Retrospective analysis of clinical decision support system use in patients with hypertension and atrial fibrillation (INTELLECT)

Aim. To evaluate the relationship between the clinical decision support system use (CDSS) and adherence to clinical guidelines.

Materials and methods. Medical records of 300 patients with atrial fibrillation and hypertension from the electronic medical database of the Almazov National Medical Research Center were analyzed. Demographic and clinical data, as well as information on anticoagulant, antiarrhythmic and antihypertensive prescriptions were analyzed. The primary endpoint was adherence of prescribed treatment to current clinical guidelines for each of the three therapies. Firstly, a group of independent clinical experts assessed primary endpoint for retrospective prescriptions. Secondly, new prescriptions were simulated by another group of clinical experts using CDSS and blinded to previous therapy. Primary endpoint at the second step was analysed by independent experts. We compared adherence to relevant clinical guidelines with and without use of CDSS. Additionally, we analyzed predictors of failing to meet the current recommendations in the retrospective records.

Results. Out of 300 patients, only 291 (97%) had all characteristics and were included in the analysis. In 26 patients (18%), all three treatment strategies were in accordance with current clinical guidelines. Anticoagulant therapy was adherent to the guidelines in 92% of cases. Experts who used CDSS were 15% (95% confidence interval [CI], 10-21%) more likely to prescribe novel oral anticoagulants and 14% (95% CI, 10-19%) less likely to prescribe warfarin compared to baseline. Antiarrhythmic therapy was adherent to the guidelines in 69% of cases. When the CDSS platform was applied, experts were 14% (95% CI 4-19%) more likely to prefer antiarrhythmic drug (AAD) monotherapy and 32% (95% CI 26-37%) more often prescribed radiofrequency ablation (RFA) of left atrium. At baseline, antihypertensive therapy combinations were adherent clinical guidelines in 28% of cases. The use of the CDSS platform by experts was significantly associated with an increase in the frequency of prescribing dual and triple antihypertensive therapy.

Conclusion. CDSS use is associated with improved adherence to current clinical guidelines. Prospective randomized trials are needed to evaluate the CDSS effectiveness in the prevention of cardiovascular events.

1. Lip GYH, Coca A, Kahan T, et al. Hypertension and cardiac arrhythmias: a consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLEACE). Europace 2017;19(6):891-911. doi:10.1093/europace/eux091.

2. Njie GJ, Proia KK, Thota AB, et al. Clinical Decision Support Systems and Prevention. Am J Prev Med. 2015;49(5):784-95. doi:10.1016/j.amepre.2015.04.006.

3. Mitchell J, Probst J, Brock-Martin A, et al. Association Between Clinical Decision Support System Use and Rural Quality Disparities in the Treatment of Pneumonia. J Rural Heal. 2014;30(2):186-95. doi:10.1111/jrh.12043.

4. Jacob V, Thota AB, Chattopadhyay SK, et al. Cost and economic benefit of clinical decision support systems for cardiovascular disease prevention: A community guide systematic review. J Am Med Informatics Assoc. 2017;24(3):669-76. doi:10.1093/jamia/ocw160.

5. American Medical Group Foundation. Measure Up Pressure Down: Provider Toolkit to Improve Hypertension Control. Alexandria, VA: American Medical Group Foundation. 2013. http://www.measureuppressuredown.com.

6. Castrillo RS, Kelemen A. Considerations for a Successful Clinical Decision Support System. CIN Comput Informatics, Nurs. 2013;31(7):319-26. doi:10.1097/NXN.0b013e3182997a9c

7. Centers for Disease Control and Prevention. Hypertension Control Change Package for Clinicians. Atlanta, GA: Centers for Disease Control and Prevention, U. S. Dept. of Health and Human Services; 2015. https://www.healthit.gov/sites/default/files/playbook/pdf/htn-change-package.pdf.

8. Fox J, Thomson R. Clinical decision support systems: a discussion of quality, safety and legal liability issues. Proc AMIA Symp. 2002:265-9.

9. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37(38):2893-962. doi:10.1093/eurheartj/ehw210.

10. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). Eur Heart J. 2018;39(33):3021-104.

11. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Russ J Cardiol. 2017;(7):7-86. (In Russ.) doi:10.15829/1560-4071-2017-7-7-86.

12. Kobalava ZD, Konradi AO, Nedogoda SV, et al. Arterial hypertension in adults. Clinical guidelines 2020. Russ J Cardiol. 2020;25(3):3786. (In Russ.) doi:10.15829/1560-4071-2020-3-3786.

13. Rucker G, Schwarzer G. Ranking treatments in frequentist network meta-analysis works without resampling methods. BMC Med Res Methodol. 2015;15(1):58. doi:10.1186/s12874-015-0060-8.

14. Milchak JL, Carter BL, James PA, et al. Measuring Adherence to Practice Guidelines for the Management of Hypertension. Hypertension. 2004;44(5):602-8. doi:10.1161/01.HYP.0000144100.29945.5e.

15. Packer DL, Mark DB, Robb RA, et al. Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) Trial: Study Rationale and Design. Am Heart J. 2018;199:192-9. doi:10.1016/j.ahj.2018.02.015.

16. Lip GYH, Laroche C, Popescu MI, et al. Improved outcomes with European Society of Cardiology guideline-adherent antithrombotic treatment in high-risk patients with atrial fibrillation: A report from the EORP-AF General Pilot Registry. Europace. 2015;17(12):1777-86. doi:10.1093/europace/euv269.

17. Boriani G, Proietti M, Laroche C, et al. Association between antithrombotic treatment and outcomes at 1-year follow-up in patients with atrial fibrillation: the EORP-AF General LongTerm Registry. EP Eur. 2019;21(7):1013-22. doi:10.1093/europace/euz032.

18. Xu KT, Moloney M, Phillips S. Economics of suboptimal drug use: cost-savings of using JNC-recommended medications for management of uncomplicated essential hypertension. Am J Manag Care. 2003;9(8):529-36.