scholarly journals 2096. System-Wide Multi-Pronged Approach Leads to Successful Reduction of Fluoroquinolone Use Across a Large Health System

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S708-S709
Author(s):  
Danielle Sebastian ◽  
Florian Daragjati ◽  
Karl Saake ◽  
Mohamad G Fakih
Keyword(s):  
Health System ◽  
Inappropriate Prescribing ◽  
Clinical Decision Support Systems ◽  
Clinical Decision ◽  
Provider Education ◽  
Serious Adverse Events ◽  
Learning Modules ◽  
Clostridioides Difficile ◽  
Days Of Therapy ◽  
Order Sets

Abstract Background Overuse of fluoroquinolones has been associated with increased rates of Clostridioides difficile infections, MRSA, and resistant Gram-negative infections due to selective pressure on normal flora. In addition, the FDA has issued several safety alerts regarding systemic use of fluoroquinolone antibiotics due to concerns for serious adverse events and antimicrobial resistance. Considerable variability in the utilization of this antibiotic class across the system resulted in a system-wide initiative to reduce inappropriate prescribing. Methods A national initiative included the integration of system-wide approved adult criteria for use into electronic health record order sets and pharmacy clinical decision support systems. System-wide education on the initiative involved learning modules, education toolkits and webinars. Fluoroquinolone utilization rates were reported monthly to help facilities determine the success of initiatives to improve performance. Results The fluoroquinolone criteria for use were integrated into several disease-specific order sets system-wide to include: pneumonia, acute exacerbation of COPD, chronic bronchitis, sepsis, acute pyelonephritis, and skin and soft-tissue infection. The learning modules were assigned to all acute care pharmacists resulting in 1,783 completions. Education toolkits were utilized by antimicrobial stewardship teams for provider education. A significant reduction in fluoroquinolone utilization rates, defined by days of therapy (DOT) per 1000 patient-days, was seen across 94 facilities (Figure 1). This resulted in a 45.84% reduction in fluoroquinolone rates from 2017 (56.96, 95% CI 56.72, 57.21) to 2018 (30.85, 95% CI 30.66, 31.04). Conclusion Developing and implementing a multi-pronged approach to maximize the effective use of fluoroquinolones can result in significant reductions in utilization across a diverse health system. Disclosures All authors: No reported disclosures.

scholarly journals 2373. Impact of a Change in Testing Strategy for Clostridioides difficile Infection on a Publicly Reported Metric and Treatment Days of Therapy

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S818-S819
Author(s):  
Ryan Miller ◽  
Jose A Morillas ◽  
Joanne Sitaras ◽  
Jacob Bako ◽  
Elizabeth A Neuner ◽  
...  
Keyword(s):  
Health System ◽  
Diagnostic Testing ◽  
Cleveland Clinic ◽  
Public Reporting ◽  
Testing Strategy ◽  
Clostridioides Difficile ◽  
Days Of Therapy ◽  
Before And After ◽  
Clostridioides Difficile Infection ◽  
The Impact

Abstract Background In an effort to optimize diagnostic testing for Clostridioides difficile infection (CDI) our health system changed from stand-alone PCR testing to a “2-step” approach wherein all positive PCR results reflexed to an EIA. We report the effects of this change on publicly reported CDI metrics and treatment days of therapy (DOT). Methods The setting includes 10 Cleveland Clinic Health System hospitals in northeast Ohio and one in Florida. On June 12, 2018, 9 NE Ohio hospitals changed from PCR alone to PCR followed by EIA. Stand-alone PCR testing remained at one and GDH / EIA / PCR for discordant for another. Testing volumes were obtained from the microbiology laboratory. C. difficile LabID event SIRs were obtained from NHSN. Public reporting interpretative categories were identified based on SIR for second half of 2018. DOT for CDI agents were obtained from an antimicrobial stewardship database. Results Among hospitals that changed strategy the volume of PCR testing and the percent PCR + was similar between time periods. EIA positivity ranged from 23% to 53%. 4/11 hospitals improved their public reporting category: 3/9 that changed testing strategy and 1/2 that did not (Table 1). Two of 3 that changed strategy and improved public reporting also had a decrease in DOT. DOT increased in the 2 hospitals that did not change strategy. Conclusion Six months after adopting a 2-step CDI testing strategy 7 of 9 hospitals had a lower SIR with 3 also demonstrating an improvement in public reporting category favorably impacting reputational and reimbursement risk for our healthcare system. CDI agent DOT was similar before and after the change. The impact of choice of test on publicly reported metrics demonstrates the difficulty of utilizing a proxy for hospital onset CDI, the CDI LabID event, as a measure of quality of care provided. Disclosures All authors: No reported disclosures.

scholarly journals 236. Incorporating Clinical Guidance into Computerized Prescriber Order Entry May Reduce Fluoroquinolone Utilization for the Treatment of Diverticulitis at a Rural Community Health System

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S118-S119
Author(s):  
Raghavendra Tirupathi ◽  
Benton Miller ◽  
Jarett Logsdon
Keyword(s):  
Time Frame ◽  
Secondary Outcome ◽  
Control Group ◽  
Order Entry ◽  
Clinical Guidance ◽  
Clostridioides Difficile ◽  
Days Of Therapy ◽  
Order Sets ◽  
Computerized Prescriber Order Entry ◽  
Order Set

Abstract Background Fluoroquinolones are associated with many adverse effects. As a result, many hospitals are investigating methods to reduce fluoroquinolone use. Computerized prescriber order entry (CPOE) provides an opportunity to develop and implement clinically guided order sets that discourage the use of fluoroquinolones. To date, there are few studies investigating the effect of clinically guided order sets on medication utilization. This study aims to investigate the hypothesis that incorporating clinical guidance and leveraging antimicrobial stewardship into a CPOE diverticulitis order set would reduce fluoroquinolone use in the treatment of diverticulitis. Methods A diverticulitis order set was revised to provide guided antibiotic selection based on a patient’s penicillin allergy. Patients were split into two groups based on admission date relative to the implementation date of the revised order set. Fluoroquinolone use was compared between both groups. The primary outcome was the percentage of patients who were ordered a fluoroquinolone-containing regimen during their stay. The secondary outcome was the percentage of regimens that contained a fluoroquinolone. A subgroup analysis was conducted exclusively on patients whose antibiotics were ordered with the diverticulitis order set. Results 494 patients were included in the study. 316 patients in the pre-order set group, 178 patients in the post-order set group. 56% of patients in the pre-group received a fluoroquinolone in their regimen versus 46% of patients in the post-group (RR=0.82; 95% CI 0.68–0.99, p = 0.028). 49% of regimens in the control group contained a fluoroquinolone versus 39% of regimens in the experimental group (RR=0.78; 95% CI 0.64–0.95; p = 0.012). 77.5% of patients in the control subgroup received a fluoroquinolone in their regimen versus 42.4% of patients in the experimental subgroup (RR=0.55; 95% CI 0.36–0.84, p = 0.0062). Fluoroquinolone days of therapy decreased from 90.6 to 58.6 from 2018–2019. Clostridioides difficile infections also decreased during this time frame. Table 1: Average fluoroquinolone days of therapy per 1000 patient days Figure 1: Percentage of Diverticulitis Orders by Antibiotic Regimen: Pre- and Post-Order Set Change. CFP=cefepime, Metro=metronidazole, PIP-TZ=piperacillin-tazobactam, AM-SB=ampicillin-sulbactam, CIP=ciprofloxacin, Levo=levofloxacin, FQ=fluoroquinolone Figure 2: Fluoroquinolone days of therapy per 1000 patient days from 2016–2020. Conclusion Our findings support the hypothesis that incorporating clinical guidance into a CPOE order set would reduce fluoroquinolone use for the treatment of diverticulitis. Figure 3: Indicence of Clostridioides difficile infection per 1000 patient days Disclosures All Authors: No reported disclosures

scholarly journals Reductions in Postdischarge Clostridioides difficile Infection after an Inpatient Health System Fluoroquinolone Stewardship

2021 ◽  
Vol 1 (S1) ◽  
pp. s4-s4
Author(s):  
K. Ashley Jones ◽  
Zanthia Wiley ◽  
Julianne Kubes ◽  
Mary Elizabeth Sexton ◽  
Benjamin Albrecht ◽  
...  
Keyword(s):  
Sensitivity Analysis ◽  
Decision Support ◽  
Healthcare System ◽  
Positive Test ◽  
Antibiotic Prescribing ◽  
Entire Study ◽  
Level Change ◽  
Clostridioides Difficile ◽  
Days Of Therapy ◽  
Order Sets

Background: Effective inpatient stewardship initiatives can improve antibiotic prescribing, but impact on outcomes like Clostridioides difficile infections (CDIs) is less apparent. However, the effect of inpatient stewardship efforts may extend to the postdischarge setting. We evaluated whether an intervention targeting inpatient fluoroquinolone (FQ) use in a large healthcare system reduced incidence of postdischarge CDI. Methods: In August 2019, 4 acute-care hospitals in a large healthcare system replaced standalone FQ orders with order sets containing decision support. Order sets redirected prescribers to syndrome order sets that prioritize alternative antibiotics. Monthly patient days (PDs) and antibiotic days of therapy (DOT) administered for FQs and NHSN-defined broad-spectrum hospital-onset (BS-HO) antibiotics were calculated using patient encounter data for the 23 months before and 13 months after the intervention (COVID-19 admissions in the previous 7 months). We evaluated hospital-onset CDI (HO-CDI) per 1,000 PD (defined as any positive test after hospital day 3) and 12-week postdischarge (PDC- CDI) per 100 discharges (any positive test within healthcare system <12 weeks after discharge). Interrupted time-series analysis using generalized estimating equation models with negative binomial link function was conducted; a sensitivity analysis with Medicare case-mix index (CMI) adjustment was also performed to control for differences after start of the COVID-19 pandemic. Results: Among 163,117 admissions, there were 683 HO-CDIs and 1,009 PDC-CDIs. Overall, FQ DOT per 1,000 PD decreased by 21% immediately after the intervention (level change; P < .05) and decreased at a consistent rate throughout the entire study period (−2% per month; P < .01) (Fig. 1). There was a nonsignificant 5% increase in BS-HO antibiotic use immediately after intervention and a continued increase in use after the intervention (0.3% per month; P = .37). HO-CDI rates were stable throughout the study period, with a nonsignificant level change decrease of 10% after the intervention. In contrast, there was a reversal in the trend in PDC-CDI rates from a 0.4% per month increase in the preintervention period to a 3% per month decrease in the postintervention period (P < .01). Sensitivity analysis with adjustment for facility-specific CMI produced similar results but with wider confidence intervals, as did an analysis with a distinct COVID-19 time point. Conclusion: Our systemwide intervention using order sets with decision support reduced inpatient FQ use by 21%. The intervention did not significantly reduce HO-CDI but significantly decreased the incidence of CDI within 12 weeks after discharge. Relying on outcome measures limited to inpatient setting may not reflect the full impact of inpatient stewardship efforts and incorporating postdischarge outcomes, such as CDI, should increasingly be considered.Funding: NoDisclosures: None

scholarly journals Decreasing ICU-associated Clostridioides difficile infection through fluoroquinolone restriction, the FIRST trial: a study protocol

BMJ Open ◽  
2021 ◽  
Vol 11 (6) ◽  
pp. e046480
Author(s):  
Nasia Safdar ◽  
Vishala Parmasad ◽  
Roger Brown ◽  
Pascale Carayon ◽  
Alexander Lepak ◽  
...  
Keyword(s):  
Systems Engineering ◽  
Average Length ◽  
Clinical Decision ◽  
Antibiotic Use ◽  
Implementation Effectiveness ◽  
Clostridioides Difficile ◽  
Institutional Review ◽  
Days Of Therapy ◽  
Study Team ◽  
The Usa

IntroductionClostridioides difficile infection (CDI) is one of the most common healthcare-associated infections in the USA, having high incidence in intensive care units (ICU). Antibiotic use increases risk of CDI, with fluoroquinolones (FQs) particularly implicated. In healthcare settings, antibiotic stewardship (AS) and infection control interventions are effective in CDI control, but there is little evidence regarding the most effective AS interventions. Preprescription authorisation (PPA) restricting FQs is a potentially promising AS intervention to reduce CDI. The FQ Restriction for the Prevention of CDI (FIRST) trial will evaluate the effectiveness of an FQ PPA intervention in reducing CDI rates in adult ICUs compared with preintervention care, and evaluate implementation effectiveness using a human-factors and systems engineering model.Methods and analysisThis is a multisite, stepped-wedge, cluster, effectiveness-implementation clinical trial. The trial will take place in 12 adult medical-surgical ICUs with ≥10 beds, using Epic as electronic health record (EHR) and pre-existing AS programmes. Sites will receive facilitated implementation support over the 15-month trial period, succeeded by 9 months of follow-up. The intervention comprises a clinical decision support system for FQ PPA, integrated into the site EHRs. Each ICU will be considered a single site and all ICU admissions included in the analysis. Clinical data will be extracted from EHRs throughout the trial and compared with the corresponding pretrial period, which will constitute the baseline for statistical analysis. Outcomes will include ICU-onset CDI rates, FQ days of therapy (DOT), alternative antibiotic DOT, average length of stay and hospital mortality. The study team will also collect implementation data to assess implementation effectiveness using the Systems Engineering Initiative for Patient Safety model.Ethics and disseminationThe trial was approved by the Institutional Review Board at the University of Wisconsin-Madison (2018-0852-CP015). Results will be made available to participating sites, funders, infectious disease societies, critical care societies and other researchers.Trial registration numberNCT03848689.

Architectures for Architects

1993 ◽  
Vol 32 (01) ◽  
pp. 12-13 ◽  
Author(s):  
M. A. Musen
Keyword(s):  
Decision Support ◽  
Decision Support Systems ◽  
Clinical Decision Support ◽  
Support Systems ◽  
Clinical Decision Support Systems ◽  
Clinical Decision ◽  
Design And Development

Abstract:Response to Heathfield HA, Wyatt J. Philosophies for the design and development of clinical decision-support systems. Meth Inform Med 1993; 32: 1-8.

Characterizing Decision Support Telemedicine Systems

2006 ◽  
Vol 45 (05) ◽  
pp. 523-527 ◽  
Author(s):  
A. Abu-Hanna ◽  
B. Nannings
Keyword(s):  
Decision Support ◽  
Decision Support Systems ◽  
Clinical Decision Support ◽  
Literature Search ◽  
Support Systems ◽  
Clinical Decision Support Systems ◽  
Clinical Decision ◽  
Problem Dimension ◽  
Process Dimension

Summary Objectives: Decision Support Telemedicine Systems (DSTS) are at the intersection of two disciplines: telemedicine and clinical decision support systems (CDSS). The objective of this paper is to provide a set of characterizing properties for DSTSs. This characterizing property set (CPS) can be used for typing, classifying and clustering DSTSs. Methods: We performed a systematic keyword-based literature search to identify candidate-characterizing properties. We selected a subset of candidates and refined them by assessing their potential in order to obtain the CPS. Results: The CPS consists of 14 properties, which can be used for the uniform description and typing of applications of DSTSs. The properties are grouped in three categories that we refer to as the problem dimension, process dimension, and system dimension. We provide CPS instantiations for three prototypical applications. Conclusions: The CPS includes important properties for typing DSTSs, focusing on aspects of communication for the telemedicine part and on aspects of decisionmaking for the CDSS part. The CPS provides users with tools for uniformly describing DSTSs.

scholarly journals 1211. Response to Fecal Microbiota Transplant (FMT) in Refractory Clostridioides difficile Infection (CDI) is Modest Compared to Recurrent CDI in Hospitalized Patients

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S627-S627
Author(s):  
Jae Hyun Shin ◽  
R Ann Hays ◽  
Cirle Warren
Keyword(s):  
Health System ◽  
Complete Resolution ◽  
Fecal Microbiota ◽  
Inpatient Setting ◽  
University Of Virginia ◽  
Cure Rate ◽  
Fecal Microbiota Transplant ◽  
Safety And Efficacy ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection

Abstract Background There are limited options for Clostridioides difficile infection (CDI) refractory to conventional antibiotic therapy (metronidazole, vancomycin, or fidaxomicin). Fecal microbiota transplant (FMT) is considered a safe and effective treatment for recurrent CDI but has not been widely utilized for refractory CDI due to concerns about safety. Even when included in studies, refractory CDI has not been analyzed separately from recurrent CDI. We reviewed cases of FMT performed in the inpatient setting for CDI to evaluate its safety and efficacy for refractory CDI. Methods Patients who received FMT inpatient at University of Virginia Health System for recurrent or refractory CDI after Infectious Diseases and Gastroenterology consultation signed informed consent acknowledging that FMT was considered investigational use in CDI not responding to standard of care as per 2014 FDA guidance. Charts were reviewed as part of quality improvement efforts to evaluate safety and efficacy of FMT in inpatient setting. Results Starting in July 2014, 13 patients received FMT for CDI as inpatients. Six received FMT for recurrent CDI, with four having complete resolution, one had recurrent CDI, and one had persistent C. difficile-negative diarrhea, for cure rate of 83%, comparable to published studies. Seven patients received FMT for refractory CDI, with three resulting in complete resolution. One responded to FMT but refused further care, one died from multiorgan failure after initial response to FMT that was possibly related to CDI, strongyloides, and/or CMV. Two patients had ongoing diarrhea suggestive of post-infectious irritable bowel syndrome, one was C. difficile-negative and one was not tested. The cure rate was 57%, lower than that of the recurrent CDI, but without any clear evidence of microbiologic failure. Outcome of patients undergoing FMT for CDI in the inpatient setting at University of Virginia Health System Conclusion Cure rate for FMT for refractory CDI was lower than recurrent CDI, but review of the cases of treatment failures did not reveal any microbiologic evidence of failure. FMT should be considered an alternative option when treating refractory CDI. Disclosures All Authors: No reported disclosures

scholarly journals The acceptance of clinical decision support systems among clinicians in the treatment of neck and/or back pain

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
S M Jansen-Kosterink ◽  
M Cabrita ◽  
I Flierman
Keyword(s):  
Back Pain ◽  
Decision Support ◽  
Focus Groups ◽  
Decision Support Systems ◽  
Clinical Decision Support ◽  
Support Systems ◽  
Clinical Decision Support Systems ◽  
Clinical Decision ◽  
Case Based Reasoning ◽  
Online Questionnaire

Abstract Background Clinical Decision Support Systems (CDSSs) are computerized systems using case-based reasoning to assist clinicians in making clinical decisions. Despite the proven added value to public health, the implementation of CDSS clinical practice is scarce. Particularly, little is known about the acceptance of CDSS among clinicians. Within the Back-UP project (Project Number: H2020-SC1-2017-CNECT-2-777090) a CDSS is developed with prognostic models to improve the management of Neck and/or Low Back Pain (NLBP). Therefore, the aim of this study is to present the factors involved in the acceptance of CDSSs among clinicians. Methods To assess the acceptance of CDSSs among clinicians we conducted a mixed method analysis of questionnaires and focus groups. An online questionnaire with a low-fidelity prototype of a CDSS (TRL3) was sent to Dutch clinicians aimed to identify the factors influencing the acceptance of CDSSs (intention to use, perceived threat to professional autonomy, trusting believes and perceived usefulness). Next to this, two focus groups were conducted with clinicians addressing the general attitudes towards CDSSs, the factors determining the level of acceptance, and the conditions to facilitate use of CDSSs. Results A pilot-study of the online questionnaire is completed and the results of the large evaluation are expected spring 2020. Eight clinicians participated in two focus groups. After being introduced to various types of CDSSs, participants were positive about the value of CDSS in the care of NLBP. The clinicians agreed that the human touch in NLBP care must be preserved and that CDSSs must remain a supporting tool, and not a replacement of their role as professionals. Conclusions By identifying the factors hindering the acceptance of CDSSs we can draw implications for implementation of CDSSs in the treatment of NLBP.

scholarly journals 216. Are Automatic Antimicrobial Stop Orders an Effective Stewardship Tool for Urinary Tract and Intra-Abdominal Infections?

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S110-S110
Author(s):  
Christina Maguire ◽  
Dusten T Rose ◽  
Theresa Jaso
Keyword(s):  
Urinary Tract ◽  
Antimicrobial Therapy ◽  
Source Control ◽  
Clostridioides Difficile ◽  
Days Of Therapy ◽  
Before And After ◽  
The Difference ◽  
Tract Infections ◽  
Length Of Therapy ◽  
The Impact

Abstract Background Automatic antimicrobial stop orders (ASOs) are a stewardship initiative used to decrease days of therapy, prevent resistance, and reduce drug costs. Limited evidence outside of the perioperative setting exists on the effects of ASOs on broad spectrum antimicrobial use, discharge prescription duration, and effects of missed doses. This study aims to evaluate the impact of an ASO policy across a health system of adult academic and community hospitals for treatment of intra-abdominal (IAI) and urinary tract infections (UTI). ASO Outcome Definitions ASO Outcomes Methods This multicenter retrospective cohort study compared patients with IAI and UTI treated before and after implementation of an ASO. Patients over the age of 18 with a diagnosis of UTI or IAI and 48 hours of intravenous (IV) antimicrobial administration were included. Patients unable to achieve IAI source control within 48 hours or those with a concomitant infection were excluded. The primary outcome was the difference in sum length of antimicrobial therapy (LOT). Secondary endpoints include length and days of antimicrobial therapy (DOT) at multiple timepoints, all cause in hospital mortality and readmission, and adverse events such as rates of Clostridioides difficile infection. Outcomes were also evaluated by type of infection, hospital site, and presence of infectious diseases (ID) pharmacist on site. Results This study included 119 patients in the pre-ASO group and 121 patients in the post-ASO group. ASO shortened sum length of therapy (LOT) (12 days vs 11 days respectively; p=0.0364) and sum DOT (15 days vs 12 days respectively; p=0.022). This finding appears to be driven by a decrease in outpatient LOT (p=0.0017) and outpatient DOT (p=0.0034). Conversely, ASO extended empiric IV LOT (p=0.005). All other secondary outcomes were not significant. Ten patients missed doses of antimicrobials due to ASO. Subgroup analyses suggested that one hospital may have influenced outcomes and reduction in LOT was observed primarily in sites without an ID pharmacist on site (p=0.018). Conclusion While implementation of ASO decreases sum length of inpatient and outpatient therapy, it may not influence inpatient length of therapy alone. Moreover, ASOs prolong use of empiric intravenous therapy. Hospitals without an ID pharmacist may benefit most from ASO protocols. Disclosures All Authors: No reported disclosures

scholarly journals Clinician acceptance of complex clinical decision support systems for treatment allocation of patients with chronic low back pain

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Stephanie Jansen-Kosterink ◽  
Lex van Velsen ◽  
Miriam Cabrita
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Clinical Decision Support Systems ◽  
Clinical Decision ◽  
Perceived Usefulness ◽  
Intention To Use ◽  
Low Back ◽  
Research Model ◽  
Online Questionnaire ◽  
Treatment Allocation

Abstract Background The uptake of complex clinical decision support systems (CDSS) in daily practice remains low, despite the proven potential to reduce medical errors and to improve the quality of care. To improve successful implementation of a complex CDSS this study aims to identify the factors that hinder, or alleviate the acceptance of, clinicians toward the use of a complex CDSS for treatment allocation of patients with chronic low back pain. Methods We tested a research model in which the intention to use a CDSS by clinicians is influenced by the perceived usefulness; this usefulness, in turn is influenced by the perceived service benefits and perceived service risks. An online survey was created to test our research model and the data was analysed using Partial Least Squares Structural Equation Modelling. The study population consisted of clinicians. The online questionnaire started with demographic questions and continued with a video animation of the complex CDSS followed by the set of measurement items. The online questionnaire ended with two open questions enquiring the reasons to use and not use, a complex CDSS. Results Ninety-eight participants (46% general practitioners, 25% primary care physical therapists, and 29% clinicians at a rehabilitation centre) fully completed the questionnaire. Fifty-two percent of the respondents were male. The average age was 48 years (SD ± 12.2). The causal model suggests that perceived usefulness is the main factor contributing to the intention to use a complex CDSS. Perceived service benefits and risks are both significant antecedents of perceived usefulness and perceived service risks are affected by the perceived threat to autonomy and trusting beliefs, particularly benevolence and competence. Conclusions To improve the acceptance of complex CDSSs it is important to address the risks, but the main focus during the implementation phase should be on the expected improvements in patient outcomes and the overall gain for clinicians. Our results will help the development of complex CDSSs that fit more into the daily clinical practice of clinicians.

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