Rosenberg SN et al. 2008 "Supporting the patient's role in guideline compliance: a controlled study."

Rosenberg SN, Shnaiden TL, Wegh AA, et al. Supporting the patient's role in guideline compliance: a controlled study. Am J Manag Care 2008;14(11):737-744.
"Objective: Clinical messages alerting physicians to gaps in the care of specific patients have been shown to increase compliance with evidence-based guidelines. This study sought to measure any additional impact on compliance when alerting messages also were sent to patients.
Study Design: For alerts that were generated by computerized clinical rules applied to claims, compliance was determined by subsequent claims evidence (eg, that recommended tests were performed). Compliance was measured in the baseline year and the study year for 4 study group employers (combined membership >100,000) that chose to add patient messaging in the study year, and 28 similar control group employers (combined membership >700,000) that maintained physician messaging but did not add patient messaging.
Methods: The impact of patient messaging was assessed by comparing changes in compliance from baseline to study year in the 2 groups. Multiple logistic regression was used to control for differences between the groups. Because a given member or physician could receive multiple alerts, generalized estimating equations with clustering by patient and physician were used.
Results: Controlling for differences in age, sex, and the severity and types of clinical alerts between the study and control groups, the addition of patient messaging increased compliance by 12.5% (P <.001). This increase was primarily because of improved responses to alerts regarding the need for screening, diagnostic, and monitoring tests.
Conclusion: Supplementing clinical alerts to physicians with messages directly to their patients produced a statistically significant increase in compliance with the evidence-based guidelines underlying the alerts."
To "measure any additional impact on compliance [with evidence-based guidelines] when alerting messages were...sent to patients" in addition to physicians.
Tools Used
Type Clinic
Primary care
not applicable
Other Information
The study involved four study group employers with over 100,000 covered patients, and 28 control group employers with over 700,000 covered patients.
Type of Health IT
Computerized clinical reminders (CRs) and alerts
Type of Health IT Functions
The system uses a rule-based engine to identify patients with "discrepancies between the care that is actually being received (as reflected in claims and lab data) and the care that patients should be receiving according to the evidence-based literature." Alerts are sent to primary care physicians about these patients and "copies of the alerts, in lay language, are also mailed to their members - with a delay of 10 working days to allow physicians to contact their patients first, if they choose, or to indicate" that the alert is clinically inappropriate and should not be sent.
Context or other IT in place
Electronic medical records were in place with "frequently updated data that include[d] physician, hospital, outpatient facility, laboratory, pharmacy, and medical equipment claims; laboratory test results; information reported by patients on health risk a
Workflow-Related Findings
"Compliance with the alerts in the study group increased from 29.0% in the baseline year to 31.0% in the study year, while decreasing from 30.0% to 29.0% in the control group. Controlling for age, sex and the mix of alert severity levels and alert types, the addition of patient messaging increased compliance by 12.5% (p<.001)."
"Statistically significant impact was limited to alerts of severity 2 (serious but not life threatening) and 3 (routine monitoring and screening) and to those alerts recommending performance of a test."
"Our finding that the addition of patient messaging appeared to have its greatest impact on compliance with do-a-test alerts suggests that patient messages exerted most of their influence on the behavior of patients themselves, increasing the number who complied with physicians' orders that involved time-consuming or unpleasant actions (e.g., going to radiologists or laboratories for the performance of tests). Lack of a similar effect for patient alerts related to adding or stopping medications suggests that the significant effort by patients was less of a barrier to compliance with these types of recommendations, which are largely under the control of their physicians, and that patients urging their physicians to follow guidelines may not be an important factor."
Study Design
Pre-postintervention (no control group)
Study Participants
Patients who were sent clinical reminders and their physicians participated.