A computerized handheld decision-support system to improve pulmonary embolism diagnosis: a randomized trial.
BACKGROUND
Testing for pulmonary embolism often differs from that recommended by evidence-based guidelines.


OBJECTIVE
To assess the effectiveness of a handheld clinical decision-support system to improve the diagnostic work-up of suspected pulmonary embolism among patients in the emergency department.


METHODS
Cluster randomized trial. Assignment was by random-number table, providers were not blinded, and outcome assessment was automated. (ClinicalTrials.gov registration number: NCT00188032).


METHODS
20 emergency departments in France.


METHODS
1103 and 1768 consecutive outpatients with suspected pulmonary embolism.


METHODS
After a preintervention period involving 20 centers and 1103 patients, in which providers grew accustomed to inputting clinical data into handheld devices and investigators assessed baseline testing, emergency departments were randomly assigned to activation of a decision-support system on the devices (10 centers, 753 patients) or posters and pocket cards that showed validated diagnostic strategies (10 centers, 1015 patients).


METHODS
Appropriateness of diagnostic work-up, defined as any sequence of tests that yielded a posttest probability less than 5% or greater than 85% (primary outcome) or as strict adherence to guideline recommendations (secondary outcome); number of tests per patient (secondary outcome).


RESULTS
The proportion of patients who received appropriate diagnostic work-ups was greater during the trial than in the preintervention period in both groups, but the increase was greater in the computer-based guidelines group (adjusted mean difference in increase, 19.3 percentage points favoring computer-based guidelines [95% CI, 2.9 to 35.6 percentage points]; P = 0.023). Among patients with appropriate work-ups, those in the computer-based guidelines group received slightly fewer tests than did patients in the paper guidelines group (mean tests per patient, 1.76 [SD, 0.98] vs. 2.25 [SD, 1.04]; P < 0.001).


CONCLUSIONS
The study was not designed to show a difference in the clinical outcomes of patients during follow-up.


CONCLUSIONS
A handheld decision-support system improved diagnostic decision making for patients with suspected pulmonary embolism in the emergency department.
Roy
Pierre-Marie
PM
Centre Hospitalier Universitaire d'Angers and Université d'Angers, Angers, France. pmroy@chu-angers.fr
Durieux
Pierre
P
Gillaizeau
Florence
F
Legall
Catherine
C
Armand-Perroux
Aurore
A
Martino
Ludovic
L
Hachelaf
Mohamed
M
Dubart
Alain-Eric
AE
Schmidt
Jeannot
J
Cristiano
Mirko
M
Chretien
Jean-Marie
JM
Perrier
Arnaud
A
Meyer
Guy
G
D034201:Computers, Handheld; D020000:Decision Support Systems, Clinical; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence; D006801:Humans; D016013:Likelihood Functions; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000175:diagnosis*