The GUIDES checklist: development of a tool to improve the successful use of guideline-based computerised clinical decision support

Background: Computerised decision support (CDS) based on trustworthy clinical guidelines is a key component of a learning healthcare system. Research shows that the effectiveness of CDS is mixed. Multifaceted context, system, recommendation and implementation factors may potentially affect the success of CDS interventions. This paper describes the development of a checklist that is intended to support professionals to implement CDS successfully. Methods: We developed the checklist through an iterative process that involved a systematic review of evidence and frameworks, a synthesis of the success factors identified in the review, 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. Results: We screened 5347 papers and selected 71 papers with relevant information on success factors for guideline-based CDS. From the selected papers, we developed a 16-factor checklist that is divided in four domains, i.e. the CDS context, content, system and implementation domains. The panel of experts evaluated the checklist positively as an instrument that could support people implementing guideline-based CDS across a wide range of settings globally. Patients and healthcare consumers identified guideline-based CDS as an important quality improvement intervention and perceived the GUIDES checklist as a suitable and useful strategy. Conclusions: The GUIDES checklist can support professionals in considering the factors that affect the success of CDS interventions. It may facilitate a deeper and more accurate understanding of the factors shaping CDS effectiveness. Relying on a structured approach may prevent that important factors are missed

What makes an effective computerized clinical decision support system? A systematic review and logistic regression analysis of randomized controlled trials.

Context: Computerized clinical decision support systems (CCDSSs) give practitioners patient-specific care advice and are considered an important increment to electronic clinical documentation and order entry systems. Despite decades of research on CCDSS, results from rigorous clinical evaluations remain mixed and systems vary greatly in design and implementation. Objective: To identify factors differentiating CCDSSs that improve the process of care or patient outcomes from those that do not. Data Sources: We searched major bibliographic databases and scanned reference lists for eligible articles up to January 2010. Study selection: 162 eligible comparisons from randomized controlled trials of CCDSS to non-CCDSS care. We deemed successful those systems that improved either 50% of reported process of care outcomes or 50% of patient outcomes. We extracted system characteristics hypothesized to impact patient care and tested them for association with system effectiveness in logistic models. Results: Our primary analysis showed that CCDSSs presented in electronic health records or order entry systems were less likely to be effective than their counterparts (OR, 0.37; 95% CI, 0.17 to 0.80). Systems more likely to succeed than their counterparts provided advice for patients in addition to practitioners (OR, 2.77; 95% CI, 1.07 to 7.17), required from practitioners a reason to override advice (OR, 11.23; 95% CI, 1.98 to 63.72), or were evaluated by their developers (OR, 4.35; 95% CI, 1.66 to 11.44). These findings remained consistent across different statistical methods, sensitivity analyses, and adjustment for other potentially important factors. Conclusions: We identified several factors that may partially explain why some systems succeed and others fail. Primary studies should investigate the impact and optimal implementation of advice provided to patients and practitioners and advice that requires reasons to be overridden. Researchers should also address the reasons for failure of advice presented within charting and order entry systems.Master of Science (MSc

Postoperative Remote Automated Monitoring:Need for and State of the Science

Worldwide, more than 230 million adults have major noncardiac surgery each year. Although surgery can improve quality and duration of life, it can also precipitate major complications. Moreover, a substantial proportion of deaths occur after discharge. Current systems for monitoring patients postoperatively, on surgical wards and after transition to home, are inadequate. On the surgical ward, vital signs evaluation usually occurs only every 4-8 hours. Reduced in-hospital ward monitoring, followed by no vital signs monitoring at home, leads to thousands of cases of undetected/delayed detection of hemodynamic compromise. In this article we review work to date on postoperative remote automated monitoring on surgical wards and strategy for advancing this field. Key considerations for overcoming current barriers to implementing remote automated monitoring in Canada are also presented

To what extent can behaviour change techniques be identified within an adaptable implementation package for primary care? A prospective directed content analysis

Interpreting evaluations of complex interventions can be difficult without sufficient description of key intervention content. We aimed to develop an implementation package for primary care which could be delivered using typically available resources and could be adapted to target determinants of behaviour for each of four quality indicators: diabetes control, blood pressure control, anticoagulation for atrial fibrillation and risky prescribing. We describe the development and prospective verification of behaviour change techniques (BCTs) embedded within the adaptable implementation packages

Preoperative estimated glomerular filtration rate to predict cardiac events in major noncardiac surgery: a secondary analysis of two large international studies

Chronic kidney disease; Risk prediction; Vascular eventsEnfermedad renal crónica; Predicción de riesgo; Eventos vascularesMalaltia renal crònica; Predicció de risc; Esdeveniments vascularsBackground Optimised use of kidney function information might improve cardiac risk prediction in noncardiac surgery. Methods In 35,815 patients from the VISION cohort study and 9219 patients from the POISE-2 trial who were ≥45 yr old and underwent nonurgent inpatient noncardiac surgery, we examined (by age and sex) the association between continuous nonlinear preoperative estimated glomerular filtration rate (eGFR) and the composite of myocardial injury after noncardiac surgery, nonfatal cardiac arrest, or death owing to a cardiac cause within 30 days after surgery. We estimated contributions of predictive information, C-statistic, and net benefit from eGFR and other common patient and surgical characteristics to large multivariable models. Results The primary composite occurred in 4725 (13.2%) patients in VISION and 1903 (20.6%) in POISE-2; in both studies cardiac events had a strong, graded association with lower preoperative eGFR that was attenuated by older age (Pinteraction<0.001 for VISION; Pinteraction=0.008 for POISE-2). For eGFR of 30 compared with 90 ml min−1 1.73 m−2, relative risk was 1.49 (95% confidence interval 1.26–1.78) at age 80 yr but 4.50 (2.84–7.13) at age 50 yr in female patients in VISION. This differed modestly (but not meaningfully) in men in VISION (Pinteraction=0.02) but not in POISE-2 (Pinteraction=0.79). eGFR contributed the most predictive information and mean net benefit of all predictors in both studies, most C-statistic in VISION, and third most C-statistic in POISE-2. Conclusions Continuous preoperative eGFR is among the best cardiac risk predictors in noncardiac surgery of the large set examined. Along with its interaction with age, preoperative eGFR would improve risk calculators. Clinical trial registration ClinicalTrials.gov NCT00512109 (VISION) and NCT01082874 (POISE-2).The POISE-2 and VISION funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. The POISE-2 study was funded by the Canadian Institutes of Health Research, the National Health and Medical Research Council of Australia, and the Spanish Ministry of Health and Social Policy. Bayer Pharma provided the aspirin used in the POISE-2 study, and Boehringer Ingelheim provided the clonidine and some financial support for the POISE-2 study. Roche Diagnostics provided the troponin T assays as well as financial support for the VISION study. Funding for the VISION study came from more than 70 grants: Canada: Canadian Institutes of Health Research (seven grants); Heart and Stroke Foundation of Ontario (two grants); Academic Health Science Centres Alternative Funding Plan Innovation Fund Ontario; Population Health Research Institute; CLARITY Research Group; McMaster University Department of Surgery Surgical Associates; Hamilton Health Science New Investigator Fund; Hamilton Health Sciences; Ontario Ministry of Resource and Innovation; Stryker Canada; McMaster University, Department of Anesthesiology (two grants); St Joseph's Healthcare, Department of Medicine (two grants); Father Sean O'Sullivan Research Centre (two grants); McMaster University Department of Medicine (two grants); Roche Diagnostics Global Office (five grants); Hamilton Health Sciences Summer Studentships (six grants); McMaster University Department of Clinical Epidemiology and Biostatistics; McMaster University, Division of Cardiology; Canadian Network and Centre for Trials Internationally; Winnipeg Health Sciences Foundation; University of Manitoba Department of Surgery (two grants); Diagnostic Services of Manitoba Research; Manitoba Medical Services Foundation; Manitoba Health Research Council; University of Manitoba Faculty of Dentistry Operational Fund; University of Manitoba Department of Anesthesia; University Medical Group, Department of Surgery, University of Manitoba, Start-up Fund. Australia: National Health and Medical Research Council Program. Brazil: Projeto Hospitais de Excelência a Serviço do SUS (PROADI-SUS) grant from the Brazilian Ministry of Health in partnership with Hcor (Cardiac Hospital Sao Paulo–SP); National Council for Scientific and Technological Development (CNPq) grant from the Brazilian Ministry of Science and Technology. China: Public Policy Research Fund (grant CUHK-4002-PPR-3), Research Grant Council, Hong Kong SAR; General Research Fund (grant 461412), Research Grant Council, Hong Kong SAR; Australian and New Zealand College of Anaesthetists (grant 13/008). Colombia: School of Nursing, Universidad Industrial de Santander; Grupo de Cardiología Preventiva, Universidad Autónoma de Bucaramanga; Fundación Cardioinfantil–Instituto de Cardiología; Alianza Diagnóstica SA. France: Université Pierre et Marie Curie, Département d'anesthésie Réanimation, Pitié-Salpêtrière, Assistance Publique–Hôpitaux de Paris. India: St John's Medical College and Research Institute; Division of Clinical Research and Training. Malaysia: University of Malaya (grant RG302-14AFR); University of Malaya, Penyelidikan Jangka Pendek. Poland: Polish Ministry of Science and Higher Education (grant NN402083939). South Africa: University of KwaZulu-Natal. Spain: Instituto de Salud Carlos III; Fundació La Marató de TV3. USA: American Heart Association; Covidien; American Society of Nephrology Student Scholar Grant. UK: National Institute for Health Research. Pavel Roshanov is recipient of a career award from the Academic Medical Organization of Southwestern Ontario and his research is supported by the William F. Clark Chair in Nephrology from Western University. Flavia Borges is recipient of an Early Career Research Award from Hamilton Health Sciences. Tyrone Harrison is supported by a Kidney Research Scientist Core Education and National Training (KRESCENT) Program New Investigator Award (co-sponsored by the Kidney Foundation of Canada and Canadian Institutes of Health Research) and is supported as a new investigator by the Roy and Vi Baay Chair for Kidney Research and the Kidney Health and Wellness Institute at the University of Calgary. Vikram Fielding-Singh has received support from the American Heart Association (23CDA1053913) and the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (K23DK138312)

Effect of Colchicine on the Risk of Perioperative Acute Kidney Injury : Clinical Protocol of a Substudy of the Colchicine for the Prevention of Perioperative Atrial Fibrillation Randomized Clinical Trial

Inflammation during and after surgery can lead to organ damage including acute kidney injury. Colchicine, an established inexpensive anti-inflammatory medication, may help to protect the organs from pro-inflammatory damage. This protocol describes a kidney substudy of the colchicine for the prevention of perioperative atrial fibrillation (COP-AF) study, which is testing the effect of colchicine versus placebo on the risk of atrial fibrillation and myocardial injury among patients undergoing thoracic surgery. Objective: Our kidney substudy of COP-AF will determine whether colchicine reduces the risk of perioperative acute kidney injury compared with a placebo. We will also examine whether colchicine has a larger absolute benefit in patients with pre-existing chronic kidney disease, the most prominent risk factor for acute kidney injury. Design and Setting: Randomized, superiority clinical trial conducted in 40 centers in 11 countries from 2018 to 2023. Patients (~3200) aged 55 years and older having major thoracic surgery. Intervention: Patients are randomized 1:1 to receive oral colchicine (0.5 mg tablet) or a matching placebo, given twice daily starting 2 to 4 hours before surgery for a total of 10 days. Patients, health care providers, data collectors, and outcome adjudicators will be blinded to the randomized treatment allocation. Serum creatinine concentrations will be measured before surgery and on postoperative days 1, 2, and 3 (or until hospital discharge). The primary outcome of the substudy is perioperative acute kidney injury, defined as an increase (from the prerandomization value) in serum creatinine concentration of either ≥26.5 μmol/L (≥0.3 mg/dL) within 48 hours of surgery or ≥50% within 7 days of surgery. The primary analysis (intention-to-treat) will examine the relative risk of acute kidney injury in patients allocated to receive colchicine versus placebo. We will repeat the primary analysis using alternative definitions of acute kidney injury and examine effect modification by pre-existing chronic kidney disease, defined as a prerandomization estimated glomerular filtration rate (eGFR) <60 mL/min per 1.73 m. The substudy will be underpowered to detect small effects on more severe forms of acute kidney injury treated with dialysis. Substudy results will be reported in 2024. This substudy will estimate the effect of colchicine on the risk of perioperative acute kidney injury in older adults undergoing major thoracic surgery. Clinical trial registration number: NCT0331012

Perioperative management of angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers: a survey of perioperative medicine practitioners

NIHR. British Oxygen Company research chair in Anaesthesia. Medical Research Council and British Journal of Anaesthesia: R/M017974/1