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Heart Disease and Stroke Prevention: Clinical Decision-Support Systems (CDSS)


What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on evidence from a broad systematic review (Bright et al. 2012, search period January 1976-January 2011) that examined the effectiveness of CDSS in improving quality of care and clinical outcomes for a variety of conditions (e.g., CVD prevention, cancer screening, immunization, antenatal care). From this broad review, CDSS studies focused on CVD prevention were identified (39 studies) and combined with evidence from an updated search (6 studies, search period January 2011-October 2012).

The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice and policy related to cardiovascular disease prevention.

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 294 KB].

  • CDSS led to modest improvements for three CVD-related quality-of-care outcomes associated with provider practices. When compared with usual care
    • Screening and preventive care services completed or ordered increased by a median of 3.8 percentage points (17 studies)
    • Clinical tests completed or ordered increased by a median of 4.0 percentage points (7 studies)
    • Treatments prescribed increased by a median of 2.0 percentage points (11 studies)
  • Eight studies implemented CDSS in combination with other approaches such as team-based care and patient-reminders. When compared with usual care, large improvements were reported for the following quality-of-care outcomes:
    • CDSS-prompted screening and preventive care services ordered
    • CDSS-prompted clinical tests completed or ordered by providers
  • Results from the broad systematic review, which examined the effectiveness of CDSS across a variety of conditions and related risk factors, found improvements for all three quality-of-care outcomes (e.g., cardiovascular disease prevention, cancer screening, immunization).

Summary of Economic Evidence

More details about study results are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 294 KB].

An overall conclusion about the economic effectiveness of CDSS cannot be reached due to limited evidence on cost and economic benefit.


Based on the settings and populations from included studies, the CPSTF finding should be applicable to the following:

  • U.S. healthcare system
  • Outpatient, primary care settings
  • Patients with multiple CVD risk factors

Evidence Gaps

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

  • How effective are longer-term programs that account for issues associated with initial integration of CDSS with clinical workflow?
  • How effective are CDSS in real-world settings?
  • What is the impact of CDSS on cardiovascular disease risk factor outcomes (e.g., blood pressure, cholesterol, and diabetes outcomes) and morbidity and mortality?
  • Are CDSS effective with different healthcare providers (i.e., other than physicians), including nurses and pharmacists?
  • How do CDSS effect patient-centered outcomes and patient involvement in decision-making?
  • Do CDSS reduce health disparities and improve patient satisfaction with care?
  • How well do CDSS, used in combination with other interventions, overcome barriers at the patient, provider, organizational, and community levels?
  • What is the impact of CDSS when used within a multicomponent approach to improve the efficiency of healthcare delivery?
  • How effective are CDSS that include public health recommendations?

Study Characteristics

  • CDSS were added to pre-existing EHRs in about one-third of included studies.
  • In most studies, CDSS were designed to do the following:
    • Prompt providers without user requests for information, meaning the prompts were 'system-initiated' (82% of included studies)
    • Deliver decision support during patient visits ‘synchronously,’ as part of the clinical workflow (84% of included studies)
  • Most studies (95%) evaluated CDSS in outpatient, primary care settings, many of which were run by group practices that had multiple primary care centers.
  • Many studies had large patient populations (median: 1,189).
  • Studies evaluated CDSS that were targeted at a variety of CVD risk factors such as high blood pressure, diabetes, and high cholesterol.