Shared learning database
Type and Title of Submission
Computerised Decision Support: Supporting hypertension management at the point-of-careDescription:
Whilst many physicians support guidelines in principle it would appear that their uptake in practice is variable (Heagerty et al, 2006); the reasons for this are manifold and, as a consequence, a series of coordinated efforts is most likely required to support adherence. Computerised decision support has been shown to improve best practice (Kawamoto et al, 2005) and as such, may provide a useful tool within an overall guideline implementation programme. In order to make guidance more accessible to practitioners and more easily applicable to individual patients, Medicines Management, Keele University, developed a computerised prescribing decision support tool driven by up-to-date NICE guidance on the management of patients with hypertension. Please note that this example was originally submitted alongside CG34 on Hypertension. CG34 has now been replaced by CG127. The principle of developing decision making support to facilitate guidance implementation, remains sound.Category: Does the submission relate to the general implementation of all NICE guidance?
NoDoes the submission relate to the implementation of a specific piece of NICE guidance?
YesFull title of NICE guidance:
CG127 - HypertensionCategory(s) that most closely reflects the nature of the submission:
Is the submission industry-sponsored in any way?
Takeda UK provided an unrestricted educational grant to support the development of the computerised decision support software. The relationship was at armslength and complied with ABPI (Association of the British Pharmaceutical Industry) guidelines.
Description of submission
Variations in prescribing practice and the associated influences on prescribing behaviour are well documented (National Audit Office, 2007; Prosser et al, 2003). Whilst NICE has taken great strides to improve standards and reduce inequalities in care, adoption and adherence to clinical guidelines remains variable in clinical practice, often despite high levels of awareness (Sheldon et al, 2004; Heagerty et al, 2006; Henegahn et al, 2007). Many barriers to guideline implementation have been identified including organisational, clinician and patient factors; process of guideline implementation; guideline quality and quantity, (Cranney et al 2001; Farquhar et al, 2002; Wathen and Dean, 2004; Carlsen et al, 2007). Medicines Management at Keele University decided to develop a computerised prescribing decision support tool that would aim to address the more practical challenges related to adoption such as guideline format and the time required to assimilate and assess guidelines. Computerised decision support has been defined as the 'provision of assessments or prompts specific to the patient and selected from a knowledge base on the basis of individual patient data' (Hunt et al, 1998). In particular, we sought to develop and deliver an easy-to-use software tool that would make NICE hypertension guidance more accessible to practitioners and more easily applicable to individual patients. Specifically, we aimed to provide patient-tailored, guidance-based prescribing recommendations at the point-of-care for patients with hypertension. Each prescribing recommendation would be generated by cross-referencing patient-specific profiles - created by the healthcare professional user - with multiple treatment algorithms. Recommendations would be supported by an appropriate NICE reference/supporting text and relevant supplementary information.Objectives
Our baseline assessment, using existing literature and local knowledge, was that despite progress in the treatment and control of hypertension, a significant proportion of hypertensive patients in the UK remain untreated (Health Survey for England, 2007). Historical evidence has also suggested that a minority of patients on treatment achieve the recommended blood pressure target (Walley et al, 2003). Although the NICE uptake report suggests movement in prescribing behaviour in line with latest guidance (NICE implementation uptake report: drugs used in the management of hypertension in primary care, 23 May 2008), we felt an independently developed implementation tool could be synergistic with other interventions designed to encourage prescribing best practice. Furthermore, as hypertension is ranked third as a worldwide cause of disability-adjusted life years (Kearney et al, 2005) and, in England, about 30% of adults have blood pressure that is at least 140/90 mmHg (Information Centre for Health and Social Care, 2008), we considered implementation of hypertension guidance to be a priority.Methods
We succeeded in producing an interactive decision support tool that can be used at the point of prescribing to apply NICE Hypertension guidance: clinical guideline 34, to individual patients (1). We have demonstrated that NICE treatment algorithms can be formatted and incorporated into a software application that provides users with timely patient-specific recommendations in addition to complimentary adherence tools and advice to aid a concordant consultation (1,2). We refined a process moving from the construction of the specific treatment algorithm framework, through an external clinical validation and practicality 'reality check' by practitioners, to software and user interface design to ensure that the tool will work within the timeframe and construct of a routine patient consultation (1,2). Cardiovascular risk assessment and adherence support components, developed in consultation with patient stakeholders, were incorporated into the tool so patient decision aids can be displayed or printed to assist with a concordant consultation. The tool is able to print a patient specific summary at the conclusion of each consultation.Results and evaluation
We now have a practical tool that has started to be distributed to primary care prescribers, including non-medical prescribers, who are beginning to use it in chronic disease management clinics. As the dissemination stage has only just started it is too soon to claim success based on formal evaluation. Early anecdotal feedback has been encouraging. We have also demonstrated that it is possible to develop a tool with pharmaceutical industry support without compromising the independence or quality of the evidence and guidance and without having to produce brand specific recommendations. We believe this provides a template that could be applied to other chronic disease guidance.Key learning points
1.It is possible to create a point-of-prescribing/point-of-care decision support tool that applies NICE guidance to individual patients 2.It is possible to produce an implementation tool with industry support whilst retaining good governance and without compromising quality
View the supporting material
|Name:||Professor Stephen Chapman / Mr Simon Thomas|
|Job Title:||Professor of Prescribing Studies, Head of the School of Pharmacy / Honorary Fellow|
|Organisation:||Medicines Management, School of Pharmacy, Keele University|
|Address:||Medicines Management, School of Pharmacy, Hornbeam Building|
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This page was last updated: 28 September 2009