Dexter PR et al. 1998 "Effectiveness of computer-generated reminders for increasing discussions about advance directives and completion of advance directive forms - a randomized, controlled trial."
Reference
Dexter PR, Wolinsky FD, Gramelspacher GP, et al. Effectiveness of computer-generated reminders for increasing discussions about advance directives and completion of advance directive forms: a randomized, controlled trial. Ann Intern Med 1998;128(2):102-112.
Abstract
"Background: Physicians can increase the rate of completion of advance directive forms by discussing directives with their patients, but the means by which physicians can be induced to initiate these discussions are unclear. Computer-generated reminders have been shown to increase physician compliance with practice guidelines.
Objective: To determine the effects of computer generated reminders to physicians on the frequency of advance directive discussions between patients and their primary caregivers and the frequency of consequent establishment of advance directives.
Design: Randomized, controlled trial with a 2 x 2 factorial design.
Setting: An outpatient general medicine practice associated with an urban public hospital.
Participants: Participants were 1) 1009 patients who were at least 75 years of age or were at least 50 years of age with serious underlying disease and 2) 147 primary care physicians (108 housestaff and 39 faculty).
Intervention: Computer-generated reminders that recommended discussion of one or both of two types of advance directives compared with no reminders.
Measurements: Discussions about advance directives, determined by patient interviews after all scheduled patient physician outpatient encounters, and completed advance directive forms. The study period was approximately 1 year.
Results: Physicians who did not receive reminders (controls) discussed advance directives with 4% of the study patients compared with 24% for physicians who received both types of reminders (adjusted odds ratio, 7,7 [95% Cl, 3,4 to 18]; P< 0, 001). Physicians who did not receive reminders completed advance directive forms with only 4% of their study patients compared with 15% for physicians who received both types of reminders (adjusted odds ratio, 7,0 [Cl, 2.9 to 17]; P< 0.001) - Overall, 45% of patients with whom advance directives were discussed completed at least one type of advance directive.
Conclusions: Simple computer-generated reminders aimed at primary caregivers can increase the rates of discussion of advance directives and completion of advance directive forms among elderly outpatients with serious illnesses."
Objective: To determine the effects of computer generated reminders to physicians on the frequency of advance directive discussions between patients and their primary caregivers and the frequency of consequent establishment of advance directives.
Design: Randomized, controlled trial with a 2 x 2 factorial design.
Setting: An outpatient general medicine practice associated with an urban public hospital.
Participants: Participants were 1) 1009 patients who were at least 75 years of age or were at least 50 years of age with serious underlying disease and 2) 147 primary care physicians (108 housestaff and 39 faculty).
Intervention: Computer-generated reminders that recommended discussion of one or both of two types of advance directives compared with no reminders.
Measurements: Discussions about advance directives, determined by patient interviews after all scheduled patient physician outpatient encounters, and completed advance directive forms. The study period was approximately 1 year.
Results: Physicians who did not receive reminders (controls) discussed advance directives with 4% of the study patients compared with 24% for physicians who received both types of reminders (adjusted odds ratio, 7,7 [95% Cl, 3,4 to 18]; P< 0, 001). Physicians who did not receive reminders completed advance directive forms with only 4% of their study patients compared with 15% for physicians who received both types of reminders (adjusted odds ratio, 7,0 [Cl, 2.9 to 17]; P< 0.001) - Overall, 45% of patients with whom advance directives were discussed completed at least one type of advance directive.
Conclusions: Simple computer-generated reminders aimed at primary caregivers can increase the rates of discussion of advance directives and completion of advance directive forms among elderly outpatients with serious illnesses."
Objective
To "determine the effects of computer-generated reminders to physicians on the frequency of advance directive discussions between patients and their primary caregivers and the frequency of consequent establishment of advanced directives."
Tools Used
Type Clinic
Primary care
Size
Large
Geography
Urban
Other Information
The study took place in "an academic primary care practice affiliated with an urban public teaching hospital" in Indiana.
Type of Health IT
Computerized clinical reminders (CRs) and alerts
Type of Health IT Functions
"All physicians routinely received computer-generated reminders for patients with scheduled visits. They were reminded to give preventive care, note abnormal test results, and avoid drug interactions. These reminders appeared at the bottom of computer-generated printed encounter forms. Physicians routinely reviewed the encounter forms and the practice chart immediately before visiting the patient... The advance directive reminders were followed by a choice list (discussed today, next visit, not applicable, patient too ill, patient refuses to discuss, I disagree with advance directives)."
Context or other IT in place
An electronic health records application (EHR) was already in place.
Workflow-Related Findings
"Patients whose physicians received reminders for both types of directives completed substantially more forms than did control patients and patients whose physicians received only proxy directive reminders. Patients whose physicians received only reminders for instruction directives also completed more forms than did control patients."
"The odds of having advance directive discussions was eight times higher among patients whose physicians received reminders for both types of directives than among patients whose physicians received no reminders."
"When discussions did occur, they were initiated by the physician in 86 percent of instances in the group that received reminders tor both types of directives, in 77 percent of instances in the instruction directive reminder group, in 43 percent of instances in the proxy directive reminder group, and in 38 percent of instances in the control group."
Study Design
Randomized controlled trial (RCT)
Study Participants
The study participants included 147 primary care physicians and 1,009 patients "who were at risk for acute deterioration" because they were 75 or more years of age or 50 or more years of age with "a serious underlying disease."