Samir Gupta

Purpose: Effective COPD management depends on structured symptom and risk assessment, individualized therapy, and action plan provision, yet these are inconsistently delivered in routine care. Electronic health record (EHR)-integrated clinical decision support systems (CDSSs) can help close these gaps but require accurate, structured patient data to drive their recommendations. Digital pre-visit questionnaires are increasingly used to collect such data, but patient preferences for their content and design remain poorly understood, particularly in COPD. Patients and Methods: We used a user-centered design process to develop an electronic COPD questionnaire to inform an EHR-integrated CDSS. Content was mapped to planned CDSS actions and built into a mobile-optimized prototype using eHealth design principles. We face validated the prototype with 10 people living with COPD, then refined it through successive focus groups until saturation. Usability was assessed with the System Usability Scale (SUS) and Likert ratings and transcripts were analyzed thematically. Results: Face validation (n=10) and three focus groups (n=13) were conducted to saturation. Four critical issues were identified and addressed. Usability was high throughout (mean SUS 88.07, "excellent”), with strong Likert ratings for functionality, navigation, and appearance. Thematic analysis yielded four themes: standardized measures versus real-life experience; usability and format as enablers; support for communication, memory, and efficient care; and desire for transparency and education. Conclusion: Through iterative co-design with older adults, we developed an EHR-integrated electronic COPD questionnaire with excellent usability and relevance to patients’ lived experience. Patients anticipated benefits beyond data capture: improved symptom recall, visit preparation, and provider efficiency. This is one of the first electronic COPD questionnaires developed through structured patient co-design and qualitative evaluation, providing a transferable model for tools that inform clinical decision support.

Smoking cessation reduces mortality and improves quality of life in chronic obstructive pulmonary disease (COPD). Brief physician counselling is effective

We previously built and validated the Electronic Asthma Management System (eAMS)-a clinic-based asthma computerized clinical decision support system (CDSS) which is in clinical use. Herein, we sought to adapt and optimize the eAMS for implementation in community pharmacy practice. We iteratively developed a system prototype (the eAMS-Pharm) with input from clinical pharmacists, and asthma, knowledge translation, and eHealth experts. After face-validation by three external community pharmacists, we used a rapid-cycle development process for optimization of system design (format), content, and user workflows (usability). This involved a sequential and repeated three-stage process: (1) system prototype demonstration and testing in 90 min, semi-structured virtual focus groups with target end-users; (2) analysis of focus group findings; and (3) corresponding modifications to the prototype, then re-testing in another focus group. This process continued until we reached pre-defined stopping criteria. We used a questionnaire to gather demographic information and further usability data and feedback. Community pharmacy team members were recruited from an existing pharmacy database. Stopping criteria were met after six focus group cycles with 28 participants [23 (83%) pharmacists, 4 (14%) registered pharmacy technicians/assistants, and 1 (3%) pharmacy student]. User feedback and corresponding system improvements spanned usability, workflow, and prescriber communication domains. The optimized system consisted of a pharmacy portal with a patient dashboard, patient and provider versions of a point-of-care questionnaire, an interactive CDSS producing guideline-based recommendations, automated documentation, and pre-formatted prescriber communications. The System Usability Scale score was 82.9 ± 16.8 (maximum 100), and user responses to Likert scale-based assessments of eAMS-Pharm design, content, workflow, impact, and overall impressions were highly favorable. We built and optimized a chronic disease CDSS for use in community pharmacies, identifying and addressing pharmacy-specific barriers to implementation. The system achieved a high system usability score and highly favorable ratings for perceived system benefits, likelihood of clinical use, and patient benefits. The eAMS-Pharm can now be evaluated for uptake, care impact, and outcome impact in real-world settings. Our findings surrounding users' design, content, and usability/workflow preferences, and our unique development strategy, can also inform future pharmacy-based chronic disease CDSS design.

COPD action plans (APs) are integral to self-management and recommended across clinical practice guidelines, but primary care provider and patient usage remain low. Given that uptake is influenced by content, format, and development methods, we sought to collect a broad sample of existing COPD APs and to analyze these characteristics. We collected English language COPD APs from: 1) an internet search; 2) international COPD guidelines; 3) pulmonary/COPD organizations and experts; and 4) published randomized controlled trials (RCTs) evaluating COPD APs. For each AP, we described background information, development methods and any available evaluation data. We used guideline-based and inductively-derived criteria for AP content analysis. For format analysis, we applied recognized evidence-based formatting standards for printed educational material. We also calculated the Flesch-Kincaid readability scores. We identified 63 unique COPD APs from seven countries. Information on the development methods was available in only seven (11%) APs, and only one included patients in development. 4/58 (7%) APs identified from sources other than RCTs had been formally evaluated (all as part of larger complex interventions). In AP content, we found inconsistency in definitions for the action point requiring treatment, in treatment instructions (eg medication options, doses, and duration), and in lifestyle/behavior change cues. Formatting across APs was also variable, and APs met a mean of only 5.4 ± 1.2 out of 8 core formatting principles for printed education material design. The average Flesch-Kincaid grade level was 6.5 ± 1.6. COPD APs are recommended across guidelines but are seldom implemented. Our novel analysis of internationally available COPD APs reveals that there are several intrinsic factors related to their development, evaluation, content, and format that may be contributing to this care gap. A uniform user preference-based COPD AP with expert consensus on content, and with usability/format optimization should be developed and evaluated.

Background: Computerized clinical decision support systems (CDSSs) can improve care by bridging knowledge to practice gaps. However, the real-world uptake of such systems in health care settings has been suboptimal. We sought to: (1) use the Theoretical Domains Framework (TDF) to identify determinants (barriers/enablers) of uptake of the Electronic Asthma Management System (eAMS) CDSS; (2) match identified TDF belief statements to elements in the Guideline Implementation with Decision Support (GUIDES) Checklist; and (3) explore the relationship between the TDF and GUIDES frameworks and the usefulness of this sequential approach for identifying opportunities to improve CDSS uptake. Methods: In Phase 1, we conducted semistructured interviews with primary care physicians in Toronto, Canada regarding the uptake of the eAMS CDSS. Using content analysis, two coders independently analyzed interview transcripts guided by the TDF to generate themes representing barriers and enablers to CDSS uptake. In Phase 2, the same reviewers independently mapped each belief statement to a GUIDES domain and factor. We calculated the proportion of TDF belief statements that linked to each GUIDES domain and the proportion of TDF domains that linked to GUIDES factors (and vice-versa) and domains. Results: We interviewed 10 participants before data saturation. In Phase 1, we identified 53 belief statements covering 12 TDF domains; 18 (34.0%) were barriers, and 35 (66.0%) were enablers. In Phase 2, 41 statements (77.4%) linked to at least one GUIDES factor, while 12 (22.6%) did not link to any specific factor. The GUIDES Context Domain was linked to the largest number of belief statements (19/53; 35.8%). Each TDF domain linked to one or more GUIDES factor, with 6 TDF domains linking to more than 1 factor and 8 TDF domains linking to more than 1 GUIDES domain. Conclusions: The TDF provides unique insights into barriers and enablers to CDSS uptake, which can then be mapped to GUIDES domains and factors to identify required changes to CDSS context, content, and system. This can be followed by conventional mapping of TDF domains to behaviour change techniques to optimize CDSS implementation. This novel step-wise approach combines two established frameworks to optimize CDSS interventions, and requires prospective validation.

Background and Aims: Hepatopulmonary syndrome (HPS) is a common complication of liver disease defined by abnormal oxygenation and intrapulmonary vascular dilatation, treated with liver transplantation. Little is known about changes in HPS physiological parameters over time. We sought to describe baseline clinical and physiological characteristics in HPS and their relationships, temporal changes in physiological parameters before and after transplant, and predictors of changes in oxygenation. Approach and Results: This was a retrospective cohort study in the Canadian HPS Program (n = 132). Rates of change after diagnosis were: −3.7 (−6.4, −0.96) mm Hg/year for partial pressure of arterial oxygen (PaO₂); −26 (−96, 44) m/year for 6-minute walk distance, and 3.3% (−6.6, −0.011) predicted/year for diffusion capacity. Noninvasive shunt of ≥ 20% predicted a slower PaO₂ decline by 0.88 (0.36, 1.4) mm Hg/month. We identified 2 PaO₂ deterioration classes—“very severe disease, slow decliners” (PaO₂ 45.0 mm Hg; −1.0 mm Hg/year); and “moderate disease, steady decliners” (PaO₂ 65.5 mm Hg; −2.5 mm Hg/year). PaO₂ increased by 6.5 (5.3, 7.7) mm Hg/month in the first year after transplant. The median time to normalization was 149 (116, 184) days. Posttransplant improvement in PaO₂ was 2.5 (0.1, 4.9) mm Hg/month faster for every 10 mm Hg greater pretransplant orthodeoxia. Conclusions: We present a large and long longitudinal data analysis in HPS. In addition to rates of physiological decline and improvement before and after liver transplantation, we present novel predictors of PaO₂ decline and improvement rates. Our findings enhance our understanding of the natural history of HPS and provide pathophysiologic clues. Importantly, they may assist providers in prognostication and prioritization before and after transplant.