Challenges in evaluating methods to improve physician practice

Teachable moments: improving pediatric asthma outcomes through physician education

In light of concerns about adherence to the 1997 National Heart Lung and Blood Institute guidelines as well as the 2002 update regarding treatment of asthma, the authors evaluate educational interventions designed to have a positive impact on pediatric patient outcomes. Social cognitive theory can provide the foundation of interventions for physicians that are intended to promote self efficacy in treating asthma patients. Emphasizing the need for physician education based on principles of adult learning, the authors call for more research in this area and encourage the incorporation of distance learning techniques into educational endeavors. The purpose of this article is to review research on the impact of healthcare provider education designed to increase use of practice guidelines on the quality of pediatric asthma care as reflected in patient outcomes and, ultimately, in cost of treatment.

Barriers to implementation of a computerized decision support system for depression: an observational report on lessons learned in "real world" clinical settings

Background

Despite wide promotion, clinical practice guidelines have had limited effect in changing physician behavior. Effective implementation strategies to date have included: multifaceted interventions involving audit and feedback, local consensus processes, marketing; reminder systems, either manual or computerized; and interactive educational meetings. In addition, there is now growing evidence that contextual factors affecting implementation must be addressed such as organizational support (leadership procedures and resources) for the change and strategies to implement and maintain new systems.

Methods

To examine the feasibility and effectiveness of implementation of a computerized decision support system for depression (CDSS-D) in routine public mental health care in Texas, fifteen study clinicians (thirteen physicians and two advanced nurse practitioners) participated across five sites, accruing over 300 outpatient visits on 168 patients.

Results

Issues regarding computer literacy and hardware/software requirements were identified as initial barriers. Clinicians also reported concerns about negative impact on workflow and the potential need for duplication during the transition from paper to electronic systems of medical record keeping.

Conclusion

The following narrative report based on observations obtained during the initial testing and use of a CDSS-D in clinical settings further emphasizes the importance of taking into account organizational factors when planning implementation of evidence-based guidelines or decision support within a system.

Medical management of children with primary hypertension by pediatric subspecialists

Our aim was to characterize medical management of children with primary hypertension (HTN) by pediatric subspecialists. We performed a medical-record review of children < or = 18 years with primary HTN seen at pediatric cardiology or pediatric nephrology clinics at an academic center. Main outcomes were whether treatment decision was in agreement with national guidelines, whether an antihypertensive medication was prescribed, and medication choice. One hundred and eighty children had > or = 1 visit to a pediatric cardiology or nephrology clinic. The majority (83%) of children were pharmacologically managed according to national guidelines. However, only 1/3 children with stage 2 HTN received appropriate antihypertensive therapy from either subspecialty. Only 26 children were prescribed an antihypertensive drug. Children evaluated by pediatric nephrologists were fourfold more likely to receive an antihypertensive than children seen by pediatric cardiologists (29% vs. 7%; p < 0.001). However, all antihypertensive prescriptions were prescribed according to guidelines by both subspecialties. Medical management of children with primary HTN by pediatric cardiologists and pediatric nephrologists is largely consistent with guidelines. However, initiation of appropriate antihypertensive drugs for children with highest severity of HTN is equally poor for both subspecialties. Future studies should explore the factors underlying physicians' reluctance to initiate recommended chronic pharmacologic therapy in children and its associated outcomes.

Measurement-based care for refractory depression: a clinical decision support model for clinical research and practice

Despite years of antidepressant drug development and patient and provider education, suboptimal medication dosing and duration of exposure resulting in incomplete remission of symptoms remains the norm in the treatment of depression. Additionally, since no one treatment is effective for all patients, optimal implementation focusing on the measurement of symptoms, side effects, and function is essential to determine effective sequential treatment approaches. There is a need for a paradigm shift in how clinical decision making is incorporated into clinical practice and for a move away from the trial-and-error approach that currently determines the "next best" treatment. This paper describes how our experience with the Texas Medication Algorithm Project (TMAP) and the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial has confirmed the need for easy-to-use clinical support systems to ensure fidelity to guidelines. To further enhance guideline fidelity, we have developed an electronic decision support system that provides critical feedback and guidance at the point of patient care. We believe that a measurement-based care (MBC) approach is essential to any decision support system, allowing physicians to individualize and adapt decisions about patient care based on symptom progress, tolerability of medication, and dose optimization. We also believe that successful integration of sequential algorithms with MBC into real-world clinics will facilitate change that will endure and improve patient outcomes. Although we use major depression to illustrate our approach, the issues addressed are applicable to other chronic psychiatric conditions including comorbid depression and substance use disorder as well as other medical illnesses.