A Randomized Trial of Electronic Clinical Reminders to Improve Quality of Care for Diabetes and Coronary Artery Disease

Abstract

A b s t r a c t 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.

Los cirujanos sobreestiman el riesgo de malignidad de los nódulos tiroideos, evaluación de los estimados subjetivos usando un análisis bayesiano

“…Many researchers have found that although there is sufficient information to make decisions, physicians do not follow recommendations and guidelines (30,31). Some authors believe that the problem is related to the impossibility of delivering the information to the final decision maker, and tools have been developed, including electronic reminders or rewards on health care systems, with good results (32,33).…”

Impact of Computerized Decision Support on Blood Pressure Management and Control: A Randomized Controlled Trial

“…Prior research has demonstrated that provider disagreement with guideline recommendations might be a significant barrier to provider guideline adherence. 18 We conducted a pragmatic randomized trial of a CDS system within academic and community-based practices providing hypertension care to a multiethnic sample of patients. Whereas we found that CDS significantly improved appropriate medication prescribing, we observed no reduction in racial and ethnic disparities in care or improvement in blood pressure control.…”

“…We selected a period of 7 days to identify medication changes that were more likely the direct result of the reminder being seen by the provider. 18 Trained abstracters then reviewed the EMR for each patient's blood pressure for the first and last hypertension-related visits during the study period to obtain participants' index and "This is a Black or elderly patient recorded as having hypertension without diabetes or heart disease, consider using a diuretic or calcium channel blocker for initial management of hypertension." B) Sample computerized reminder for uncomplicated White patient (≤65 years old) with HTN: "This is a White patient recorded as having hypertension without diabetes or heart disease, consider using a diuretic or beta-blocker for initial management of hypertension."…”

“…18 Each time that a clinician opened a patient's chart, an algorithm was run within the EMR to determine whether the patient was receiving a medication in an antihypertensive drug class in accordance with JNC guidelines. The algorithm searched patients' vital signs, problem lists, medication lists, and allergy lists within the electronic record.…”

“…In a prior randomized trial, we found that CDS for diabetes and coronary artery disease care were effective for improving provider adherence with recommended processes of care. 18 Other studies have also demonstrated that computer-based reminders are effective in improving measures of process of care, but intermediate clinical outcomes, such as blood pressure control, are rarely examined and when studied are frequently not improved. [19][20][21][22][23] We utilized a practical cluster randomized controlled trial 24 to examine the effectiveness of CDS, designed to remind physicians about hypertension treatment guidelines with the goals of: (1) improving levels of blood pressure control, (2) improving provider adherence with recommended drug therapy, and (3) reducing racial/ethnic disparities in hypertension care and outcomes.…”