased at 2 (85.7%), 3 (81.3%) and 4 years (77.8%). INTERPRETATION: Recommendations quickly become outdated, with 1 out of 5 recommendations being out of date after 3 years. Waiting more than 3 years to review a guideline is potentially too long.

Use of clinical practice guidelines and factors related to their uptake: a survey of health professionals in Spain.

RATIONALE, AIMS AND OBJECTIVE: This study aims to assess the use of clinical practice guidelines (CPGs) among health professionals and factors related to their uptake in clinical practice. METHODS: Cross-sectional study based on an online survey conducted among primary care (PC) and hospital-based care (HC) doctors in Spain in 2011. Questionnaire development included adaptation of similar surveys and contextualization through a qualitative study. After a pilot study and review, the final survey contained five domains: demographics, involvement in CPGs, consultation of CPGs, perceptions and attitudes regarding CPGs and Spanish NHS CPGs Programme. Professionals from selected health care centres in seven regions were contacted by email with an invitation and link to the Web-based questionnaire. We analysed between-group differences and explored potential predictors of CPGs use by means of a logistic regression. RESULTS: Six hundred seventy-six doctors responded to the survey (27.7% response rate). 47.1% were PC and 49.5% were HC doctors. 32.5% stated previous involvement in CPGs and 56.5% stated training in research methodology. 67.5% of the surveyed professionals reported using CPGs more than one time per week. The use of a system for classifying the quality of evidence (62.3%) and for grading the strength of the recommendations (58.6%), as well as the use of a rigorous methodology (49.6%), were the most frequently reported aspects related to CPG credibility. The lack of time (56.4%), especially in PC (65.3% versus 49.5% in HC; P < 0.001), and the absence of brief and easily accessible format (42.2%) were the main reported barriers to using CPGs. None of the studied factors showed statistically significant association in the logistic regression model. CONCLUSIONS: Study results suggest that, in general, Spanish doctors trust and use CPGs frequently. To improve uptake by health professionals and to overcome existing barriers, CPGs should be rigorously developed and made accessible at the point-of-care in user-friendly electronic formats. Due to the low response rate, findings should be extrapolated with caution.

Guía de práctica clínica para el tratamiento de depresión en adultos / Clinical practice guideline for the treatment of depression in adults

La guía trata de temas relacionados al tratamiento de la depresión, tocando temas como: las perspectivas y experiencias de los pacientes con depresión y sus familiares; evaluación y cribado de la depresión; los modelos de atención; tratamiento psicoterapéutico, tratamiento farmacológico; estrategias psicoterapéuticas y farmacológicas en la depresión resistente.

Strategies to assess the validity of recommendations: a study protocol.

BACKGROUND: Clinical practice guidelines (CPGs) become quickly outdated and require a periodic reassessment of evidence research to maintain their validity. However, there is little research about this topic. Our project will provide evidence for some of the most pressing questions in this field: 1) what is the average time for recommendations to become out of date?; 2) what is the comparative performance of two restricted search strategies to evaluate the need to update recommendations?; and 3) what is the feasibility of a more regular monitoring and updating strategy compared to usual practice?. In this protocol we will focus on questions one and two. METHODS: The CPG Development Programme of the Spanish Ministry of Health developed 14 CPGs between 2008 and 2009. We will stratify guidelines by topic and by publication year, and include one CPG by strata.We will develop a strategy to assess the validity of CPG recommendations, which includes a baseline survey of clinical experts, an update of the original exhaustive literature searches, the identification of key references (reference that trigger a potential recommendation update), and the assessment of the potential changes in each recommendation.We will run two alternative search strategies to efficiently identify important new evidence: 1) PLUS search based in McMaster Premium LiteratUre Service (PLUS) database; and 2) a Restrictive Search (ReSe) based on the least number of MeSH terms and free text words needed to locate all the references of each original recommendation.We will perform a survival analysis of recommendations using the Kaplan-Meier method and we will use the log-rank test to analyse differences between survival curves according to the topic, the purpose, the strength of recommendations and the turnover. We will retrieve key references from the exhaustive search and evaluate their presence in the PLUS and ReSe search results. DISCUSSION: Our project, using a highly structured and transparent methodology, will provide guidance of when recommendations are likely to be at risk of being out of date. We will also assess two novel restrictive search strategies which could reduce the workload without compromising rigour when CPGs developers check for the need of updating.

EBM in primary care: a qualitative multicenter study in Spain.

BACKGROUND: Evidence based medicine (EBM) has made a substantial impact on primary care in Spain over the last few years. However, little research has been done into family physicians (FPs)' attitudes related to EBM. The present study investigates FPs' perceptions of EBM in the primary care context. METHODS: This study used qualitative methodology. Information was obtained from 8 focus groups composed of 67 FPs from 47 health centers in 4 autonomous regions in Spain. Intentional sampling considered participants' previous education in EBM, and their experience as tutors in family medicine or working groups' members of the Spanish Society of Family Practice. Sociological discourse analysis was used with the support of the MAXqda software. Results were validated by means of triangulation among researchers and contrast with participants. RESULTS: Findings were grouped into three main areas: 1) The tug-of-war between the "science" of EBM and "experience" in the search for good clinical practice in primary care; 2) The development of EBM sensemaking as a reaction to contextual factors and interests; 3) The paradox of doubt and trust in the new EBM experts.The meaning of EBM was dynamically constructed within the primary care context. FPs did not consider good clinical practice was limited to the vision of science that EBM represents. Its use appeared to be conditioned by several factors that transcended the common concept of barriers. Along with concerns about its objectivity, participants showed a tendency to see EBM as the use of simplified guidelines developed by EBM experts. CONCLUSIONS: The identification of science with EBM and its recognition as a useful but insufficient tool for the good clinical practice requires rethinking new meanings of evidence within the primary care reality. Beyond the barriers related to accessing and putting into practice the EBM, its reactive use can determine FPs' questions and EBM development in a direction not always centred on patients' needs. The questioning of experts' authority as a pillar of EBM could be challenged by the emergence of new kinds of EBM texts and experts to believe in.

Análisis de las dudas de los médicos de atención primaria / Analysis of the doubts of primary care doctors

ObjetivoDeterminar las dudas, cuántas y de qué tipo, que se plantea un facultativo de atención primaria durante su consulta ordinaria así como establecer los métodos que utiliza para resolverlas.DiseñoEstudio de prevalencia.EmplazamientoCentros de salud de las provincias de A Coruña y Lugo.ParticipantesOchenta y un médicos de atención primaria (MAP) seleccionados por muestreo aleatorizado simple. El tamaño de la muestra se calculó para localizar un total de 500 dudas. Sólo 2 facultativos rehusaron participar.MedicionesNúmero de dudas y su tipología. Sistemas utilizados para resolverlas y momento en que se efectuaron.ResultadosSe detectaron 1,7 dudas (intervalo de confianza del 95%: 1,59 a 1,82) por cada 10 pacientes. El 92% de éstas se refería a problemas clínicos. Las 12 dudas más frecuentes representaron el 75% de todas las planteadas, en las que la interpretación de un signo clínico y las indicaciones de un tratamiento fueron las más habituales. En el 51,6% de los casos se intentó resolver la duda bien durante la consulta o bien durante esa mañana. El 35,7% de éstas generó nuevas citas, bien en la propia consulta o bien como interconsulta (23%). El 81,5% de los encuestados no utilizaba nunca internet durante la consulta y sólo el 6,2% lo hacía diariamente o a menudo.ConclusionesEl número de dudas que se plantea un MAP es relativamente bajo (1,7 por cada 10 pacientes). La forma más habitual de intentar solucionarlas es realizar una interconsulta con un especialista(A)

ObjectiveTo determine the doubts, their number and type that doctors have during routine clinics in primary care, as well as establishing methods that may be used to resolve them.DesignPrevalence study.SettingHealth centres in the provinces of A Coruña and Lugo.ParticipantsA total of 81 primary care doctors, selected by simple random sampling. The sample size was calculated to obtain a total of 500 doubts. Only 2 doctors refused to take part.MeasurementsNumber and types of doubts. Systems used to resolve them and when they were carried out.ResultsA mean of 1.7 doubts were detected (95% confidence interval; 1.59–1.82) for every 10 patients, of which 92% were seen as clinical problems. The 12 most frequent doubts made up 75% of all those that arose, with the interpretation of a clinical sign and treatment indications being the most common. In 51.6% of cases an attempt was made to resolve the doubt either during the consultation or during that day. A total of 35.7% of the doubts led to new appointments, either in the clinic itself or as a referral (23%). A total of 81.5% of those surveyed never used the Internet during the consultation and only 6.2% did this daily or often.ConclusionsThe number of doubts that primary care doctor has is relatively small (1.7 for every 10 patients). The most common way to try to resolve them is by referral to a specialist(AU)

[Analysis of the doubts of primary care doctors]. / Análisis de las dudas de los médicos de atención primaria.

OBJECTIVE: To determine the doubts, their number and type that doctors have during routine clinics in primary care, as well as establishing methods that may be used to resolve them. DESIGN: Prevalence study. SETTING: Health centres in the provinces of A Coruña and Lugo. PARTICIPANTS: A total of 81 primary care doctors, selected by simple random sampling. The sample size was calculated to obtain a total of 500 doubts. Only 2 doctors refused to take part. MEASUREMENTS: Number and types of doubts. Systems used to resolve them and when they were carried out. RESULTS: A mean of 1.7 doubts were detected (95% confidence interval; 1.59-1.82) for every 10 patients, of which 92% were seen as clinical problems. The 12 most frequent doubts made up 75% of all those that arose, with the interpretation of a clinical sign and treatment indications being the most common. In 51.6% of cases an attempt was made to resolve the doubt either during the consultation or during that day. A total of 35.7% of the doubts led to new appointments, either in the clinic itself or as a referral (23%). A total of 81.5% of those surveyed never used the Internet during the consultation and only 6.2% did this daily or often. CONCLUSIONS: The number of doubts that primary care doctor has is relatively small (1.7 for every 10 patients). The most common way to try to resolve them is by referral to a specialist.

Perceptions, attitudes and knowledge of evidence-based medicine in primary care in Spain: a study protocol.

BACKGROUND: The philosophy of evidence-based medicine (EBM) was introduced in the early 90s as a new approach to the practice of medicine, using the best available evidence to make decisions about health care. Despite ongoing controversy, EBM has developed enormously and physicians' attitude towards it is generally positive. Nevertheless, in Spain little is known about this topic. We will therefore undertake a study to explore perceptions, attitudes and knowledge about EBM among primary care physicians. METHODS AND DESIGN: A mixed-method study combining qualitative and quantitative designs will target family practitioners in Spain with the objective of evaluating current attitudes and perceptions about evidence-based medicine. The project will consist of two phases: a first phase running focus groups to identify perceptions and attitudes of participants, and a second phase assessing their attitudes and knowledge about EBM by means of a survey. Both phases will explore these issues in three different subgroups: family practitioners, with or without previous formal education in EBM; members of working groups that formulate healthcare recommendations; and physicians in charge of training family practice residents. Additionally, we will undertake a systematic review to identify and synthesize the available evidence on this topic. DISCUSSION: The study will identify and gain insight into the perceived problems and barriers to the practice of evidence-based medicine among general practitioners in Spain. The project will also evaluate the main knowledge gaps and training needs, and explore how evidence-based medicine is being taught to family medicine residents, the medical practitioners of the future. Our results will aid researchers and health care planners in developing strategies to improve the practice of evidence-based medicine in our country.