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Hertz JT, Stark K, Sakita FM, Mlangi JJ, Kweka GL, Prattipati S, Shayo F, Kaboigora V, Mtui J, Isack MN, Kindishe EM, Ngelengi DJ, Limkakeng AT, Thielman NM, Bloomfield GS, Bettger JP, Tarimo TG. Adapting an Intervention to Improve Acute Myocardial Infarction Care in Tanzania: Co-Design of the MIMIC Intervention. Ann Glob Health 2024; 90:21. [PMID: 38495415 PMCID: PMC10941691 DOI: 10.5334/aogh.4361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/23/2024] [Indexed: 03/19/2024] Open
Abstract
Background Uptake of evidence-based care for acute myocardial infarction (AMI) is suboptimal in Tanzania, but there are currently no published interventions to improve AMI care in sub-Saharan Africa. Objectives Co-design a quality improvement intervention for AMI care tailored to local contextual factors. Methods An interdisciplinary design team consisting of 20 physicians, nurses, implementation scientists, and administrators met from June 2022 through August 2023. Half of the design team consisted of representatives from the target audience, emergency department physicians and nurses at a referral hospital in northern Tanzania. The design team reviewed multiple published quality improvement interventions focusing on ED-based AMI care. After selecting a multicomponent intervention to improve AMI care in Brazil (BRIDGE-ACS), the design team used the ADAPT-ITT framework to adapt the intervention to the local context. Findings The design team audited current AMI care processes at the study hospital and reviewed qualitative data regarding barriers to care. Multiple adaptations were made to the original BRIDGE-ACS intervention to suit the local context, including re-designing the physician reminder system and adding patient educational materials. Additional feedback was sought from topical experts, including patients with AMI. Draft intervention materials were iteratively refined in response to feedback from experts and the design team. The finalized intervention, Multicomponent Intervention to Improve Myocardial Infarction Care in Tanzania (MIMIC), consisted of five core components: physician reminders, pocket cards, champions, provider training, and patient education. Conclusion MIMIC is the first locally tailored intervention to improve AMI care in sub-Saharan Africa. Future studies will evaluate implementation outcomes and efficacy.
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Affiliation(s)
- Julian T. Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kristen Stark
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Francis M. Sakita
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
- Kilimanjaro Christian Medical University, Moshi, Tanzania
| | | | | | | | - Frida Shayo
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | | | - Julius Mtui
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | | | | | | | - Alexander T. Limkakeng
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nathan M. Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Internal Medicine, Duke University, Durham, North Carolina, USA
| | - Gerald S. Bloomfield
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Janet P. Bettger
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
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Pantoja T, Grimshaw JM, Colomer N, Castañon C, Leniz Martelli J. Manually-generated reminders delivered on paper: effects on professional practice and patient outcomes. Cochrane Database Syst Rev 2019; 12:CD001174. [PMID: 31858588 PMCID: PMC6923326 DOI: 10.1002/14651858.cd001174.pub4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Health professionals sometimes do not use the best evidence to treat their patients, in part due to unconscious acts of omission and information overload. Reminders help clinicians overcome these problems by prompting them to recall information that they already know, or by presenting information in a different and more accessible format. Manually-generated reminders delivered on paper are defined as information given to the health professional with each patient or encounter, provided on paper, in which no computer is involved in the production or delivery of the reminder. Manually-generated reminders delivered on paper are relatively cheap interventions, and are especially relevant in settings where electronic clinical records are not widely available and affordable. This review is one of three Cochrane Reviews focused on the effectiveness of reminders in health care. OBJECTIVES 1. To determine the effectiveness of manually-generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually-generated reminders delivered on paper. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers on 5 December 2018. We searched grey literature, screened individual journals, conference proceedings and relevant systematic reviews, and reviewed reference lists and cited references of included studies. SELECTION CRITERIA We included randomised and non-randomised trials assessing the impact of manually-generated reminders delivered on paper as a single intervention (compared with usual care) or added to one or more co-interventions as a multicomponent intervention (compared with the co-intervention(s) without the reminder component) on professional practice or patients' outcomes. We also included randomised and non-randomised trials comparing manually-generated reminders with other quality improvement (QI) interventions. DATA COLLECTION AND ANALYSIS Two review authors screened studies for eligibility and abstracted data independently. We extracted the primary outcome as defined by the authors or calculated the median effect size across all reported outcomes in each study. We then calculated the median percentage improvement and interquartile range across the included studies that reported improvement related outcomes, and assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We identified 63 studies (41 cluster-randomised trials, 18 individual randomised trials, and four non-randomised trials) that met all inclusion criteria. Fifty-seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty-four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test-ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention. Forty-eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process-of-care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Manually-generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% (IQR 2.54% to 20.58%); 39 comparisons, 40,346 participants; moderate certainty of evidence) and may make little or no difference to continuous process-of-care outcomes (8 comparisons, 3263 participants; low certainty of evidence). Adding manually-generated paper reminders to one or more QI co-interventions may slightly improve professional practice measured as dichotomous process adherence outcomes (median improvement 4.24% (IQR -1.09% to 5.50%); 12 comparisons, 25,359 participants; low certainty of evidence) and probably slightly improve professional practice measured as continuous outcomes (median improvement 0.28 (IQR 0.04 to 0.51); 2 comparisons, 12,372 participants; moderate certainty of evidence). Compared with other QI interventions, manually-generated reminders may slightly decrease professional practice measured as process adherence outcomes (median decrease 7.9% (IQR -0.7% to 11%); 14 comparisons, 21,274 participants; low certainty of evidence). We are uncertain whether manually-generated reminders delivered on paper, compared with usual care or with other QI intervention, lead to better or worse patient outcomes (dichotomous or continuous), as the certainty of the evidence is very low (10 studies, 13 comparisons). Reminders added to other QI interventions may make little or no difference to patient outcomes (dichotomous or continuous) compared with the QI alone (2 studies, 2 comparisons). Regarding resource use, studies reported additional costs per additional point of effectiveness gained, but because of the different currencies and years used the relevance of those figures is uncertain. None of the included studies reported outcomes related to harms or adverse effects. AUTHORS' CONCLUSIONS Manually-generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single QI intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually-generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect.
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Affiliation(s)
- Tomas Pantoja
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Jeremy M Grimshaw
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramThe Ottawa Hospital ‐ General Campus501 Smyth Road, Box 711OttawaONCanadaK1H 8L6
| | - Nathalie Colomer
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Carla Castañon
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Javiera Leniz Martelli
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
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van Driel ML, Morledge MD, Ulep R, Shaffer JP, Davies P, Deichmann R. Interventions to improve adherence to lipid-lowering medication. Cochrane Database Syst Rev 2016; 12:CD004371. [PMID: 28000212 PMCID: PMC6464006 DOI: 10.1002/14651858.cd004371.pub4] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Lipid-lowering drugs are widely underused, despite strong evidence indicating they improve cardiovascular end points. Poor patient adherence to a medication regimen can affect the success of lipid-lowering treatment. OBJECTIVES To assess the effects of interventions aimed at improving adherence to lipid-lowering drugs, focusing on measures of adherence and clinical outcomes. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO and CINAHL up to 3 February 2016, and clinical trials registers (ANZCTR and ClinicalTrials.gov) up to 27 July 2016. We applied no language restrictions. SELECTION CRITERIA We evaluated randomised controlled trials of adherence-enhancing interventions for lipid-lowering medication in adults in an ambulatory setting with a variety of measurable outcomes, such as adherence to treatment and changes to serum lipid levels. Two teams of review authors independently selected the studies. DATA COLLECTION AND ANALYSIS Three review authors extracted and assessed data, following criteria outlined by the Cochrane Handbook for Systematic Reviews of Interventions. We assessed the quality of the evidence using GRADEPro. MAIN RESULTS For this updated review, we added 24 new studies meeting the eligibility criteria to the 11 studies from prior updates. We have therefore included 35 studies, randomising 925,171 participants. Seven studies including 11,204 individuals compared adherence rates of those in an intensification of a patient care intervention (e.g. electronic reminders, pharmacist-led interventions, healthcare professional education of patients) versus usual care over the short term (six months or less), and were pooled in a meta-analysis. Participants in the intervention group had better adherence than those receiving usual care (odds ratio (OR) 1.93, 95% confidence interval (CI) 1.29 to 2.88; 7 studies; 11,204 participants; moderate-quality evidence). A separate analysis also showed improvements in long-term adherence rates (more than six months) using intensification of care (OR 2.87, 95% CI 1.91 to 4.29; 3 studies; 663 participants; high-quality evidence). Analyses of the effect on total cholesterol and LDL-cholesterol levels also showed a positive effect of intensified interventions over both short- and long-term follow-up. Over the short term, total cholesterol decreased by a mean of 17.15 mg/dL (95% CI 1.17 to 33.14; 4 studies; 430 participants; low-quality evidence) and LDL-cholesterol decreased by a mean of 19.51 mg/dL (95% CI 8.51 to 30.51; 3 studies; 333 participants; moderate-quality evidence). Over the long term (more than six months) total cholesterol decreased by a mean of 17.57 mg/dL (95% CI 14.95 to 20.19; 2 studies; 127 participants; high-quality evidence). Included studies did not report usable data for health outcome indications, adverse effects or costs/resource use, so we could not pool these outcomes. We assessed each included study for bias using methods described in the Cochrane Handbook for Systematic Reviews of Interventions. In general, the risk of bias assessment revealed a low risk of selection bias, attrition bias, and reporting bias. There was unclear risk of bias relating to blinding for most studies. AUTHORS' CONCLUSIONS The evidence in our review demonstrates that intensification of patient care interventions improves short- and long-term medication adherence, as well as total cholesterol and LDL-cholesterol levels. Healthcare systems which can implement team-based intensification of patient care interventions may be successful in improving patient adherence rates to lipid-lowering medicines.
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Affiliation(s)
- Mieke L van Driel
- Discipline of General Practice, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia, 4029
- Department of Family Medicine and Primary Health Care, Ghent University, 1K3, De Pintelaan 185, Ghent, Belgium, 9000
| | - Michael D Morledge
- Ochsner Clinical School, School of Medicine, The University of Queensland, New Orleans, USA
| | - Robin Ulep
- Ochsner Clinical School, School of Medicine, The University of Queensland, New Orleans, USA
| | - Johnathon P Shaffer
- Ochsner Clinical School, School of Medicine, The University of Queensland, New Orleans, USA
| | - Philippa Davies
- School of Social and Community Medicine, University of Bristol, Canynge Hall, Bristol, UK, BS8 2PS
| | - Richard Deichmann
- Department of Internal Medicine, Ochsner Health System, 1514 Jefferson Hwy, New Orleans, USA, 70121
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Brenner SK, Kaushal R, Grinspan Z, Joyce C, Kim I, Allard RJ, Delgado D, Abramson EL. Effects of health information technology on patient outcomes: a systematic review. J Am Med Inform Assoc 2016; 23:1016-36. [PMID: 26568607 PMCID: PMC6375119 DOI: 10.1093/jamia/ocv138] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 07/28/2015] [Accepted: 07/29/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To systematically review studies assessing the effects of health information technology (health IT) on patient safety outcomes. MATERIALS AND METHODS The authors employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement methods. MEDLINE, Cumulative Index to Nursing Allied Health (CINAHL), EMBASE, and Cochrane Library databases, from 2001 to June 2012, were searched. Descriptive and comparative studies were included that involved use of health IT in a clinical setting and measured effects on patient safety outcomes. RESULTS Data on setting, subjects, information technology implemented, and type of patient safety outcomes were all abstracted. The quality of the studies was evaluated by 2 independent reviewers (scored from 0 to 10). A total of 69 studies met inclusion criteria. Quality scores ranged from 1 to 9. There were 25 (36%) studies that found benefit of health IT on direct patient safety outcomes for the primary outcome measured, 43 (62%) studies that either had non-significant or mixed findings, and 1 (1%) study for which health IT had a detrimental effect. Neither the quality of the studies nor the rate of randomized control trials performed changed over time. Most studies that demonstrated a positive benefit of health IT on direct patient safety outcomes were inpatient, single-center, and either cohort or observational trials studying clinical decision support or computerized provider order entry. DISCUSSION AND CONCLUSION Many areas of health IT application remain understudied and the majority of studies have non-significant or mixed findings. Our study suggests that larger, higher quality studies need to be conducted, particularly in the long-term care and ambulatory care settings.
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Affiliation(s)
- Samantha K Brenner
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA Center for Healthcare Informatics and Policy, New York, NY, USA Department of Medicine, Stanford School of Medicine, Palo Alto, CA, USA Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Rainu Kaushal
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA Center for Healthcare Informatics and Policy, New York, NY, USA Department of Medicine, Weill Cornell Medical College, New York, NY, USA Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA New York-Presbyterian Hospital, New York, NY, USA
| | - Zachary Grinspan
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA Center for Healthcare Informatics and Policy, New York, NY, USA Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA New York-Presbyterian Hospital, New York, NY, USA
| | - Christine Joyce
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA New York-Presbyterian Hospital, New York, NY, USA
| | - Inho Kim
- New York-Presbyterian Hospital, New York, NY, USA Department of Emergency Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Rhonda J Allard
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Diana Delgado
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medical College, New York, NY, USA
| | - Erika L Abramson
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA Center for Healthcare Informatics and Policy, New York, NY, USA Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA New York-Presbyterian Hospital, New York, NY, USA
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Unverzagt S, Peinemann F, Oemler M, Braun K, Klement A. Meta-regression analyses to explain statistical heterogeneity in a systematic review of strategies for guideline implementation in primary health care. PLoS One 2014; 9:e110619. [PMID: 25343450 PMCID: PMC4208765 DOI: 10.1371/journal.pone.0110619] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 09/15/2014] [Indexed: 11/18/2022] Open
Abstract
This study is an in-depth-analysis to explain statistical heterogeneity in a systematic review of implementation strategies to improve guideline adherence of primary care physicians in the treatment of patients with cardiovascular diseases. The systematic review included randomized controlled trials from a systematic search in MEDLINE, EMBASE, CENTRAL, conference proceedings and registers of ongoing studies. Implementation strategies were shown to be effective with substantial heterogeneity of treatment effects across all investigated strategies. Primary aim of this study was to explain different effects of eligible trials and to identify methodological and clinical effect modifiers. Random effects meta-regression models were used to simultaneously assess the influence of multimodal implementation strategies and effect modifiers on physician adherence. Effect modifiers included the staff responsible for implementation, level of prevention and definition pf the primary outcome, unit of randomization, duration of follow-up and risk of bias. Six clinical and methodological factors were investigated as potential effect modifiers of the efficacy of different implementation strategies on guideline adherence in primary care practices on the basis of information from 75 eligible trials. Five effect modifiers were able to explain a substantial amount of statistical heterogeneity. Physician adherence was improved by 62% (95% confidence interval (95% CI) 29 to 104%) or 29% (95% CI 5 to 60%) in trials where other non-medical professionals or nurses were included in the implementation process. Improvement of physician adherence was more successful in primary and secondary prevention of cardiovascular diseases by around 30% (30%; 95% CI -2 to 71% and 31%; 95% CI 9 to 57%, respectively) compared to tertiary prevention. This study aimed to identify effect modifiers of implementation strategies on physician adherence. Especially the cooperation of different health professionals in primary care practices might increase efficacy and guideline implementation seems to be more difficult in tertiary prevention of cardiovascular diseases.
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Affiliation(s)
- Susanne Unverzagt
- Institute of Medical Epidemiology, Biostatistics and Informatics, University Halle/Wittenberg, Halle (Saale), Germany
| | - Frank Peinemann
- Children's Hospital, University of Cologne, Cologne, Germany
| | - Matthias Oemler
- Section of General Practice, Institute of Medical Epidemiology, Biostatistics and Informatics, University Halle/Wittenberg, Halle (Saale), Germany
| | - Kristin Braun
- Section of General Practice, Institute of Medical Epidemiology, Biostatistics and Informatics, University Halle/Wittenberg, Halle (Saale), Germany
| | - Andreas Klement
- Section of General Practice, Institute of Medical Epidemiology, Biostatistics and Informatics, University Halle/Wittenberg, Halle (Saale), Germany
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Unverzagt S, Oemler M, Braun K, Klement A. Strategies for guideline implementation in primary care focusing on patients with cardiovascular disease: a systematic review. Fam Pract 2014; 31:247-66. [PMID: 24367069 DOI: 10.1093/fampra/cmt080] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Guidelines should reduce inappropriate practice and improve the efficiency of treatment. Not only methodological quality but also acceptance and successful implementation in daily practice are crucial for the benefit on patients. Focusing on cardiovascular diseases (CVD), it is still unclear which implementation strategy can improve physician adherence to the recommendations of guidelines in primary care. METHODS We conducted a systematic review on randomized controlled trials about guideline implementation strategies on CVD. Medline, Embase, CENTRAL, conference proceedings and registers of ongoing studies were searched. RESULTS Eighty-four trials met our predefined inclusion criteria, of them 54 trials compared unimodal strategies and 30 multimodal strategies to usual care. Concerning unimodal strategies, 15 trials investigated provider reminder systems, 3 audit and feedback, 15 provider education, 4 patient education, 5 promotion of self-management and 14 organizational change. The strongest benefit of a unimodal implementation strategy was found due to organizational change (odds ratio 1.96; 95% CI 1.4 to 2.75), followed by patient education, provider education and provider reminder systems. Trials on the efficacy of audit and feedback and patient self-management showed differing results or small advantages in terms of physician adherence. Multimodal interventions showed almost similar effect measures and ranking of strategies. CONCLUSION The use of implementation strategies for the distribution of guidelines on CVD can be convincingly effective on physician adherence, regardless whether based on a unimodal or multimodal design. Three distinct strategies should be well considered in such an attempt: organizational changes in the primary care team, patient education and provider education.
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Affiliation(s)
- Susanne Unverzagt
- Institute of Medical Epidemiology, Biostatistics and Informatics and
| | - Matthias Oemler
- Section of General Practice, Institute of Medical Epidemiology, Biostatistics and Informatics, University Halle/Wittenberg, Halle (Saale), Germany
| | - Kristin Braun
- Section of General Practice, Institute of Medical Epidemiology, Biostatistics and Informatics, University Halle/Wittenberg, Halle (Saale), Germany
| | - Andreas Klement
- Section of General Practice, Institute of Medical Epidemiology, Biostatistics and Informatics, University Halle/Wittenberg, Halle (Saale), Germany
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Arditi C, Rège-Walther M, Wyatt JC, Durieux P, Burnand B. Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2012; 12:CD001175. [PMID: 23235578 DOI: 10.1002/14651858.cd001175.pub3] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting the doctor to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time. OBJECTIVES To evaluate the effects of reminders automatically generated through a computerized system and delivered on paper to healthcare professionals on processes of care (related to healthcare professionals' practice) and outcomes of care (related to patients' health condition). SEARCH METHODS For this update the EPOC Trials Search Co-ordinator searched the following databases between June 11-19, 2012: The Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Library (Economics, Methods, and Health Technology Assessment sections), Issue 6, 2012; MEDLINE, OVID (1946- ), Daily Update, and In-process; EMBASE, Ovid (1947- ); CINAHL, EbscoHost (1980- ); EPOC Specialised Register, Reference Manager, and INSPEC, Engineering Village. The authors reviewed reference lists of related reviews and studies. SELECTION CRITERIA We included individual or cluster-randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals on processes and/or outcomes of care. DATA COLLECTION AND ANALYSIS Review authors working in pairs independently screened studies for eligibility and abstracted data. We contacted authors to obtain important missing information for studies that were published within the last 10 years. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median absolute improvement and interquartile range (IQR) in process adherence across included studies using the primary outcome or median outcome as representative outcome. MAIN RESULTS In the 32 included studies, computer-generated reminders delivered on paper to healthcare professionals achieved moderate improvement in professional practices, with a median improvement of processes of care of 7.0% (IQR: 3.9% to 16.4%). Implementing reminders alone improved care by 11.2% (IQR 6.5% to 19.6%) compared with usual care, while implementing reminders in addition to another intervention improved care by 4.0% only (IQR 3.0% to 6.0%) compared with the other intervention. The quality of evidence for these comparisons was rated as moderate according to the GRADE approach. Two reminder features were associated with larger effect sizes: providing space on the reminder for provider to enter a response (median 13.7% versus 4.3% for no response, P value = 0.01) and providing an explanation of the content or advice on the reminder (median 12.0% versus 4.2% for no explanation, P value = 0.02). Median improvement in processes of care also differed according to the behaviour the reminder targeted: for instance, reminders to vaccinate improved processes of care by 13.1% (IQR 12.2% to 20.7%) compared with other targeted behaviours. In the only study that had sufficient power to detect a clinically significant effect on outcomes of care, reminders were not associated with significant improvements. AUTHORS' CONCLUSIONS There is moderate quality evidence that computer-generated reminders delivered on paper to healthcare professionals achieve moderate improvement in process of care. Two characteristics emerged as significant predictors of improvement: providing space on the reminder for a response from the clinician and providing an explanation of the reminder's content or advice. The heterogeneity of the reminder interventions included in this review also suggests that reminders can improve care in various settings under various conditions.
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Affiliation(s)
- Chantal Arditi
- Institute of Social and Preventive Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.
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McKibbon KA, Lokker C, Handler SM, Dolovich LR, Holbrook AM, O'Reilly D, Tamblyn R, Hemens BJ, Basu R, Troyan S, Roshanov PS. The effectiveness of integrated health information technologies across the phases of medication management: a systematic review of randomized controlled trials. J Am Med Inform Assoc 2012; 19:22-30. [PMID: 21852412 PMCID: PMC3240758 DOI: 10.1136/amiajnl-2011-000304] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 07/11/2011] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The US Agency for Healthcare Research and Quality funded an evidence report to address seven questions on multiple aspects of the effectiveness of medication management information technology (MMIT) and its components (prescribing, order communication, dispensing, administering, and monitoring). MATERIALS AND METHODS Medline and 11 other databases without language or date limitations to mid-2010. Randomized controlled trials (RCTs) assessing integrated MMIT were selected by two independent reviewers. Reviewers assessed study quality and extracted data. Senior staff checked accuracy. RESULTS Most of the 87 RCTs focused on clinical decision support and computerized provider order entry systems, were performed in hospitals and clinics, included primarily physicians and sometimes nurses but not other health professionals, and studied process changes related to prescribing and monitoring medication. Processes of care improved for prescribing and monitoring mostly in hospital settings, but the few studies measuring clinical outcomes showed small or no improvements. Studies were performed most frequently in the USA (n=63), Europe (n=16), and Canada (n=6). DISCUSSION Many studies had limited description of systems, installations, institutions, and targets of the intervention. Problems with methods and analyses were also found. Few studies addressed order communication, dispensing, or administering, non-physician prescribers or pharmacists and their MMIT tools, or patients and caregivers. Other study methods are also needed to completely understand the effects of MMIT. CONCLUSIONS Almost half of MMIT interventions improved the process of care, but few studies measured clinical outcomes. This large body of literature, although instructive, is not uniformly distributed across settings, people, medication phases, or outcomes.
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Affiliation(s)
- K Ann McKibbon
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
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Abstract
BACKGROUND Lipid lowering drugs are still widely underused, despite compelling evidence about their effectiveness in the treatment and prevention of cardiovascular disease. Poor patient adherence to a medication regimen is a major factor in the lack of success in treating hyperlipidaemia. In this updated review we focus on interventions which encourage patients at risk of heart disease or stroke to take lipid lowering medication regularly. OBJECTIVES To assess the effects of interventions aimed at improved adherence to lipid lowering drugs, focusing on measures of adherence and clinical outcomes. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 1), MEDLINE, EMBASE, PsycINFO and CINAHL (March 2008). No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials of adherence-enhancing interventions for lipid lowering medication in adults for both primary and secondary prevention of cardiovascular disease in an ambulatory setting looking at adherence, serum lipid levels, adverse effects and health outcomes. Studies were selected independently by two review authors. DATA COLLECTION AND ANALYSIS Data were extracted and assessed by two review authors following criteria outlined by the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS Three additional studies were found in the update and, in total, 11 studies were included in this review. The studies included interventions that caused a change in adherence ranging from -3% to 25% (decrease in adherence by 3% to increase in adherence by 25%). Patient re-enforcement and reminding was the most promising category of interventions, investigated in six trials of which four showed improved adherent behaviour of statistical significance (absolute increase: 24%, 9%, 8% and 6%). Other interventions associated with increased adherence were simplification of the drug regimen (absolute increase 11%) and patient information and education (absolute increase 13%). The methodological and analytical quality of some studies was low and results have to be considered with caution. AUTHORS' CONCLUSIONS At this stage, reminding patients seems the most promising intervention to increase adherence to lipid lowering drugs. The lack of a gold standard method of measuring adherence is one major barrier in adherence research. More reliable data might be achieved by newer methods of measurement, more consistency in adherence assessment and longer duration of follow up. More recent studies have started using more reliable methods for data collection but follow-up periods remain too short. Increased patient-centredness with emphasis on the patient's perspective and shared decision-making might lead to more conclusive answers when searching for tools to encourage patients to take lipid lowering medication.
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Affiliation(s)
- Angela Schedlbauer
- Division of Primary Care, School of Community Health Studies, University of Nottingham, Nottingham, UK, NG7 2RD
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10
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Bywood PT, Lunnay B, Roche AM. Strategies for facilitating change in alcohol and other drugs (AOD) professional practice: a systematic review of the effectiveness of reminders and feedback. Drug Alcohol Rev 2008; 27:548-58. [PMID: 18696301 DOI: 10.1080/09595230802245535] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In all areas of health research, including the alcohol and other drugs (AOD) field, funds are committed to developing and evaluating research and resources, yet little is invested into helping potential resource users understand, adopt and implement innovations. This study evaluated the effectiveness of two professional practice change interventions (reminders and feedback) that are designed to bridge the 'research-practice gap' by increasing knowledge and changing behaviour of health-care professionals and specialist AOD workers. We conducted a systematic review of general health, AOD and mental health literature (1966 to March 2005). Fourteen existing systematic reviews and 15 primary studies were assessed. Because few studies evaluated the effectiveness of reminders and feedback in the AOD context, evidence is drawn largely from the general health-care literature. Use of reminders and feedback is supported for a range of health behaviours. AOD-specific clinical behaviours that are most likely to be improved with the use of reminders or feedback include pharmacotherapy prescribing, AOD education, screening and counselling and monitoring/management of AOD treatment and/or related problems (e.g. depression). Reminders and feedback are effective strategies to facilitate professional practice change and have potential in the AOD field. However, further well-designed empirical studies are needed to assess fully the effectiveness of these professional practice change strategies in AOD-specific contexts.
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Affiliation(s)
- Petra T Bywood
- National Centre for Education and Training on Addiction, Flinders University, South Australia, Australia.
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11
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Ismail HM, Jackson K, Smith D. Diagnosis and Treatment of Peripheral Arterial Disease Compared with Other Atherosclerotic Vascular Diseases in a University Primary Care Clinic. J Investig Med 2006; 54:255-61. [PMID: 16984798 DOI: 10.2310/6650.2006.05049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Despite the fact that peripheral arterial disease (PAD) significantly increases the risk of cardiovascular mortality, it is significantly underdiagnosed and undertreated. The purpose of this study was to evaluate the practice at a northeast Tennessee university primary care clinic regarding the diagnosis and treatment of PAD. METHODS A retrospective medical record survey was conducted to evaluate practice patterns in diagnosing and treating PAD in a university primary care clinic. A clinic population of 711 patients was selected using International Classification of Diseases-9 codes for coronary artery disease (CAD), cerebovascular disease (CVD), and/or PAD. A sample of 180 patients (25.3%) was randomly selected using a systematic statistical method. Of these, 125 patients met the diagnostic criteria for CAD, CVD, and/or PAD. The study covered a 3-year period, from July 2001 until June 2004. Demographic and other data, including the use of antiplatelet therapy, were collected. RESULTS One hundred ten patients met all of the inclusion and exclusion criteria. Thirty-nine percent were males, and 61% were females. Overall, 79% had CAD, 53% had CVD, and 25% had PAD. Almost half of the patients had some combination of these. Only about 2% had PAD only compared with 36% with CAD only and 17% with CVD only. Although the prevalence of CAD and CVD (among other atherosclerotic vascular diseases) in our clinic was comparable to national figures, the prevalence of PAD was significantly lower (p = .004). The overall use of any antiplatelet agent was 84.2% for patients with only CAD and 80% for only CVD. There was not an adequate number of patients with only PAD to evaluate the use of antiplatelet therapy in this group. CONCLUSION The low prevalence of PAD only (most PAD patients had coexisting CAD and CVD) indicates that PAD is underdiagnosed at our clinic. There was suboptimal use of aspirin and other antiplatelet drugs among patients with atherosclerotic vascular disease.
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Affiliation(s)
- Hassan M Ismail
- Department of Internal Medicine, East Tennessee State University/James Quillen College of Medicine, Johnson City, TN 37604, USA.
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12
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Berlin A, Sorani M, Sim I. A taxonomic description of computer-based clinical decision support systems. J Biomed Inform 2006; 39:656-67. [PMID: 16442854 DOI: 10.1016/j.jbi.2005.12.003] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2005] [Revised: 11/30/2005] [Accepted: 12/04/2005] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Computer-based clinical decision support systems (CDSSs) vary greatly in design and function. Using a taxonomy that we had previously developed, we describe the characteristics of CDSSs reported in the literature. METHODS We searched PubMed and the Cochrane Library for randomized controlled trials (RCTs) published in English between 1998 and 2003 that evaluated CDSSs. We coded each CDSS using our taxonomy. RESULTS 58 studies met our inclusion criteria. The 74 reported CDSSs varied greatly in context of use, knowledge and data sources, nature of decision support offered, information delivery, and workflow impact. Two distinct subsets of CDSSs were seen: patient-directed systems that provided decision support for preventive care or health-related behaviors via mail or phone (38% of systems), and inpatient systems targeting clinicians with online decision support and direct online execution of the recommendations (18%). 84% of the CDSSs required extra staffing for handling CDSS-related input or output. CONCLUSION Reported CDSSs are heterogeneous along many dimensions. Caution should be taken in generalizing the results of CDSS RCTs to different clinical or workflow settings.
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Affiliation(s)
- Amy Berlin
- Department of Psychiatry, University of California, San Francisco, CA, USA
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13
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Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ 2005; 330:765. [PMID: 15767266 PMCID: PMC555881 DOI: 10.1136/bmj.38398.500764.8f] [Citation(s) in RCA: 1445] [Impact Index Per Article: 76.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To identify features of clinical decision support systems critical for improving clinical practice. DESIGN Systematic review of randomised controlled trials. DATA SOURCES Literature searches via Medline, CINAHL, and the Cochrane Controlled Trials Register up to 2003; and searches of reference lists of included studies and relevant reviews. STUDY SELECTION Studies had to evaluate the ability of decision support systems to improve clinical practice. DATA EXTRACTION Studies were assessed for statistically and clinically significant improvement in clinical practice and for the presence of 15 decision support system features whose importance had been repeatedly suggested in the literature. RESULTS Seventy studies were included. Decision support systems significantly improved clinical practice in 68% of trials. Univariate analyses revealed that, for five of the system features, interventions possessing the feature were significantly more likely to improve clinical practice than interventions lacking the feature. Multiple logistic regression analysis identified four features as independent predictors of improved clinical practice: automatic provision of decision support as part of clinician workflow (P < 0.00001), provision of recommendations rather than just assessments (P = 0.0187), provision of decision support at the time and location of decision making (P = 0.0263), and computer based decision support (P = 0.0294). Of 32 systems possessing all four features, 30 (94%) significantly improved clinical practice. Furthermore, direct experimental justification was found for providing periodic performance feedback, sharing recommendations with patients, and requesting documentation of reasons for not following recommendations. CONCLUSIONS Several features were closely correlated with decision support systems' ability to improve patient care significantly. Clinicians and other stakeholders should implement clinical decision support systems that incorporate these features whenever feasible and appropriate.
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Affiliation(s)
- Kensaku Kawamoto
- Division of Clinical Informatics, Department of Community and Family Medicine, Box 2914, Duke University Medical Center, Durham, NC 27710, USA
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14
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Abstract
BACKGROUND Lipid lowering drugs are still widely underused, despite compelling evidence about their effectiveness in the treatment and prevention of cardiovascular disease. Poor patient adherence to medication regimen is a major factor in the lack of success in treating hyperlipidaemia. In this review we focus on interventions, which encourage patients at risk of heart disease or stroke to take lipid lowering medication regularly. OBJECTIVES To assess the effect of interventions aiming at improved adherence to lipid lowering drugs, focusing on measures of adherence and clinical outcomes. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycInfo and CINAHL. Date of most recent search was in February 2003. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials of adherence-enhancing interventions to lipid lowering medication in adults for both primary and secondary prevention of cardiovascular disease in an ambulatory setting. DATA COLLECTION AND ANALYSIS Two reviewers extracted data independently and assessed studies according to criteria outlined by the Cochrane Reviewers' Handbook. MAIN RESULTS The eight studies found contained data on 5943 patients. Interventions could be stratified into four categories : 1. simplification of drug regimen, 2. patient information/education, 3. intensified patient care such as reminding and 4. complex behavioural interventions such as group sessions. Change in adherence ranged from -3% to 25% (decrease in adherence by 3% to increase in adherence by 25%). Three studies reported significantly improved adherence through simplification of drug regimen (category 1), improved patient information/education (category 2) and reminding (category 3). The fact that the successful interventions were evenly spread across the categories, does not suggest any advantage of one particular type of intervention. The methodological and analytical quality was generally low and results have to be considered with caution. Combining data was not appropriate due to the substantial heterogeneity between included randomised controlled trials (RCTs). REVIEWERS' CONCLUSIONS At this stage, no specific intervention aimed at improving adherence to lipid lowering drugs can be recommended. The lack of a gold standard method of measuring adherence is one major barrier in adherence research. More reliable data might be achieved by newer methods of measurement, more consistency in adherence assessment and longer duration of follow-up. Increased patient-centredness with emphasis on the patient's perspective and shared-decision-making might lead to more conclusive answers when searching for tools to encourage patients to take lipid lowering medication.
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Affiliation(s)
- A Schedlbauer
- Academic Unit of Primary Health Care, Department of Community Based Medicine, University of Bristol, Cotham House, Cotham Hill, Bristol, UK, BS6 6JL.
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15
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Bennett JW, Glasziou PP. Computerised reminders and feedback in medication management: a systematic review of randomised controlled trials. Med J Aust 2003; 178:217-22. [PMID: 12603185 DOI: 10.5694/j.1326-5377.2003.tb05166.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2002] [Accepted: 12/13/2002] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To systematically review randomised controlled trials (RCTs) of computer-generated medication reminders or feedback directed to healthcare providers or patients. DATA SOURCES Extensive computerised and manual literature searches identified 76 English-language reports of RCTs reported before 1 January 2002. Searches were conducted between June 1998 and April 2002. STUDY SELECTION 26 papers making 29 comparisons (two papers reported on multiple interventions) of computer-supported medication management to a control group. DATA EXTRACTION The quality of the RCTs was systematically assessed and scored independently by two reviewers. Rates of compliance with (potential) reminders for the control and intervention groups were extracted. DATA SYNTHESIS Heterogeneity of studies prevented a meta-analysis. Where possible, rates were calculated using the intention-to-treat principle. The comparisons were grouped into five areas. Reminders to providers in outpatient settings: six of 12 comparisons demonstrated positive effects (relative rates [RRs: intervention rates/control rates], 1.0 to 42.0). Provider feedback in outpatient settings: five of seven comparisons showed improved clinician behaviour (RRs, 1.0 to 2.5). Combined reminders and feedback in outpatient settings: the single comparison found no improvement. Reminders to providers in inpatient settings: three of five comparisons showed improvements (RRs, 1.0 to 2.1). Patient-directed reminders: two of four comparisons showed improvements in patient compliance. CONCLUSION Reminders are more effective than feedback in modifying physician behaviour related to medication management. Patient-directed reminders can improve medication adherence.
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Affiliation(s)
- John W Bennett
- University Health Service, University of Queensland, Gordon Greenwood Building, Brisbane, Queensland 4072, Australia.
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Sanders KM, Satyvavolu A. Improving blood pressure control in diabetes: limitations of a clinical reminder in influencing physician behavior. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2002; 22:23-32. [PMID: 12004637 DOI: 10.1002/chp.1340220104] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Hypertension should be aggressively treated, especially in diabetic patients. But studies of physician prescribing habits reveal that physicians often delay making medication changes or initiating antihypertensive therapy. A chart-based reminder was designed to improve physician medication prescribing in this clinical situation. METHODS A randomized controlled trial was conducted at the Veterans Affairs Medical Center in Richmond, Virginia. Patients with diabetes and hypertension were selected. A highly visible chart reminder was applied to the front of outpatient charts in the intervention group practice. A chart review was conducted to assess physician-directed medication changes. A successful outcome was defined as any antihypertensive medication increase or addition at that same visit. RESULTS Physicians were more likely to intensify antihypertensive medication as the blood pressure increased regardless of the reminder. Overall, only 33% of visits resulted in a medication change, even though 93% of patients had elevations over target blood pressure at the follow-up visit. Physicians in the intervention and control groups made changes to medication at similar rates (chi 2 = 0.621, p = .511). DISCUSSION In this study, a chart reminder failed to improve physician compliance with the clinical guideline for hypertension management in diabetics, Sixth Report of the Joint National Committee on the Detection, Evaluation, Prevention and Treatment of High Blood Pressure. To inform the design of effective intervention strategies, further research should explore specific barriers to guideline adherence in this clinical situation.
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Affiliation(s)
- Karen M Sanders
- Office of Continuing Medical Education, Virginia Commonwealth University School of Medicine, Hunter Holmes McGuire Department of Veterans Affairs Medical Center, Richmond, Virginia, USA
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