Sequist T et al. 2005 "A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease."
Reference
Sequist T, Gandhi T, Karson A, et al. A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease. J Am Med Inform Assoc 2005;12(4):431-437.
Abstract
"Objective: The aim of this study was to evaluate the impact of an integrated patient-specific electronic clinical reminder system on diabetes and coronary artery disease (CAD) care and to assess physician attitudes toward this reminder system.
Design: We enrolled 194 primary care physicians caring for 4549 patients with diabetes and 2199 patients with CAD at 20 ambulatory clinics. Clinics were randomized so that physicians received either evidence-based electronic reminders within their patients' electronic medical record or usual care. There were five reminders for diabetes care and four reminders for CAD care.
Measurements: The primary outcome was receipt of recommended care for diabetes and CAD. We created a summary outcome to assess the odds of increased compliance with overall diabetes care (based on five measures) and overall CAD care (based on four measures). We surveyed physicians to assess attitudes toward the reminder system.
Results: Baseline adherence rates to all quality measures were low. While electronic reminders increased the odds of recommended diabetes care (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.01-1.67) and CAD (OR 1.25, 95% CI 1.01-1.55), the impact of individual reminders was variable. A total of three of nine reminders effectively increased rates of recommended care for diabetes or CAD. The majority of physicians (76%) thought that reminders improved quality of care.
Conclusion: An integrated electronic reminder system resulted in variable improvement in care for diabetes and CAD. These improvements were often limited and quality gaps persist."
Design: We enrolled 194 primary care physicians caring for 4549 patients with diabetes and 2199 patients with CAD at 20 ambulatory clinics. Clinics were randomized so that physicians received either evidence-based electronic reminders within their patients' electronic medical record or usual care. There were five reminders for diabetes care and four reminders for CAD care.
Measurements: The primary outcome was receipt of recommended care for diabetes and CAD. We created a summary outcome to assess the odds of increased compliance with overall diabetes care (based on five measures) and overall CAD care (based on four measures). We surveyed physicians to assess attitudes toward the reminder system.
Results: Baseline adherence rates to all quality measures were low. While electronic reminders increased the odds of recommended diabetes care (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.01-1.67) and CAD (OR 1.25, 95% CI 1.01-1.55), the impact of individual reminders was variable. A total of three of nine reminders effectively increased rates of recommended care for diabetes or CAD. The majority of physicians (76%) thought that reminders improved quality of care.
Conclusion: An integrated electronic reminder system resulted in variable improvement in care for diabetes and CAD. These improvements were often limited and quality gaps persist."
Objective
"To evaluate the impact of an integrated patient-specific electronic clinical reminder system on diabetes and coronary artery disease (CAD) care and to assess physician attitudes toward this reminder system" in an ambulatory primary care setting.
Tools Used
Type Clinic
Primary care
Size
Large
Geography
Urban
Other Information
The study took place at Partners HealthCare System which is affiliated with Brigham and Women's and Massachusetts General Hospitals. There are 255 primary care physicians practicing out of 20 clinics, which consist of four community health centers, nine hospital-based clinics, and seven offsite practices.
Type of Health IT
Computerized clinical reminders (CRs) and alerts
Type of Health IT Functions
"Each time that a clinician opened a patient chart within the [EMR], the algorithm for all reminders was run to determine whether the patient had received care in accordance with the recommended practice guidelines. This algorithm searched all laboratory and radiology results as well as the problem list, medication list, and allergy list... For clinicians in the intervention group, the appropriate reminders were then displayed within the main patient summary screen ... alongside other pertinent information such as the patient medication list and problem list." Paper reminders were also printed at 60 percent of the clinics and given to physicians at the beginning of a practice session.
Context or other IT in place
An ambulatory electronic medical record system (EMR) has been in place since July 2000. "This electronic record allows physicians to maintain patient problem, medication, and allergy lists as well as to view laboratory results. Physicians also use the sy
Workflow-Related Findings
"Using the composite outcome, patients in the intervention group received recommended coronary artery disease care more often than those in the control group (OR 1.25, 95% confidence interval 1.01-1.55) after adjusting for baseline differences. Individual reminders effective for improving care for patients with coronary artery disease included those for the use of statins
in the presence of hypercholesterolemia (HR 1.51, 95% CI 1.05-2.17) and the use of aspirin therapy (HR 2.36, 95% CI 1.37-4.07). Reminders for overdue annual cholesterol monitoring and the use of beta-blocker therapy had no effect."
in the presence of hypercholesterolemia (HR 1.51, 95% CI 1.05-2.17) and the use of aspirin therapy (HR 2.36, 95% CI 1.37-4.07). Reminders for overdue annual cholesterol monitoring and the use of beta-blocker therapy had no effect."
"It is important for electronic decision support systems to provide actionable recommendations in a simple format to maximize their effectiveness. Our reminders provided succinct messages generally shorter than ten words in length with an immediately actionable item."
"We also limited our reminder system to providing recommendations for aspects of care in which there is very little disagreement on appropriate management and kept the recommendations somewhat conservative to avoid inappropriate recommendations (for example, using an LDL cholesterol goal of 130 mg/dL for coronary artery disease instead of 100 mg/dL). This strategy avoids the pitfall of generating physician distrust of the reminder system while also capturing those patients in most need of improved disease management."
"A large majority (71%) of physicians preferred to receive clinical decision support in an electronic format over a paper-based system."
"Only one third [of physicians] reported noticing the electronic reminders and acting on the recommendations.... Among physicians who noticed reminders, approximately 70% reported acting on the recommendation."
"A majority of physicians in the intervention group found electronic reminders for diabetes care (68%) and coronary artery disease (53%) useful for disease management. Overall, 76% of physicians thought that this clinical decision support system helps to improve quality of care for patients."
"After adjusting for baseline patient and physician characteristics, patients in the intervention group were significantly more likely than control patients to receive recommended diabetes care based on the composite outcome (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.01-1.67).... Reminders for overdue annual cholesterol testing resulted in increased screening rates after adjusting for the use of a paper reminder system, and baseline patient and physician characteristics (hazard ratio [HR] 1.41, 95% CI 1.15-1.72)." The other three reminders had no significant impact.
Study Design
Only postintervention with intervention and control groups
Study Participants
Study participants included 194 primary care physicians caring for 4,549 patients with diabetes and 2,199 patients with CAD at 20 ambulatory clinics.