Effect of computerised, knowledge-based, clinical decision support systems on patient-reported and clinical outcomes of patients with chronic disease managed in primary care settings: a systematic review

1 El AsmarMline, etal. BMJ Open 2021;11:e054659. doi:10.1136/bmjopen-2021-054659 Open access Effect of computerised, knowledgebased, clinical decision support systems on patientreported and clinical outcomes of patients with chronic disease managed in primary care settings: a systematic review Marie line El Asmar ,1 Kanika I Dharmayat,2 Antonio J Vallejo- Vaz,3,4,5 Ryan Irwin,6 Nikolaos Mastellos7 To cite: El AsmarMline, DharmayatKI, Vallejo- VazAJ, etal. Effect of computerised, knowledgebased, clinical decision support systems on patientreported and clinical outcomes of patients with chronic disease managed in primary care settings: a systematic review. BMJ Open 2021;11:e054659. doi:10.1136/ bmjopen-2021-054659 ►Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2021- 054659). RI and NM contributed equally. Received 23 June 2021 Accepted 22 November 2021 For numbered affiliations see end of article. Correspondence to Dr Marie line El Asmar; me719@ ic. ac. uk Original research © Author(s) (or their employer(s)) 2021. Reuse permitted under CC BYNC. No commercial reuse. See rights and permissions. Published by BMJ. ABSTRACT Objectives Chronic diseases are the leading cause of disability globally. Most chronic disease management occurs in primary care with outcomes varying across primary care providers. Computerised clinical decision support systems (CDSS) have been shown to positively affect clinician behaviour by improving adherence to clinical guidelines. This study provides a summary of the available evidence on the effect of CDSS embedded in electronic health records on patientreported and clinical outcomes of adult patients with chronic disease managed in primary care. Design and eligibility criteria Systematic review, including randomised controlled trials (RCTs), cluster RCTs, quasi- RCTs, interrupted time series and controlled before- and- after studies, assessing the effect of CDSS (vs usual care) on patientreported or clinical outcomes of adult patients with selected common chronic diseases (asthma, chronic obstructive pulmonary disease, heart failure, myocardial ischaemia, hypertension, diabetes mellitus, hyperlipidaemia, arthritis and osteoporosis) managed in primary care. Data sources Medline, Embase, CENTRAL, Scopus, Health Management Information Consortium and trial register clinicaltrials. gov were searched from inception to 24 June 2020. Data extraction and synthesis Screening, data extraction and quality assessment were performed by two reviewers independently. The Cochrane risk of bias tool was used for quality appraisal. Results From 5430 articles, 8 studies met the inclusion criteria. Studies were heterogeneous in population characteristics, intervention components and outcome measurements and focused on diabetes, asthma, hyperlipidaemia and hypertension. Most outcomes were clinical with one study reporting on patientreported outcomes. Quality of the evidence was impacted by methodological biases of studies. Conclusions There is inconclusive evidence in support of CDSS. A firm inference on the intervention effect was not possible due to methodological biases and study heterogeneity. Further research is needed to provide evidence on the intervention effect and the interplay between healthcare setting features, CDSS characteristics and implementation processes. PROSPERO registration number CRD42020218184. INTRODUCTION Noncommunicable chronic diseases are the leading cause of disability and mortality worldwide, affecting one in three adults globally.1 Rising healthcare expenditure because of chronic disease prevalence has led to an evergrowing demand for effective primary care services for the longterm management of chronic conditions.2–4 Considering that Strengths and limitations of this study ►In contrast to other reviews, this review focuses on interventions involving clinical decision support systems (CDSS) that are knowledgebased, are embedded within electronic health record systems, provide electronic alerts and are used by physicians in primary care. ►The electronic search strategy was piloted, and hand searching of reference lists of previous reviews permitted a sufficient level of confidence that all relevant articles were included. ►Some limitations arose related to studies being of 1- year duration on average, making it difficult to deduce longterm effects on patient outcomes. ►The scope of the review was restricted to nine chronic diseases; however, the selection included the most common chronic diseases; yet, there were no eligible studies in five of them. ►The included studies were of low- to- moderate quality of evidence, and heterogeneity among the included studies limited the ability to conduct a metaanalysis. Protected by copyright. on December 1, 2022 at USE/Fac Medicina Biblioteca FME.http://bmjopen.bmj.com/BMJ Open: first published as 10.1136/bmjopen-2021-054659 on 22 December 2021. Downloaded from Protected by copyright. on December 1, 2022 at USE/Fac Medicina Biblioteca FME.http://bmjopen.bmj.com/BMJ Open: first published as 10.1136/bmjopen-2021-054659 on 22 December 2021. Downloaded from Protected by copyright. on December 1, 2022 at USE/Fac Medicina Biblioteca FME.http://bmjopen.bmj.com/BMJ Open: first published as 10.1136/bmjopen-2021-054659 on 22 December 2021. Downloaded from Protected by copyright. on December 1, 2022 at USE/Fac Medicina Biblioteca FME.http://bmjopen.bmj.com/BMJ Open: first published as 10.1136/bmjopen-2021-054659 on 22 December 2021. Downloaded from Protected by copyright. on December 1, 2022 at USE/Fac Medicina Biblioteca FME.http://bmjopen.bmj.com/BMJ Open: first published as 10.1136/bmjopen-2021-054659 on 22 December 2021. 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BMJ Open 2021;11:e054659. doi:10.1136/bmjopen-2021-054659 Open access health systems have mainly adapted to providing periodic care for acute problems, an even greater need to achieve efficient, comprehensive and coordinated longterm care persists.5 Models such as the chronic care model have been proposed to improve the quality of care in chronic care systems.6 This model recommends ‘decision support’ as one of six applicable changes in primary care settings that promote better patient outcomes, if successfully implemented.6–8 Within this and other models of primary care and chronic condition management, clinicians are encouraged to provide patient care according to evidencebased clinical practice guidelines (CPGs) to support improved patient outcomes.9 10 Given the frequent updates to CPGs resulting from rapid advancements in medical knowledge, a major challenge is the maintenance of clinicians’ knowledge of evidencebased CPGs.10 Consequently, clinicians’ adherence to CPGs may be variable and frequently insufficient, which may result in suboptimal disease management outcomes.10 11 Clinical decision support is an umbrella term that includes various care structures, processes and tools.12 Clinical decision support systems (CDSS) range from noncomputerised to computerised systems and basic to advanced systems.12 13 Currently, most attention is driven toward computerised advanced CDSS, which perform complex decisionmaking functions from electronic health record (EHR) patient data.12 Such systems are termed knowledgebased, as they use software algorithms to generate actionable patientspecific outputs in the form of recommendations to the practitioner using conditional (IF–THEN) rule statements derived from CPGs.14 15 They also differ in their technical and clinical interface, whether passive (providing userinitiated prompts to generate clinical advice, eg, by clicking buttons) or active (automatic systeminitiated prompts).12 16 17 CDSS also differ in system–user communication, which could be of consulting nature (ie, provide appropriate ‘nextsteps’ clinical recommendations) or of critiquing nature (verify decisions taken by practitioners).12 16 Given the differences in interfaces, the scope of this review includes computerised, knowledgebased CDSS embedded in EHRs that are of either passive or active, consulting or critiquing, nature. Although CDSS are ubiquitous, few have been successfully adopted.18 Previous reviews appraised the efficacy of different types of CDSS in primary care, presenting a greater consensus on the useful role of CDSS on practitionerrelated outcomes such as guideline adherence.19–23 However, the impact of CDSS on patient outcomes remains largely uncertain.19–23 Bryan et al demonstrated a positive association between the use of CDSS in primary care and patient outcomes.23 However, a need to further evaluate the effect of CDSS on patient outcomes was identified, particularly in primary care and specifically for chronic disease management. The novel focus of this review is in the combined focus on the effect of computerised, knowledgebased, CDSS and their effect on patientreported and clinical outcomes of patients and with chronic disease and managed in primary care settings. This particular focus was chosen to inform more specific and efficacious implementation strategies in primary care management of chronic disease and attract the industry’s consideration of CDSS use in primary care settings, which a more generalised focus on multiple care settings, multiple diseases beyond just chronic disease or lack of focus on patientreported outcomes may not achieve. There remains a need to assess the capabilities of CDSS in distinctive clinical professional areas and disease entities, particularly on patient outcomes.18 A recent review on EHR- embedded CDSS focused on process delivery (practitioner outcomes) and was not limited to primary care settings and chronic conditions.24 Despite obvious heterogeneity, clinically meaningful improvements in care processes were shown.24 However, it was unclear under what clinical circumstances these improvements could be replicated in every clinical context to affect clinical outcomes presumptively.24 In this systematic review, patient outcomes refer to quantifiable clinical biomarkers such as glycated haemoglobin (HbA1c) and lowdensity lipoprotein cholesterol (LDL- C) levels, clinical outcomes such as mortality and morbidity, and patientreported outcomes, such as healthrelated quality of life. To the best of our knowledge, and in the view of rapid upgrades in the world of CDSS, no review exists solely on the effect of CDSS embedded within EHRs on patient outcomes for patients with chronic disease managed in primary care. This review aims to fill this knowledge gap by collating all the available evidence on this classification of CDSS. METHODS Study design and eligibility criteria A systematic review of the existing literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guidelines.25 26 The research question, inclusion and exclusion criteria were defined using the PICOS framework.27 Nine common chronic diseases were selected as part of the inclusion criteria, following a review by Reynolds et al28 namely asthma, chronic obstructive pulmonary disease (COPD), heart failure, myocardial ischaemia, hypertension, type 2 diabetes mellitus (T2DM), hyperlipidaemia, arthritis and osteoporosis. Studies reporting on patientrelated and clinical outcomes managed by primary care clinicians using CDSSEHR compared with usual care were included. Studies involving participants<18 years of age, multidisciplinary (nonclinician) system users, and other varieties of CDSS (not linked with EHR) were excluded. A detailed view of the criteria is provided in online supplemental table 1. Figure 1 depicts an analytic framework of the intervention adapted from a framework published by Lobach et al.22 The framework provides a theoretical context for possible features that could underpin the success, or lack of success, of a complex intervention such as Protected by copyright. on December 1, 2022 at USE/Fac Medicina Biblioteca FME.http://bmjopen.bmj.com/BMJ Open: first published as 10.1136/bmjopen-2021-054659 on 22 December 2021. Downloaded from 3 El AsmarMline, etal. BMJ Open 2021;11:e054659. doi:10.1136/bmjopen-2021-054659 Open access implementing CDSS in a primary care setting. The framework guided the extraction of relevant data from studies to inform the narrative synthesis. Search strategy Electronic databases Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL) and Health Management Information Consortium, and one clinical trial registry ( clinicaltrials. gov), were searched from inception to 24 June 2020. Cochrane reviews were screened for relevant search terms and subject headings (MeSH) terms under the following categories ‘registries supported by CDSS’ AND ‘General Practice/Primary care’ OR each of the nine chronic diseases combined with AND ‘Asthma’, ‘heart failure/myocardial ischaemia’, ‘hypertension’, ‘diabetes mellitus’, ‘hyperlipidaemia’, ‘COPD’, ‘arthritis’, ‘osteoporosis’ (online supplemental tables 2 and 3). The search was limited to articles in English. Terms for patientreported outcome measures (PROM) were excluded. Existing PROM filters are not comprehensive, and the use of those filters in the search strategy could increase the risk of missing relevant studies.29 However, we manually screened papers to identify any ‘patientreported outcomes’ measured in studies. PROM may be described in various ways; thus, attempting to list specific patient outcomes for each entity could introduce bias and lead to missing relevant studies. Previous systematic reviews around CDSS in primary care were also searched for potentially eligible studies.19–21 23 24 Study screening and selection Search results were exported to RefWorks, then screened using Covidence. After removal of duplicates, screening was conducted by two reviewers independently (MLEA and KID). Disagreements were resolved by consensus within the review group. After an initial screening of titles and abstracts, the full text of potentially relevant articles was assessed. Data extraction A data extraction form was adapted using the ‘Cochrane data collection form for intervention reviews: randomised Figure 1 Analytic framework. CDSS, clinical decision support system; CPGs, clinical practice guidelines; EHR, electronic health record. Protected by copyright. on December 1, 2022 at USE/Fac Medicina Biblioteca FME.http://bmjopen.bmj.com/BMJ Open: first published as 10.1136/bmjopen-2021-054659 on 22 December 2021. Downloaded from 4El AsmarMline, etal. BMJ Open 2021;11:e054659. doi:10.1136/bmjopen-2021-054659 Open access controlled trials (RCTs) and non- RCTs’ and aided by Lobach et al’s data abstraction guidance.30 31 The form was piloted and two reviewers (MLEA and KID) completed data extraction independently. Quality assessment of individual studies Risk of bias (RoB) was assessed using the Cochrane RoB tool,32 33 by two reviewers independently (MLEA and KID). The methodological RoB was assessed per the following elements in RCTs: selection bias, performance bias, detection bias, attrition bias, reporting bias and other biases.33 34 Quasi- RCTs were reported as high risk for random sequence generation. Cluster RCTs were assessed for an additional element ‘selective recruitment of cluster participants’. All judgements were made with guidance from the Cochrane Handbook and the guidelines of the Cochrane Consumers and Communication Review Group.33–35 Studies were considered as high risk if they scored ‘high’ or ‘unclear’ for either random sequence generation or allocation concealment, based on the rising evidence that these two elements are particularly significant sources of bias.34 A summary ‘RoB’ figure was generated for all risk assessments of elements with a narrative commentary for each study. Additionally, a detailed adapted table was generated to visualise subelements that fit under each element in the Cochrane RoB tool.34 Quality assessment of outcomes The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool was used to assess the quality of outcomes from individual studies.36 The tool involves five elements: RoB, inconsistency, indirectness, imprecision and publication bias. The tool is primarily used for metaanalyses; however, it can be adapted for use in narrative reviews. Study outcomes were appraised, ranked as high, moderate, low or very low and justifications were provided, in line with Cochrane guidance.37 Data synthesis Treatment effect was reported as ORs with 95% CIs and p values for dichotomous outcomes, where available. Continuous data were presented as mean differences with 95% CIs and p values. Heterogeneity in the results was anticipated due to the wide spectrum of possible patientrelated outcomes reported by the studies. Methodological heterogeneity was assessed using Cochrane RoB tool. Heterogeneity in included studies varied in terms of intervention components, population characteristics and outcome measurements; thus, conducting a metaanalysis was deemed not appropriate by the fourperson author group. Patient and public involvement No patients were involved. RESULTS The search identified 5430 articles. Following removal of duplicates, 4498 articles remained for screening by title and abstract. Of these, 266 articles were selected for fulltext review and 10 articles met the inclusion criteria. Among them, two articles were published protocols of included articles; thus, eight different studies were finally included. The detailed search results are presented in the PRISMA flowchart (figure 2). Study characteristics Characteristics of included studies are presented in table 1. Included studies comprised of patients in four disease areas: T2DM, asthma, hyperlipidaemia and hypertension.38–45 No studies on COPD, heart failure, myocardial ischaemia, arthritis and osteoporosis were identified. Six studies were cluster RCTs, one study was parallelgroup RCT and one was quasi- RCT of steppedwedge design. Most studies were conducted in the USA, and three studies took place in the UK, Spain and Belgium. Studies, both among the disease conditions and within each disease entity, differed appreciably in participant covariates, setting attributes and CDSS characteristics. These factors, compounded with the heterogeneity of the studies (as described in the Methods section) suggested that the reported outcomes were not fit for statistical pooling; hence, these factors justified not conducting a metaanalysis. Followup ranged from 6 months to 1.5 years. No study incorporated financial reimbursement before the implementation of interventions. Further details are presented in table 1. CDSS characteristics CDSS interventions were characterised based on their origin (commercial/local), delivery mode (user or systeminitiated), user response (optional/mandatory), events (system functions), coupled EHR and auxiliary features (local clinician involvement in system development process, system accessibility to other team members, provision of performance feedback or coupled with user education). Additional information such as user training, user adherence and reported usability was recorded. Details are provided in table 2. RoB and quality of the evidence Online supplemental tables 4 and 5 provide risk assessments details. Overall, the included studies were impacted by RoB, mainly due to incomplete outcome data and uncertainty on blinding of outcome assessment and personnel. In most studies, it was unclear if outcome assessors were blinded. Additionally, blinding of physicians (CDSS users) was not possible across all studies, as they were the intended system users. Most studies reported substantial withdrawal rates due to poor followup. These limitations resulted in analysing subgroups (rather than the initially intended full cohorts) in some trials; hence, most studies were considered of high risk for incomplete outcome data. Protected by copyright. on December 1, 2022 at USE/Fac Medicina Biblioteca FME.http://bmjopen.bmj.com/BMJ Open: first published as 10.1136/bmjopen-2021-054659 on 22 December 2021. Downloaded from 5 El AsmarMline, etal. BMJ Open 2021;11:e054659. doi:10.1136/bmjopen-2021-054659 Open access Overall, quality of the evidence was rated as either moderate or low, with the most impact resulting from methodological risks of bias within studies. Online supplemental table 6 presents the quality of evidence evaluated using GRADE, with reasons stated for quality downgrading. Narrative synthesis Diabetes mellitus Three studies assessed the effect of CDSS on clinical and patientreported outcomes in patients with T2DM.38–40 Gill et al retrieved slight, yet statistically significant, reduced HbA1c and LDL- C with the CDSS intervention compared with the control group, with a small betweengroup difference in HbA1c and LDL- C levels of 0.12% and 3.57 mg/dL, respectively (table 3).39 The reported reductions in HbA1c and LDL- C were clinically small; however, statistically, the intervention group had 52% higher odds of achieving personalised HbA1c levels, 56% higher odds of achieving HbA1c <7.0% and 34% higher odds of achieving an LDL- C <100 mg/dL compared with usual care patients over 1 year of followup. Nevertheless, compared with the control group, the intervention group had bettercontrolled baseline levels of HbA1c and LDL- C. The study by Gill et al involved systeminitiated ‘push’ CDSS, which were integrated into EHRs already operating at participating practices. Reported limitations were of EHRCDSS interoperability difficulties, which resulted in missing patient lab values.39 Other missing lab values also resulted from patients not returning for lab tests. In view of these limitations, a subset of randomised Figure 2 PRISMA flowchart detailing the systematic search results. CDSS, clinical decision support systems; CENTRAL, Cochrane Central Register of Controlled Trials; HMIC, Health Management Information Consortium; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta- Analyses. Protected by copyright. on December 1, 2022 at USE/Fac Medicina Biblioteca FME.http://bmjopen.bmj.com/BMJ Open: first published as 10.1136/bmjopen-2021-054659 on 22 December 2021. Downloaded from 6El AsmarMline, etal. BMJ Open 2021;11:e054659. doi:10.1136/bmjopen-2021-054659 Open access Table 1 Characteristics of included studies Study Disease Study design Duration Sponsorship Setting Condition identification from EHR Participants Comparability Target outcomesIntervention Control Age Sex Disease severity Schnipper et al38 USA T2DM RCT 6 months The Agency for Healthcare Research and Quality Partners HealthCare System, 10 practices at Brigham and Women’s Hospital and Massachusetts General Hospital (academic) NS 3431 patients 3578 patients Comparable IG: more females (statistically significant) Comparable Patients meeting management goals Gill et al39 USA T2DM Cluster RCT 1 year Sanofi, USA Primary care practices in Delaware and Maryland (community) ICD- 9CM EHR code 5 offices 29 PCPs 4484 patients Analysed (by subgroups): HbA1c: 2041 patients LDL- C: 2793 patients 5 offices 23 PCPs 1902 patients Analysed (by subgroups): HbA1c: 723 patients LDL- C: 931 patients Overall: 18–75 IG: older (statistically significant) Comparable IG: better glycaemic control, lower LDL- C HbA1c and LDL- C Heselmans et al40 Belgium T2DM Cluster RCT 1 year None Belgian primary care practices using OneHealth EHR (community) ICPC- 2 EHR code or confirming lab tests 25 offices 60 PCPs Analysed: 14 offices 21 PCPs 1351 patients 26 offices 60 PCPs Analysed: 15 offices 31 PCPs 2464 patients Overall: ≥18 years IG: older (significant statistically) CG: more females (statistically significant) Comparable for: mean HbA1c, mean BP, % patients meeting target for HbA1c, BP and LDL- C HbA1c, LDL- C and BP Eccles et al41 UK Asthma and angina Cluster RCT 1 year UK NHS research and development General practices in northeast England (community) Asthma or angina EHR code in prior 12 months Asthma: 31 offices Angina: 29 offices Angina: 29 offices Asthma: 31 offices ≥18 years; no details presented NS NS Quality of life and conditionspecific outcomes Gill et al42 US Hyperlipidaemia Cluster RCT 1 year None MQIC of primary care practices across the country (academic and community) Identified as having LDL levels recorded in EHR 12 offices 49 PCPs 26 696 patients 13 offices 56 PCPs 37 454 patients Overall: 20–79 years CG younger CG: more males (statistically significant) CG lower disease risk LDL- C Cobos et al43 Spain Hyperlipidaemia Cluster RCT 1 year Novartis General practices in Catalonia Identified as having TC between 200 mg/dL and 400 mg/dL 20 offices 1046 patients 22 offices 1145 patients Overall: 18–94 years CG: more females (statistically significant) Comparable Lipid values Hicks et al44 USA Hypertension Cluster RCT 1.5 years The Agency of Healthcare Research and Quality Primary care practices affiliated with the Brigham and Women’s Hospital Identified as having two or more hypertensionrelated outpatient visits using EHR codes 7 offices 786 patients 7 offices 1048 patients Comparable Comparable: >20 years IG: significantly higher % of patients with controlled BP at first visit BP control Lopez et al45 USA Hypertension Non- RCT 1 year (2016) Centre for Disease Control Primary care practices in New York Identified as having at least 1 ICD code for hypertension in EHR 7 offices 7 offices 18–85 years NS NS BP control BP, blood pressure; CG, control group; EHR, electronic health record; HbA1c, glycated haemoglobin; ICD, International Classification of Diseases; ICPC- 2, International Classification of Primary Care, 2nd edition; IG, intervention group; LDL- C, lowdensity lipoprotein cholesterol; MQIC, medical quality improvement consortium; NS, not stated; PCPs, primary care physicians; RCT, randomised controlled trial; TC, total cholesterol; T2DM, type 2 diabetes mellitus. Protected by copyright. on December 1, 2022 at USE/Fac Medicina Biblioteca FME.http://bmjopen.bmj.com/BMJ Open: first published as 10.1136/bmjopen-2021-054659 on 22 December 2021. Downloaded from 7 El AsmarMline, etal. BMJ Open 2021;11:e054659. doi:10.1136/bmjopen-2021-054659 Open access Table 2 CDSS characteristics of interventions in included studies Study Disease Origin Delivery mode User response Events Guidelines Integrated EHR (name) User training User adherence Usability Auxiliary features Schnipper et al38 Diabetes mellitus Commercial Userinitiated Optional ►Requests missing data. ►Alerts outputs of assessments of clinical care. ►Recommends orders for medication changes, laboratory studies, appointments and referrals NS Longitudinal medical record Brief instructions at start monthly tips Tracked use by clinician and sent customised emails Used for 5.6% of eligible patients Local user involvement in development process Gill et al39 Diabetes mellitus Commercial Systeminitiated Optional ►Generates reports for patientspecific recommendations American diabetes Association; European Association for the study of diabetes and ICD 9 coding Multiple EHRs (previously employed) Not provided Qualitatively assessed through informal interviews 4/5 practices reported use Recommendations also received by nonclinicians in care team Heselmans et al40 Diabetes mellitus Commercial Userinitiated Unclear ►Alerts for reminders, therapeutic suggestions and diagnosisspecific guideline links Belgian and International Guidelines HealthOne Not provided Not assessed Not assessed None Eccles et al41 Asthma and angina Local Systeminitiated (4 months) then altered to userinitiated Optional ►Alerts management and prescription options and patient referrals NS AAH Meditel or EMIS systems 1- day training Measured by a usage log Median number of system interactions was 0 Education on system guidelines Gill et al42 Hyperlipidaemia Commercial Systeminitiated Optional ►Alerts for overdue lipid tests. ►Alerts if patient has not met personalised lipid goals. ►Generates disease risk categories ATPIII guidelines Electronic medical record (centricity) 1- year familiarity with system Not measured Not measured Generates a list of patients who have not met lipid goals, outside office visits. Listed patients were sent a letter at the start and after 6 months of the study Cobos et al43 Hyperlipidaemia Local Systeminitiated Optional ►Recommends therapeutic options. ►Recommends followups. ►Recommends lab testing ESCHM Not specified None Monitored by CDSS 71% None Hicks et al (2008)44 Hypertension Local Systeminitiated Optional Alerts for therapeutic options AHA/ACC 2001 guidelines Not specified None Assessed prescription of a recommended drug class within 1 week of clinic visit NS None Lopez et al45 Hypertension Local Systeminitiated Optional ►Alerts for missing BP readings ►Alerts for therapeutic options JNC- 7 guidelines eClinicalWorks or MD Land 2- day training at start, 7 training sessions during second year and adhoc sessions as needed Semistructured interviews Reported all practices have used all CDSS components Generates reports of patients by status to manage visits AHA/AAC, American Heart Association/American College of Cardiology; ATPIII, Adult Treatment Panel- III; CDSS, clinical decision support systems; EHR, electronic health record; ESCHM, The European Society of Cardiology and other societies for Hypercholesterolemia Management; ICD, International Classification of Diseases; JNC- 7, The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; NS, not stated. Protected by copyright. on December 1, 2022 at USE/Fac Medicina Biblioteca FME.http://bmjopen.bmj.com/BMJ Open: first published as 10.1136/bmjopen-2021-054659 on 22 December 2021. Downloaded from 8El AsmarMline, etal. BMJ Open 2021;11:e054659. doi:10.1136/bmjopen-2021-054659 Open access Table 3 The effects of CDSS on patient health outcomes Study Disease Outcome Outcome definition Absolute effects Relative effects Conclusions QualityIntervention Usual care Schnipper et al38 Diabetes Odds of patients meeting management goals at the end compared with baseline Targets undefined Not reported ITT: OR=1.02; 95% CI 0.99 to 1.04, p value not reported. PP: OR=1.16; 95% CI 1.08 to 1.25, p<0.001 Intention- to- treat: nonsignificant odds of intervention patients meeting management goals compared with control patients at 6 months. Per Protocol: significant odds of intervention patients meeting management goals compared with control patients after followup period ⊕⊕◯◯ Low Gill et al (2017)39 Diabetes Difference in A1c from baseline. Difference in LDL- C from baseline. Odds of patients achieving A1c and LDL- C goals HbA1c goals:<7% and <7.5% in patients with microvascular complications. LDL- C goals:<100 mg/dL Difference in HbA1c from baseline: −0.08%±1.15%. Difference in LDL- C from baseline: −4.35±24.54 mg/dL Difference in HbA1c from baseline: −0.14%±1.51%. Difference in LDL- C from baseline: −1.70±26.16 mg/dL Adjusted HbA1c betweengroup difference (%): 0.12%, 95% CI 0.02 to 0.22; p=0.02. Adjusted LDL- C betweengroup difference (mg/dL): 3.57 mg/dL, 95% CI 1.80 to 5.34, p<0.0001. Odds of achieving personalised HbA1c goals: aOR=1.52, 95% CI 1.24 to 1.86, p<0.0001. Odds of achieving HbA1c <7%: 1.56, 95% CI 1.27 to 1.91, p<0.0001. Odds of achieving HbA1c ≤9%: 1.07, 95% CI 0.75 to 1.52, p=0.71. Odds of achieving LDL- C<100 mg/dL: 1.34; 95% CI 1.11 to 1.61, p=0.002 Clinically small, yet statistically significant betweengroup reductions in HbA1c and LDL- C ⊕⊕⊕◯ Moderate Heselmans et al40 Diabetes Mean change of HbA1c. Mean change in BP. Mean change in LDL- C levels NA Not reported Betweengroup difference in HbA1c means: −0.09%, 95% CI − 0.18 to 0.01, p=0.06. Betweengroup change difference in SBP: 0.13% (95% CI −0.91 to 1.16, p=0.81. Betweengroup change difference in DBP: 0.12% (95% CI −1.25 to 1.49, p=0.86. Betweengroup change difference in LDL- C: 1.76% (95% CI −0.46 to 3.98, p=0.12 No significant changes in betweengroup means for HbA1c, BP or LDL- C ⊕⊕⊕◯ Moderate Continued Protected by copyright. on December 1, 2022 at USE/Fac Medicina Biblioteca FME.http://bmjopen.bmj.com/BMJ Open: first published as 10.1136/bmjopen-2021-054659 on 22 December 2021. Downloaded from 9 El AsmarMline, etal. BMJ Open 2021;11:e054659. doi:10.1136/bmjopen-2021-054659 Open access Study Disease Outcome Outcome definition Absolute effects Relative effects Conclusions QualityIntervention Usual care Eccles et al41 Asthma and angina Patientreported outcomes using generic measures: The Short Form 36 Health Survey Questionnaire (SF- 36) and European Quality of Life Five Dimension (EQ- 5D). Conditionspecific measures: the Seattle Angina Questionnaire and the Newcastle Asthma Symptoms Questionnaire Not reported No effect on any patient outcome ⊕⊕⊕◯ Moderate Gill et al42 Hyperlipidaemia The percentage of patients whose most recent LDL- C was at goal (%) Defined by the ATPIII guidelines LDL goals: <100 for highrisk, <130 for moderate risk and <160 for low risk patients High risk: Baseline: 50% End: 53.3% P<0.001 Moderate risk: Baseline: 64.1% End: 64.7% P>0.1 Low risk: Baseline: 88.5% End: 87.9% P<0.05 High risk: Baseline: 52.3% End: 56.1% P<0.001 Moderate risk: Baseline: 67.1% End: 68.5% p<0.001 Low risk: Baseline: 90.2% End: 90.9% P<0.001 High risk: OR=1.17 (95% CI not reported), p<0.05. Moderate risk: OR=0.29 (95% CI not reported), p<0.05. Low risk: OR=1.74 (95% CI not reported), p<0.05 A significant increase in proportion of patients attaining goals for all categories except the moderaterisk IG. No significant difference in improvement in any category compared with the CG ⊕⊕◯◯ Low Cobos et al43 Hyperlipidaemia Betweengroup differences in means of lipid values (mg/dL) NA TC: 233.8 LDL- C: 149.2 HDL- C: 58.0 Triglycerides: 136.6 TC: 231.0 LDL- C: 146.5 HDL- C: 56.3 Triglycerides: 135.2 Difference, 95% CI, P value TC: −2.8 (–1.7 to –7.3), 0.218 LDL- C: −2.7 (–1.7 to –7.1), 0.227 HDL- C: −1.6 (–0.6 to –3.6), 0.142 Triglycerides: −1.4 (–8.3 to –11.2), 0.766 No impact detected on final lipid values ⊕⊕⊕◯ Moderate Hicks et al44 Hypertension Absolute effects: Percentage of patients with controlled BP (%). Mean baseline and end SBP and DBP Relative effects: Odds of BP control at outcome visit Baseline and end difference in SBP and DBP Controlled BP: <130/80 mm Hg for patients with diabetes or renal failure <140/90 mm Hg for other patients 48% baseline SBP: 136 mm Hg End SBP: 138 mm Hg Baseline DBP: 78 mm Hg End DBP: 77 mm Hg 45% baseline SBP:138 mm Hg End SBP: 137 mm Hg Baseline DBP: 80 mm Hg End DBP: 78 mm Hg OR: 0.96 Baseline betweengroup difference in SBP: 2 mm Hg, p =0.59 Baseline betweengroup difference in DBP: 2 mm Hg, p=0.07 End betweengroup difference in SBP: 0 mm Hg, p=0.67 End betweengroup difference DBP: 1 mm Hg, p=0.05 No differences between IGs in mean SBP or DBP readings at (end) outcome visits ⊕⊕◯◯ Low Lopez et al45 Hypertension Relative effects: odds of BP control postintervention Controlled BP:<140/90 mm Hg for all patients Not reported OR=1.36, 95% CI 1.08 to 1.71, p=0.009 Significant odds of improvement of BP in the IG compared with usual care ⊕⊕◯◯ Low aOR, adjusted OR; ATPIII, Adult Treatment Panel- III; BP, blood pressure; CG, control group; DBP, diastolic blood pressure; HbA1c, glycated haemoglobin; HDL- C, highdensity lipoprotein cholesterol; IG, intervention group; LDL- C, lowdensity lipoprotein cholesterol; LDL- C, lowdensity lipoprotein cholesterol; SBP, systolic blood pressure; TC, total cholesterol. Table 3 Continued Protected by copyright. on December 1, 2022 at USE/Fac Medicina Biblioteca FME.http://bmjopen.bmj.com/BMJ Open: first published as 10.1136/bmjopen-2021-054659 on 22 December 2021. Downloaded from 2 Supplementary Table 2: List of search terms CDSS terms Dashboard*, registry, clinical decision support system*, medical order entry system*, computeri?ed physician order entry system*, CPOE, order set*, computer assisted decision making, (computer$ adj3 decision$), knowledge management system*, case-finding algorithm*, advisory decision support, (computer* adj2 therap*) AND General Practice/Primary care general practi*, family practice, family clinic*, family practi*, family physician*, family doctor*, primary care physician*, primary care clinic*, primary care practi*, OR each of the below individual entities combined with AND Chronic Disease Entities Asthma asthma*, antiasthma*, wheez*, (bronch* adj3 spasm*), bronchoconstrict*, (bronch$ adj3 constrict$), ((bronchial$ or respiratory or airway$ or lung$) adj3 (hypersensitiv$ or hyperreactiv$ or allerg$ or insufficiency)), Heart Failure/ Myocardial Ischemia (heart* adj2 decomp*), ((heart* or cardiac* or myocard*) adj2 (fail* or insuff* or infarct* or ishcem* or disease*)), ((heart* or cardiac* or myocard*) adj2 (fail* or insuff* or infarct* or ishcem* or disease*)) Hypertension ((elevat$ or increas$ or lower or high or rais$ or rising) adj2 (arterial pressure or blood pressure or diastolic pressure or systolic pressure)), hypertens$ or prehypertens$), Diabetes Mellitus (IDDM or T2DM or T2D), (insulin* depend* or insulin?depend*)., (non insulin* depend* or noninsulin* depend* or non insulin?depend* or noninsulin?depend*)., diabet*. Hyperlipidemia LDL, (dyslipid?emia* or lipoprotein* or dyslipidprotein?emia* or hyperlipoprotein?emia), (hyperlipid?emia* or cholesterol* or lip?emia* or hypercholesterol?emia* or hypercholester?emia* or hyperlip?emia* or triglycerid* or hypertriglycerid?emia*)., COPD (COPD or COAD or COBD or AECB), ((obstruct$ adj3 lung$) or (obstruct$ adj 3 airway$)), (obstruct$ adj3 pulmonary), (chronic* adj3 bronchiti*), emphysema*., Arthritis Osteoarthritis, undifferentiated oligoarthritis, ((rheumatoid or reumatoid or revmatoid or rheumatic or reumatic or revmatic or rheumat$ or reumat$ or revmarthrit$) adj3 (arthrit$ or artrit$ or diseas$ or condition$ or nodule$))., (joint pain or chronic joint symptoms or gonarthrosis or osteoarthrosis or astoarthrosis or degeneretive arthritis or joint diseases or arthralgia), Osteoporosis Densitometry, osteopenia, bone mass, bone densit*, osteoporos?s, (osteoporosis or osteopenia or (bone and (density or mass or loss)) or hepatic osteodystrophy), BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline 3 Supplementary Table 3 - Full Search Strategy Full Medline Search Strategy 1 Dashboard*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating subheading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (1228) 2 registry.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating subheading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (109312) 3 registries.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating subheading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (104552) 4 exp Registries/ (95452) 5 1 or 2 or 3 or 4 (173943) 6 exp Decision Support Systems, Clinical/ (7925) 7 clinical decision support system*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (2132) 8 medical order entry system*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (2297) 9 computeri?ed physician order entry system*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (224) 10 CPOE.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating subheading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (1113) 11 order set*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating subheading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (1009) 12 exp Decision Making, Computer-Assisted/ (144386) 13 computer assisted decision making.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (76) 14 (computer$ adj3 decision$).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (4723) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline 4 15 knowledge management system*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (109) 16 case-finding algorithm*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (84) 17 advisory decision support.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (1) 18 exp Therapy, Computer-Assisted/ (63908) 19 (computer* adj2 therap*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (8758) 20 exp Reminder Systems/ (3443) 21 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 (159108) 22 5 or 21 (331941) 23 exp Asthma/ (127501) 24 asthma*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating subheading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (179286) 25 antiasthma*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating subheading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (1458) 26 exp Respiratory Sounds/ (12994) 27 wheez*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating subheading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (13724) 28 exp Bronchial Spasm/ (4303) 29 (bronch* adj3 spasm*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (4523) 30 exp Bronchoconstriction/ (4131) 31 bronchoconstrict*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (11491) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline 5 32 (bronch$ adj3 constrict$).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (715) 33 exp Bronchial Hyperreactivity/ (7348) 34 exp Respiratory Hypersensitivity/ (154474) 35 ((bronchial$ or respiratory or airway$ or lung$) adj3 (hypersensitiv$ or hyperreactiv$ or allerg$ or insufficiency)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating subheading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (66254) 36 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 (261794) 37 exp Heart Failure/ (120835) 38 (heart* adj2 decomp*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (4261) 39 ((heart* or cardiac* or myocard*) adj2 (fail* or insuff* or infarct* or ishcem* or disease*)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (664015) 40 ((heart* or cardiac* or myocard*) adj2 (fail* or insuff* or infarct* or ishcem* or disease*)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (664015) 41 exp Myocardial Ischemia/ (428216) 42 exp Coronary Disease/ (216812) 43 37 or 38 or 39 or 40 or 41 or 42 (842183) 44 exp Hypertension/ (253393) 45 exp Essential Hypertension/ (2255) 46 (hypertens$ or prehypertens$).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (510526) 47 ((elevat$ or increas$ or lower or high or rais$ or rising) adj2 (arterial pressure or blood pressure or diastolic pressure or systolic pressure)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (63244) 48 44 or 45 or 46 or 47 (537839) 49 exp Diabetes Mellitus/ (423542) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline 6 50 diabet*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating subheading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (693674) 51 (non insulin* depend* or noninsulin* depend* or non insulin?depend* or noninsulin?depend*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (12372) 52 (insulin* depend* or insulin?depend*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (29531) 53 (IDDM or T2DM or T2D).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (37329) 54 exp Diabetes Mellitus, Type 2/ (132230) 55 49 or 50 or 51 or 52 or 53 or 54 (697363) 56 exp Hyperlipidemias/ (65918) 57 exp Dyslipidemias/ (79414) 58 exp Cholesterol/ (159670) 59 (hyperlipid?emia* or cholesterol* or lip?emia* or hypercholesterol?emia* or hypercholester?emia* or hyperlip?emia* or triglycerid* or hypertriglycerid?emia*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (389543) 60 (dyslipid?emia* or lipoprotein* or dyslipidprotein?emia* or hyperlipoprotein?emia*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (209412) 61 LDL.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating subheading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (101128) 62 56 or 57 or 58 or 59 or 60 or 61 (479855) 63 exp Pulmonary Disease, Chronic Obstructive/ (55377) 64 exp Lung Diseases, Obstructive/ (210481) 65 emphysema*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (35893) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline 7 66 (chronic* adj3 bronchiti*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (11493) 67 (obstruct$ adj3 pulmonary).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (67392) 68 ((obstruct$ adj3 lung$) or (obstruct$ adj 3 airway$)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (24368) 69 (COPD or COAD or COBD or AECB).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (46979) 70 63 or 64 or 65 or 66 or 67 or 68 or 69 (256014) 71 exp Arthritis/ (258204) 72 exp Osteoarthritis/ (62805) 73 osteoarthritis.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (88630) 74 exp Joint Diseases/ (378029) 75 exp Arthralgia/ (13069) 76 (joint pain or chronic joint symptoms or gonarthrosis or osteoarthrosis or astoarthrosis or degeneretive arthritis or joint diseases or arthralgia).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (49768) 77 ((rheumatoid or reumatoid or revmatoid or rheumatic or reumatic or revmatic or rheumat$ or reumat$ or revmarthrit$) adj3 (arthrit$ or artrit$ or diseas$ or condition$ or nodule$)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (176792) 78 undifferentiated oligoarthritis.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (36) 79 71 or 72 or 73 or 74 or 75 or 76 or 77 or 78 (466351) 80 exp Osteoporosis/ (55499) 81 (osteoporosis or osteopenia or (bone and (density or mass or loss)) or hepatic osteodystrophy).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline 8 word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (229156) 82 osteoporos?s.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (86861) 83 exp Bone Density/ (52984) 84 bone densit*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (70284) 85 exp Bone Demineralization, Pathologic/ (652) 86 exp Bone Diseases, Metabolic/ (76180) 87 bone mass.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating subheading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (18851) 88 osteopenia.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating subheading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (9555) 89 exp Densitometry/ (34775) 90 densitometry.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (20649) 91 80 or 81 or 82 or 83 or 84 or 85 or 86 or 87 or 88 or 89 or 90 (266936) 92 exp General Practitioners/ (7841) 93 exp General Practice/ (74873) 94 general practi*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (91362) 95 exp Physicians, Family/ (16348) 96 exp Family Practice/ (65161) 97 family practice.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (68324) 98 family clinic*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (470) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline 9 99 family physician*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (14677) 100 family practi*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (69798) 101 family doctor*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (4649) 102 primary care physician*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (19694) 103 primary care clinic*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (7532) 104 exp Physicians, Primary Care/ (3421) 105 primary care practi*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (7576) 106 92 or 93 or 94 or 95 or 96 or 97 or 98 or 99 or 100 or 101 or 102 or 103 or 104 or 105 (180127) 107 22 and 106 (4326) 108 91 and 107 (50) 109 79 and 107 (76) 110 70 and 107 (184) 111 62 and 107 (206) 112 55 and 107 (568) 113 48 and 107 (239) 114 43 and 107 (343) 115 36 and 107 (148) 116 108 or 109 or 110 or 111 or 112 or 113 or 114 or 115 (1211) 117 from 116 keep 1-1211 (1211) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline 10 Full Embase Search Strategy 1 Dashboard*.mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (2390) 2 registry.mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (208322) 3 registries.mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (39715) 4 exp register/ (115531) 5 1 or 2 or 3 or 4 (266586) 6 exp clinical decision support system/ (3039) 7 clinical decision support system*.mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (4672) 8 medical order entry system*.mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (136) 9 computeri?ed physician order entry system*.mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (362) 10 CPOE.mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (1664) 11 order set*.mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (2621) 12 exp decision support system/ (25185) 13 computer assisted decision making.mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (116) 14 (computer$ adj3 decision$).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (2950) 15 knowledge management system*.mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (141) 16 case-finding algorithm*.mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (141) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline 11 17 advisory decision support.mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (1) 18 exp computer assisted therapy/ (15163) 19 (computer* adj2 therap*).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (5331) 20 exp reminder system/ (2611) 21 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 (48813) 22 5 or 21 (314449) 23 exp asthma/ (275547) 24 asthma*.mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (309894) 25 antiasthma*.mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (9548) 26 exp abnormal respiratory sound/ (60406) 27 wheez*.mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (33727) 28 exp bronchospasm/ (27974) 29 (bronch* adj3 spasm*).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (861) 30 exp bronchoconstriction/ (29996) 31 bronchoconstrict*.mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (12976) 32 (bronch$ adj3 constrict$).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (1187) 33 exp bronchus hyperreactivity/ (12410) 34 exp respiratory tract allergy/ (316133) 35 ((bronchial$ or respiratory or airway$ or lung$) adj3 (hypersensitiv$ or hyperreactiv$ or allerg$ or insufficiency)).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] (55027) 36 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 (435382) 37 22 and 36 (3673) 38 exp heart failure/ (531445) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline 18 62. Arthritis/ or exp Rheumatoid arthritis/ 63. exp Joint diseases/ or exp Bone diseases/ 64. (joint pain or chronic joint symptoms or gonarthrosis or osteoarthrosis or astoarthrosis or degeneretive arthritis or joint diseases or arthralgia).mp. [mp=title, other title, abstract, heading words] 65. ((rheumatoid or reumatoid or revmatoid or rheumatic or reumatic or revmatic or rheumat$ or reumat$ or revmarthrit$) adj3 (arthrit$ or artrit$ or diseas$ or condition$ or nodule$)).mp. [mp=title, other title, abstract, heading words] 66. ((rheumatoid or reumatoid or revmatoid or rheumatic or reumatic or revmatic or rheumat$ or reumat$ or revmarthrit$) adj3 (arthrit$ or artrit$ or diseas$ or condition$ or nodule$)).mp. [mp=title, other title, abstract, heading words] 67. undifferentiated oligoarthritis.mp. [mp=title, other title, abstract, heading words] 68. 60 or 61 or 62 or 63 or 64 or 65 or 66 or 67 69. exp Osteoporosis/ 70. (osteoporosis or osteopenia or (bone and (density or mass or loss)) or hepatic osteodystrophy).mp. [mp=title, other title, abstract, heading words] 71. osteoporos?s.mp. [mp=title, other title, abstract, heading words] 72. bone densit*.mp. [mp=title, other title, abstract, heading words] 73. bone mass.mp. [mp=title, other title, abstract, heading words] 74. osteopenia.mp. [mp=title, other title, abstract, heading words] 75. densitometry.mp. [mp=title, other title, abstract, heading words] 76. 69 or 70 or 71 or 72 or 73 or 74 or 75 77. exp General practitioners/ 78. exp General practice/ 79. general practi*.mp. [mp=title, other title, abstract, heading words] 80. family clinic*.mp. [mp=title, other title, abstract, heading words] 81. family practi*.mp. [mp=title, other title, abstract, heading words] 82. family physician*.mp. [mp=title, other title, abstract, heading words] 83. family doctor*.mp. [mp=title, other title, abstract, heading words] 84. primary care physician*.mp. [mp=title, other title, abstract, heading words] 85. primary care clinic*.mp. [mp=title, other title, abstract, heading words] 86. primary care practi*.mp. [mp=title, other title, abstract, heading words] 87. 77 or 78 or 79 or 80 or 81 or 82 or 83 or 84 or 85 or 86 88. 20 and 87 89. 31 and 88 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline 19 90. 37 and 88 91. 38 or 39 or 40 92. 88 and 91 93. 46 and 88 94. 52 and 88 95. 59 and 88 96. 68 and 88 97. 76 and 88 98. 89 or 90 or 92 or 93 or 94 or 95 or 96 or 97 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline 20 Full Scopus Search Strategy ( ( "Dashboard" OR "registry" OR "registries" OR "clinical decision support system" OR "medical order entry system" OR "CPOE" OR "decision support system" OR "computer assisted decision making" OR "case-finding algorithm" OR "advisory decision support" OR "computer assisted therapy" ) AND ( "general practi*" OR "family practi*" OR "family clinic*" OR "family physician" OR "family doctor" OR "primary care clinic*" OR " primary care physician" ) ) AND ( ( "asthma*" "wheez*" OR "bronchus hyperreactivity" OR "heart failure" OR "heart insufficiency" OR "cardiac failure" OR " cardiac insufficiency" OR "myocardial infarction" OR "myocardial insufficiency" OR "myocardial ischemia" OR "cardiac disease" OR "coronary artery disease" ) OR ( "diabet*" OR ( "non insulin* depend*" OR "noninsulin* depend*" OR "non insulin depend*" OR "noninsulin?depend*" ) OR "IDDM" OR "T2DM" OR "T2D" ) OR ( "hyperlipidemia" OR "dyslipidemia" OR "hyperlipid?emia*" OR "cholesterol*" OR "lip?emia*" OR "hypercholesterol?e mia*" OR "hypercholester?emia*" OR "hyperlip?emia*" OR "triglycerid*" OR "hypertriglycerid?emia*" OR "dyslipid?emia*" OR "lipoprotein*" OR "dyslipidprotein?emia*" OR "hyperlipoprotein?emia*" OR "chronic obstructive lung disease" OR "emphysema*" OR ( ( "obstruct* N/3lung*" ) OR ( "obstruct* N/3 airway*" ) ) OR copd OR coad OR cobd OR aecb ) OR ( "hypertension" OR "Prehypertension" OR ( ( "elevat* OR increas* OR lower OR high OR rais* OR rising" ) W/2 ( "arterial pressure" OR "blood pressure" OR "diastolic pressure" OR "systolic pressure" ) ) ) OR ( "arthritis" OR "osteoarthritis" OR "joint pain" OR "chronic joint symptoms" OR "gonarthrosis" OR "osteoarthrosis" OR "arthrosis" OR "degeneretive arthritis" OR "joint diseases" OR "arthralgia" OR "rheumat*" OR "reumat*" OR "arthrit*" OR "artrit*" ) OR ( "osteopo rosis" OR "osteopenia" OR bone AND density AND loss OR "osteopenia" OR "bone mass loss" ) ) AND NOT INDEX ( medline ) AND ( LIMIT-TO ( SRCTYPE , "j" ) ) AND ( LIMIT- TO ( DOCTYPE , "ar" ) ) AND ( LIMIT-TO ( SUBJAREA , "MEDI" ) ) AND ( LIMIT- TO ( LANGUAGE , "English" ) ) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline 23 Risk of Bias Assessment: Type 2 Diabetes Mellitus Referring to Supplementary Tables 4 and 5, Schnipper et al was rated at 'low risk' for random sequence generation as a random number generation on Excel was used 1.Allocation concealment was rated as 'high' after considering the randomisation an open allocation method. Blinding of personnel was not cited. Thus, it was rated as unclear. There was no mention of withdrawals; hence, the risk was unclear for incomplete outcome reporting. All outcomes set be studied were reported, and no other risks related to study funding were detected. Gill et al's study was rated at 'high risk' for incomplete and selective outcome reporting due to analysing subgroups of patients for A1C and LDL-C for the narrated study limitations in the following section 2.Randomisation was at 'high risk' since clusters of practices were allocated based on the number of clinicians. Although the randomisation method could be considered open to predictability, eligibility criteria for patients within clusters of practices were pre-defined, which could not have been subverted by allocation knowledge. All other elements were considered at 'low risk.' Heselmans et al's study was at 'low risk' for all elements except incomplete outcome data due to the withdrawal of a significant number of practices, with less than 80% of practices remaining after randomisation for analysis3. Reasons for system concerns were attributed to withdrawals. 3.2.2 Risk of Bias Assessment: Asthma and Angina Referring to Supplementary Tables 4 and 5, the risk of bias in Eccles et al. 's study was 'low' for all elements due to the use of a computerised randomisation process and blinding of assessors4. However, less than 80% of eligible patients completed the provided questionnaires, which could have introduced attrition bias. Baseline characteristics of patients and practitioners were not sufficiently addressed, but there was a mention that participating practices were of similar size and training. Selective recruitment of clusters was adequately prevented by recruiting practices and enrolling all patients who met the inclusion criteria. Risk of Bias Assessment: Hyperlipidaemia Referring to Supplementary Tables 4 and 5, Cobos et al. 's study was rated at 'low-risk' for random sequence generation and allocation concealment due to the use of a random number table to randomise, which does not allow predictable sequences5. There was no mention of blinding of assessors, statisticians, or patients. Although <80% of randomised patients had follow-up visits and LDL-C follow-up tests, the study was rated as 'low risk' for attrition and reporting bias because the ITT analysis yielded insignificant outcomes as did the PP analyses. Study funding did not seem to introduce methodological bias since the outcome was patient-reported. Selective recruitment of clusters was adequately prevented by recruiting practices and enrolling all patients of randomised practices who met the inclusion criteria. Gill et al 's trial was rated at 'high risk' for random sequence generation but 'low risk' for allocation concealment due to randomising clusters of practices based on practice similarities, which is not preferable randomisation6. The Eligibility criteria for patients within clusters of practices were predefined, which could not have been subverted by allocation knowledge. Blinding of assessors and BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline 24 statisticians was not mentioned. The number of patients analysed was not reported. However, all outcomes set to be studied were undertaken. The first author is a consultant researcher at the company that holds the concerned EHR's licensing rights, but this conflict of interest did not seem to reflect in methodological risks. Similarly, selective recruitment of clusters was prevented. Risk of Bias Assessment: Hypertension Referring to Supplementary Tables 4 and 5, Hick's et al 's study was rated 'high risk' for random sequence generation, as clusters of practices were randomised by size and type of practice, which may not be a desirable method of randomisation 7. Although randomisation could have been open to predictability, patient eligibility criteria practices were pre-defined, which could not have been subverted by allocation knowledge. Thus, the study was rated at 'low risk' for allocation concealment. Blinding of assessors or patients was not mentioned. Thus, the study was rated 'unclear' for blinding participants and outcome assessments. Due to the high number of randomised patients that were withdrawn due to stated reasons, it was rated at 'high risk' for attrition bias. All outcomes were explored, and there was a 'low risk' for selective recruitment of cluster members. Lopez et al. 's study was rated at 'high risk' for random sequence generation and allocation concealment due to its non-randomised design8. There was no mention of blinding personnel, hence it was rated 'unclear' for blinding. There was no mention of withdrawals, and all outcomes were reported. Thus, it was rated as 'low risk' for attrition and selective outcome reporting. No other risks related to funding were significant. BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline 25 Supplementary Table 6: Quality of Evidence from individual studies evaluated using GRADE Study Outcome Risk of bias Level of inconsist -ency Level of indirect -ness Level of imprecise -on Public ation bias Quality Reason for downgrading Schnipper et al. (2010) Difference in proportion of patients meeting management goals at the end compared to the beginning of the study severe NA some low NA ⊕⊕◯◯ LOW RoB: High risk for allocation concealment and unclear whether personnel blinding occurred Indirectness: population identification and management goals were not pre-defined Gill et al. (2017) • Difference in HbA1c from baseline • Difference in LDL-C from baseline • % patients achieving HbA1c goals some NA low low NA ⊕⊕⊕◯ MODERATE RoB: High risk for random sequence generation and selective outcome reporting Heselmans et al. (2020) • Difference between the mean value of HbA1c, LDL-C, and blood pressure of the previous year at the moment of the study start and the mean value of HbA1c, LDL-C, and blood pressure of the previous year at 6 and 12 months. low NA some low NA ⊕⊕⊕◯ MODERATE Indirectness: patients had reasonable HbA1c mean values, which does not necessarily reflect diabetic populations with a higher severity of illness Eccles et al. (2002) Quality of life and condition specific outcomes using validated questionnaires some NA low low NA ⊕⊕⊕◯ MODERATE RoB: High risk for incomplete and selective outcome reporting Gill et al. (2009) The percentage of patients with most recent LDL-C at goal severe NA low low NA ⊕⊕◯◯ LOW RoB: High risk for random sequence generation and incomplete outcome data. Unclear for personnel blinding Cobos et al. (2006) • Between-group differences in means of lipid values some NA some low NA ⊕⊕⊕◯ MODERATE ROB: Unclear for blinding of personnel Indirectness: excludes general populations with more severe elevations of LDL Hicks et al. (2008) • Percentage of patients with controlled blood pressure • Odds of blood pressure control at outcome visit severe NA low low NA ⊕⊕◯◯ LOW RoB: High risk for random sequence allocation, incomplete outcome reporting and unclear for personnel blinding Lopez et al. (2019) • Odds of blood pressure control postintervention severe NA low low NA ⊕⊕◯◯ LOW RoB: NRCT, non-randomised and high risk for blinding of personnel BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline 26 References 1) Schnipper JL, Linder JA, Palchuk MB, et al. Effects of documentation-based decision support on chronic disease management. The American Journal of Managed Care. 2010; 16 (12 Suppl HIT) (pp SP72-81): ate of Pubaton: e 2010. 2) Gill J, Kucharski K, Turk B, Pan C, Wei W. Using Electronic Clinical Decision Support in Patient-Centered Medical Homes to Improve Management of Diabetes in Primary Care: The DECIDE Study. Journal of Ambulatory Care Management. 2019; 42 (2): 105-115. doi:10.1097/JAC.0000000000000267 3) Heselmans A, Delvaux N, Laenen A, Van de Velde S, Ramaekers D, Kunnamo I, et al. Computerized clinical decision support system for diabetes in primary care does not improve quality of care: a cluster-randomized controlled trial. Implementation science : IS. 2020; 15 (1): 5. doi:10.1186/s13012-019-0955-6 4) Eccles M, McColl E, Steen N, Liaw ST. Computerised evidence-based guidelines may not improve asthma or angina management in primary care. Evidence-Based Healthcare. 2003; 7 (2): 81-82. 5) Cobos A, Vilaseca J, Asenjo C, et al. Cost effectiveness of a clinical decision support system based on the recommendations of the European Society of Cardiology and other societies for the management of hypercholesterolemia: Report of a cluster-randomized trial. Disease Management and Health Outcomes. 2005; 13 (6): 421-432. doi:10.2165/00115677- 200513060-00007 6) Gill JM, Chen YX, Glutting JJ, et al. Impact of decision support in electronic medical records on lipid management in primary care. Population health management. 2009; 12 (5): 221-226. doi:10.1089/pop.2009.0003. doi:10.1089/pop.2009.0003 7) Hicks LS, Sequist TD, Ayanian JZ, et al. Impact of computerized decision support on blood pressure management and control: A randomized controlled trial. Journal of General Internal Medicine. 2008; 23 (4): 429-441. doi:10.1007/s11606-007-0403-1 8) Lopez PM, Divney A, Goldfeld K, et al. Feasibility and Outcomes of an Electronic Health Record Intervention to Improve Hypertension Management in Immigrant-serving Primary Care Practices. Medical care. 2019; 57 (Supplement 62) (pp S164-S171): ate of Pubaton: 01 Jun 2019. doi:10.1097/MLR.0000000000000994 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open doi: 10.1136/bmjopen-2021-054659:e054659. 11 2021;BMJ Open, et al. El Asmar Mline