Learning implementation of a guideline-based decision support system to improve hypertension management in primary care: a pragmatic cluster randomized controlled trial

Journal article

Objective:

To evaluate the effectiveness of a clinical decision support system (CDSS) in improving the use of guideline-accordant antihypertensive treatment in Chinese primary care settings.

Design:

Pragmatic, open-label, cluster randomized trial.

Setting:

94 primary care practices in four urban regions of China― Luoyang (Central China), Jining (East China), and Shenzhen (South China, including two regions), between August 2019 and July 2022.

Participants:

12,137 hypertensive participants (mean age 61±13 years; 42.5% women) taking up to 2 classes of antihypertensive medication and with systolic blood pressure (BP) <180 mmHg and diastolic BP <110 mmHg, were enrolled.

Interventions:

Primary care practices were randomized to use an electronic health record (EHR)-based CDSS which recommended a specific guideline-accordant regimen for initiation, titration, or switching of antihypertensive medication (the intervention), or to use the same EHR (without the CDSS) and provide treatment as usual (the control).

Main outcome measures:

The primary outcome was the proportion of hypertension visits during which an appropriate (guideline-accordant) treatment was provided. Secondary outcomes included the average reduction in systolic BP, and the proportion with controlled BP (<140/90 mmHg) at the last scheduled follow-up. Safety outcomes were patient-reported antihypertensive treatment-related events including syncope, injurious fall, symptomatic hypotension or systolic BP <90 mmHg, and bradycardia.

Results:

5755 participants who attended 23,113 visits in the intervention group (46 practices) and 6382 participants with 27,868 visits in the control group (48 practices) were included. During 11.6 months of follow-up, the proportion of visits at which appropriate treatment was given was higher in the intervention group than in the control group (77.8% vs. 62.2%; absolute difference of 15.2 percentage points [95% confidence interval 10.7 to 19.8], P<0.001; odds ratio 2.17 [95% confidence interval 1.75 to 2.69], P<0.001). Participants in the intervention group had a 1.6 mmHg greater reduction in systolic BP (-1.5mmHg vs. 0.3 mmHg; 95% confidence interval -2.7 to -0.5, P=0.006) and a 4.4 percentage point improvement in BP control rate (69.0% vs. 64.6%; 95% confidence interval -0.7 to 9.5, P=0.07) compared with those in the control group. In both groups, patient-reported antihypertensive treatment-related adverse effects were rare.

Conclusions:

The use of the CDSS for hypertension management improved guideline-accordant antihypertensive treatment and led to a modest reduction in BP. The CDSS offers a promising approach to delivering better hypertension care safely and efficiently.

Trial Registration:

ClinicalTrials.gov Identifier: NCT03636334

Authors: Song, J; Wang, X; Wang, B; Ge, Y; Bi, L

• Publication status: Published
• Peer review status: Peer reviewed
• Publisher: BMJ Publishing Group
• Journal: BMJ
• Volume: 386
• Article number: e079143
• Publication date: 2024-07-23
• Acceptance date: 2024-06-10
• DOI: 10.1136/bmj-2023-079143
• EISSN: 0959-8138
• ISSN: 1759-2151
• Language: English