Bloomfield H et al. 2005 "A trial of education, prompts, and opinion leaders to improve prescription of lipid modifying therapy by primary care physicians for patients with ischemic heart disease."
Reference
Bloomfield H, Nelson D, Van Ryn M, et al. A trial of education, prompts, and opinion leaders to improve prescription of lipid modifying therapy by primary care physicians for patients with ischemic heart disease. Br Med J 2005;14(4):258.
Abstract
"Background: Recent clinical trials indicate that treatment with lipid modifying therapy improves outcomes in patients with ischemic heart disease (IHD) and low levels of high density lipoprotein (HDL) cholesterol. The results of these trials, however, have not been widely implemented in clinical practice.
Objectives: To develop and test an intervention designed to increase the rate of prescription of lipid modifying therapy and to determine the relative effectiveness of three different prompts (progress notes, patient letters, or computer chart reminders). Methods: The study was conducted in 11 US Department of Veterans Affairs Medical Centers. The effect of the intervention on the proportion of eligible patients receiving lipid modifying therapy was compared between five intervention sites and six matched control sites using a controlled before and after study design. Additionally, 92 providers within the intervention clinics were randomized to receive one of the three prompts. Data were analyzed using logistic regression modeling which incorporated terms to account for the clustered nature of the data. Results: At the intervention sites the prescription rate increased from 8.3% during the pre-intervention period to 39.1% during the intervention (OR = 6.5, 95% CI 5.2 to 8.2, p<0.0001) but remained unchanged at the control sites. The interaction between group (control v intervention) and time period was highly significant (p<0.0001). The adjusted odds of receiving a prescription during the intervention period was 3.1 times higher at the intervention sites than at the control sites (95% CI 2.1 to 4.7). Overall, there was no significant difference in prescription rates among the three prompt groups. However, there was a significant interaction between prompt group and site, indicating that the efficacy of the prompts differed by site. Conclusion: An intervention for primary care providers consisting of an educational workshop, opinion leader influence, and prompts substantially increased the prescription rate of lipid modifying therapy."
Objectives: To develop and test an intervention designed to increase the rate of prescription of lipid modifying therapy and to determine the relative effectiveness of three different prompts (progress notes, patient letters, or computer chart reminders). Methods: The study was conducted in 11 US Department of Veterans Affairs Medical Centers. The effect of the intervention on the proportion of eligible patients receiving lipid modifying therapy was compared between five intervention sites and six matched control sites using a controlled before and after study design. Additionally, 92 providers within the intervention clinics were randomized to receive one of the three prompts. Data were analyzed using logistic regression modeling which incorporated terms to account for the clustered nature of the data. Results: At the intervention sites the prescription rate increased from 8.3% during the pre-intervention period to 39.1% during the intervention (OR = 6.5, 95% CI 5.2 to 8.2, p<0.0001) but remained unchanged at the control sites. The interaction between group (control v intervention) and time period was highly significant (p<0.0001). The adjusted odds of receiving a prescription during the intervention period was 3.1 times higher at the intervention sites than at the control sites (95% CI 2.1 to 4.7). Overall, there was no significant difference in prescription rates among the three prompt groups. However, there was a significant interaction between prompt group and site, indicating that the efficacy of the prompts differed by site. Conclusion: An intervention for primary care providers consisting of an educational workshop, opinion leader influence, and prompts substantially increased the prescription rate of lipid modifying therapy."
Objective
"To develop and test an intervention designed to increase the rate of prescription of lipid modifying therapy and to determine the relative effectiveness of three different prompts (progress notes, patient letters, or computer chart reminders)."
Tools Used
Type Clinic
Primary care
Size
Large
Geography
Urban and rural
Other Information
The intervention sites were 11 Veterans Administration (VA) medical centers in Minnesota, South Dakota and North Dakota. The control sites were in Des Moines, Wichita, Madison, Honolulu, Little Rock, and Charleston.
Type of Health IT
Computerized clinical reminders (CRs) and alerts
Type of Health IT Functions
"Prompts were generated only for patients in the study cohort who were not receiving a lipid medication. Patient letters were sent 1-2 weeks before the patient's visit... A cover letter with a brightly colored card gave information about lipid management for IHD patients and suggested that the patient should bring the letter and discuss its contents with his [primary care] provider at the beginning of his forthcoming visit... Chart reminders consisted of a short phrase that appeared on the cover page of the patient's computerized medical record in a box entitled 'reminders due'. This reminder was visible to the clinician when s/he opened a specific patient chart at the time of the visit... Progress notes consisted of a short message to the primary care clinician reminding him/her about the appropriate approach to the lipid management of the IHD patient with the target lipid profile. When the clinician logged onto the computerized patient record system s/he encountered a screen that included a 'notifications' box. In this box was a message [sent a few days before the patient's visit] stating that there was a progress note requiring co-signature on a particular patient. When the provider selected that notification, the progress note appeared."
Workflow-Related Findings
"The prescription rate increased from 8.3% during the preintervention period to 39.1% during the intervention (OR=6.5, 95% CI 5.2 to 8.2, p 0.0001) at the intervention sites." There was no significant difference in prescription rates at the control sites pre-post. "The adjusted odds of receiving a prescription during the intervention period was 3.1 times higher at the intervention sites than at the control sites (95% CI 2.1 to 4.7)."
"There was no statistically significant difference in prescription rates among the three prompt groups (40.7% for progress notes, 36.9% for patient letters, and 39.4% for reminders, p=0.60)."
"Reaction to the prompts was mixed. Only about half the providers agreed or strongly agreed that prompts positively influenced their lipid management and 40% found the prompts annoying. 14% believed that 'prompts of this kind do more harm than good'."
Study Design
Pre-postintervention (no control group)
Study Participants
The study participants included 92 providers within the intervention clinics that were randomized into three groups, each receiving a different type of prompt: progress notes, patient letters, and computer chart reminders. Also, the primary care physicians at the intervention clinics were given an educational workshop and opinion leaders were trained.