Abstract
Objectives
Electronic health record-based clinical decision support (CDS) has the potential to improve health outcomes. This systematic review investigates the design, effectiveness, and ...economic outcomes of CDS targeting several common chronic diseases.
Material and Methods
We conducted a search in PubMed (Medline), EBSCOHOST (CINAHL, APA PsychInfo, EconLit), and Web of Science. We limited the search to studies from 2011 to 2021. Studies were included if the CDS was electronic health record-based and targeted one or more of the following chronic diseases: cardiovascular disease, diabetes, chronic kidney disease, hypertension, and hypercholesterolemia. Studies with effectiveness or economic outcomes were considered for inclusion, and a meta-analysis was conducted.
Results
The review included 76 studies with effectiveness outcomes and 9 with economic outcomes. Of the effectiveness studies, 63% described a positive outcome that favored the CDS intervention group. However, meta-analysis demonstrated that effect sizes were heterogenous and small, with limited clinical and statistical significance. Of the economic studies, most full economic evaluations (n = 5) used a modeled analysis approach. Cost-effectiveness of CDS varied widely between studies, with an estimated incremental cost-effectiveness ratio ranging between USD$2192 to USD$151 955 per QALY.
Conclusion
We summarize contemporary chronic disease CDS designs and evaluation results. The effectiveness and cost-effectiveness results for CDS interventions are highly heterogeneous, likely due to differences in implementation context and evaluation methodology. Improved quality of reporting, particularly from modeled economic evaluations, would assist decision makers to better interpret and utilize results from these primary research studies.
Registration
PROSPERO (CRD42020203716)
Abstract
Background
Clinical decision support (CDS) is increasingly used to facilitate chronic disease care. Despite increased availability of electronic health records and the ongoing development of ...new CDS technologies, uptake of CDS into routine clinical settings is inconsistent. This qualitative systematic review seeks to synthesise healthcare provider experiences of CDS—exploring the barriers and enablers to implementing, using, evaluating, and sustaining chronic disease CDS systems.
Methods
A search was conducted in Medline, CINAHL, APA PsychInfo, EconLit, and Web of Science from 2011 to 2021. Primary research studies incorporating qualitative findings were included if they targeted healthcare providers and studied a relevant chronic disease CDS intervention. Relevant CDS interventions were electronic health record-based and addressed one or more of the following chronic diseases: cardiovascular disease, diabetes, chronic kidney disease, hypertension, and hypercholesterolaemia. Qualitative findings were synthesised using a meta-aggregative approach.
Results
Thirty-three primary research articles were included in this qualitative systematic review. Meta-aggregation of qualitative data revealed 177 findings and 29 categories, which were aggregated into 8 synthesised findings. The synthesised findings related to clinical context, user, external context, and technical factors affecting CDS uptake. Key barriers to uptake included CDS systems that were simplistic, had limited clinical applicability in multimorbidity, and integrated poorly into existing workflows. Enablers to successful CDS interventions included perceived usefulness in providing relevant clinical knowledge and structured chronic disease care; user confidence gained through training and post training follow-up; external contexts comprised of strong clinical champions, allocated personnel, and technical support; and CDS technical features that are both highly functional, and attractive.
Conclusion
This systematic review explored healthcare provider experiences, focussing on barriers and enablers to CDS use for chronic diseases. The results provide an evidence-base for designing, implementing, and sustaining future CDS systems. Based on the findings from this review, we highlight actionable steps for practice and future research.
Trial registration
PROSPERO
CRD42020203716
Since the turn of the millennium, Japanese variety television has witnessed a revival in onê-kyara (queen personalities). In contemporary lifestyle media, the trans-gendered onê-personality figure is ...demonstrative of how suitable consumption and personal effort can bring forth the transformational happiness of the individual. The transgressive, radical potential of the figure of transformative non-normative gender is muffled by the onê-personality's positioning within variety television as a friendly expert of extraordinary and often comical proportions. Language is one of the key sites where the tensions of critical expertise and queerness are negotiated via synthetic friendship and comic relief. In lifestyle media, onê-kyara-kotoba (queen-personality-talk) is juxtaposed with conventional Japanese and emerging practices of digital orthography. This social practice of writing effectively facilitates the contemporary fetish of the onê (queen), and the consumption of homosexual and trans-gendered lifestyle experts selling the promise of heteronormative romantic love.
Major curriculum and assessment reforms in Australia have generated research interest in issues related to standards, teacher judgement and moderation. This article is based on one related inquiry of ...a large-scale Australian Research Council Linkage project conducted in Queensland. This qualitative study analysed interview data to identify teachers' views on standards and moderation as a means to achieving consistency of teacher judgement. A complementary aspect of the research involved a blind review that was conducted to determine the degree of teacher consistency without the experience of moderation. Empirical evidence was gained that most teachers, of the total interviewed, articulated a positive attitude towards the use of standards in moderation and perceived that this process produces consistency in teachers' judgements. Context was identified as an important influential factor in teachers' judgements and it was concluded that teachers' assessment beliefs, attitudes and practices impact on their perceptions of the value of moderation practice and the extent to which consistency can be achieved.
This study analyses four women’s speech from Kobe who were interviewed by the same researcher in 1989 and in 2000. We focused on highly indexical pragmatic youth language features (discourse markers ...and end‐rising intonation) to understand about societal pressures that young women in Japan face when transitioning into adulthood. The analysis reveals a complex picture; some women use them more as time goes by, while others use them less. The vast ethnographic information helps us to understand their persona style (Eckert 2008), and to have an insight into their linguistic capital (Bourdieu and Boltanski 1978, Woolard 2008).
Summary Objective To explore the reasons why nursing staff use the subjective “worried” Medical Emergency Team (MET) calling criterion and compare the outcomes of calls activated using the “worried” ...criterion with those calls activated using “objective” criteria such as vital sign abnormalities. Methods A descriptive study of MET calls in six acute hospitals over a 12 months period. Outcomes for “objective” and “worried” calls were compared. Results The “worried” criterion was used to activate 29% of 3194 MET calls studied; it was the single most common reason for a MET call. Half (51.7%) of the “worried” calls were related to problems with Airway, Breathing, Circulation or Neurology. ‘Breathing’ problems accounted for the largest proportion (35.2%). A low oxygen saturation by pulse oximetry (SpO2 ) ( n = 249, 26.9%) and ‘respiratory distress’ ( n = 133, 14.4%) were the most common reasons for a “worried” call. Only 1.1% (10) of calls triggered by the “worried” criteria had cardiac arrest as an outcome compared with 170 calls (7.6%) for “objective” criteria. The proportion of patients who remained in a general ward area after MET calls was higher for the “worried” calls. Conclusions The “worried” criterion was the most frequent reason for MET calls, implying a high degree of empowerment and independent action by nursing staff. Low SpO2 and respiratory distress were the most common causes for concern. There was a significant difference between MET calls triggered by “worried” criteria and “objective” criteria for outcomes immediately following MET ( p < 0.001). Further assessment and refinement of MET triggers particularly in relation to respiratory distress and pulse oximetry may be needed.
This article explores the under-studied gender dimensions of immigrants' civic life by focusing on the role of ethnic Chinese women in community-led volunteering in Victoria, Australia. It integrates ...population-based cross-sectional data from the 2016 Australian Census and qualitative data gathered from ethnographic fieldwork conducted from 2016 to 2019. Census data identifies a more salient presence of ethnic Chinese women than ethnic Chinese men in civic life. Our interviews demonstrate that these women's civic participation remains patterned and constrained by heteronormative gender norms which extend beyond the private sphere and the workplace to civic life. These empirical findings challenge both the overly optimistic presumption that equates civic presence of migrant women with civic empowerment or emancipation and the overly pessimistic presumption of them as inactive or marginalised civic actors. Taking a relational approach, the article argues that civic engagement among women from ethnic and migrant backgrounds should be studied in relation to, rather than isolated from, divergent gendered experiences in the labour market and domestic sphere.
Representations of gender and sexuality in mainstream media operate to both shape the contours of, and contest the limits to, sexual citizenship. The ‘citational practices’ of media representations ...mould contemporary understandings of these limits. In this article, the author examines mainstream and social media reports of two separate same-sex wedding ceremonies in Japan; the first at a queer community event in 2007 and the second at a major theme park in 2013. Through citations and quotations, a multitude of voices are embedded in the media texts. In the 2007 case, increased media visibility is mitigated by citational practices that clearly mark the same-sex wedding as devoid of legal standing. Whereas media reports situate the 2013 ceremony in the context of marriage equality trends internationally, an instance of possible discrimination is emphasised as being a ‘misunderstanding’. Similarly, a microanalysis of a light news documentary of the ceremony uncovers citational practices that highlight the importance of ‘forgiveness’ or ‘tolerance’ for ‘mutual coexistence’ in society. Furthermore, the reporting confines the ceremony to a ‘fairytale’-like ‘foreign’ domain. The process of ‘othering’ issues of sexual citizenship is linked to a cyclical process since the 1950s wherein representations of queerness are posited as ‘new’ forms of being in Japan. Discourse surrounding sexual citizenship is thereby projected into a non-domestic, non-specific future time.
AsiaPacifiQueer Fran Martin, Peter Jackson, Mark McLelland, Audrey Yue / Fran Martin, Peter Jackson, Mark McLelland, Audrey Yue
10/2008
eBook
This interdisciplinary collection examines the shaping of local sexual cultures in the Asian Pacific region in order to move beyond definitions and understandings of sexuality that rely on Western ...assumptions. The diverse studies in AsiaPacifiQueer demonstrate convincingly that in the realm of sexualities, globalization results in creative and cultural admixture rather than a unilateral imposition of the Western values and forms of sexual culture. These essays range across the Pacific Rim and encompass a variety of forms of social, cultural, and personal expression, examining sexuality through music, cinema, the media, shifts in popular rhetoric, comics and magazines, and historical studies. By investigating complex processes of localization, interregional borrowing, and hybridization, the contributors underscore the mutual transformation of gender and sexuality in both Asian Pacific and Western cultures._x000B__x000B_Contributors are Ronald Baytan, J. Neil C. Garcia, Kam Yip Lo Lucetta, Song Hwee Lim, J. Darren Mackintosh, Claire Maree, Jin-Hyung Park, Teri Silvio, Megan Sinnott, Yik Koon Teh, Carmen Ka Man Tong, James Welker, Heather Worth, and Audrey Yue.
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