Clinical effect of computer generated physician reminders in health screening in primary health care--a controlled clinical trial of preventive services among the elderly

Surveillance mammography in older breast cancer survivors: Current practice patterns and patient perceptions

INTRODUCTION

Although the benefits of surveillance mammography for older breast cancer survivors have not been quantified prospectively, it is unlikely that mammography provides substantial benefit (and possible that mammography is harmful) to women with limited life expectancy and a low risk for in-breast cancer events.

MATERIALS AND METHODS

We identified 1268 women aged 77 and older with a history of Stage I-III breast cancer, who did not undergo bilateral mastectomy, were diagnosed with cancer at least three years prior to study entry, and who had consented to be surveyed as part of the Mayo Clinic Breast Disease Registry. We mailed them a one-time survey asking about their experiences with surveillance mammography. Women with metastatic disease were excluded. The primary endpoint was whether or not women reported at least one mammogram since breast cancer surgery.

RESULTS

Eight hundred forty-six of 1268 (67%) returned the survey, 734 of whom were eligible for analysis. The median age at the time of survey was 82, and the median time since cancer diagnosis was 12 years. Ninety-three percent reported having had at least one mammogram since their initial breast cancer surgery. Seventy-nine percent reported that they had surveillance mammography annually over the prior three years, including 76% of the 491 aged 80+ and 64% of the 189 aged 85 + .

DISCUSSION

Most older breast cancer survivors who have residual breast tissue are undergoing annual mammograms. Additional educational materials may be beneficial for patients and clinicians to better individualize plans for surveillance mammography in older breast cancer survivors.

A Regional Health Care Network: eHealth.Braunschweig

Background: Health care network eHealth.Braunschweig has been started in the South-East region of Lower Saxony in Germany in 2009. It composes major health care players, participants from research institutions and important local industry partners.

Objectives: The objective of this paper is firstly to describe the relevant regional characteristics and distinctions of the eHealth.Braunschweig health care network and to inform about the goals and structure of eHealth.Braunschweig; secondly to picture and discuss the main concepts and domain fields which are addressed in the health care network; and finally to discuss the architectural challenges of eHealth.Braunschweig regarding the addressed domain fields and defined requirements.

Methods: Based on respective literature and former conducted projects we discuss the project structure and goals of eHealth.Braunschweig, depict major domain fields and requirements gained in workshops with participants and discuss the architectural challenges as well as the architectural approach of eHealth.Braunschweig network.

Results: The regional healthcare network eHealth.Braunschweig has been established in April 2009. Since then the network has grown constantly and a sufficient progress in network activities has been achieved. The main domain fields have been specified in different workshops with network participants and an architectural realization approach for the transinstitutional information system architecture in the healthcare network has been developed. However, the effects on quality of information processing and quality of patient care have not been proved yet. Systematic evaluation studies have to be done in future in order to investigate the impact of information and communication technology on the quality of information processing and the quality of patient care.

Conclusions: In general, the aspects described in this paper are expected to contribute to a systematic approach for the establishment of regional health care networks with lasting and sustainable effects on patient-centered health care in a regional context.

Are interventions to increase the uptake of screening for cardiovascular disease risk factors effective? A systematic review and meta-analysis

Background

Cardiovascular disease (CVD) is the leading cause of death globally. However, many individuals are unaware of their CVD risk factors. The objective of this systematic review is to determine the effectiveness of existing intervention strategies to increase uptake of CVD risk factors screening.

Methods

A systematic search was conducted through Pubmed, CINAHL, EMBASE and Cochrane Central Register of Controlled Trials. Additional articles were located through cross-checking of the references list and bibliography citations of the included studies and previous review papers. We included intervention studies with controlled or baseline comparison groups that were conducted in primary care practices or the community, targeted at adult populations (randomized controlled trials, non-randomized trials with controlled groups and pre- and post-intervention studies). The interventions were targeted either at individuals, communities, health care professionals or the health-care system. The main outcome of interest was the relative risk (RR) of screening uptake rates due to the intervention.

Results

We included 21 studies in the meta-analysis. The risk of bias for randomization was low to medium in the randomized controlled trials, except for one, and high in the non-randomized trials. Two analyses were performed; optimistic (using the highest effect sizes) and pessimistic (using the lowest effect sizes). Overall, interventions were shown to increase the uptake of screening for CVD risk factors (RR 1.443; 95% CI 1.264 to 1.648 for pessimistic analysis and RR 1.680; 95% CI 1.420 to 1.988 for optimistic analysis). Effective interventions that increased screening participation included: use of physician reminders (RR ranged between 1.392; 95% CI 1.192 to 1.625, and 1.471; 95% CI 1.304 to 1.660), use of dedicated personnel (RR ranged between 1.510; 95% CI 1.014 to 2.247, and 2.536; 95% CI 1.297 to 4.960) and provision of financial incentives for screening (RR 1.462; 95% CI 1.068 to 2.000). Meta-regression analysis showed that the effect of CVD risk factors screening uptake was not associated with study design, types of population nor types of interventions.

Conclusions

Interventions using physician reminders, using dedicated personnel to deliver screening, and provision of financial incentives were found to be effective in increasing CVD risk factors screening uptake.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0579-8) contains supplementary material, which is available to authorized users.

Clinical Decision Support Systems and Prevention: A Community Guide Cardiovascular Disease Systematic Review

CONTEXT

Clinical decision support systems (CDSSs) can help clinicians assess cardiovascular disease (CVD) risk and manage CVD risk factors by providing tailored assessments and treatment recommendations based on individual patient data. The goal of this systematic review was to examine the effectiveness of CDSSs in improving screening for CVD risk factors, practices for CVD-related preventive care services such as clinical tests and prescribed treatments, and management of CVD risk factors.

EVIDENCE ACQUISITION

An existing systematic review (search period, January 1975-January 2011) of CDSSs for any condition was initially identified. Studies of CDSSs that focused on CVD prevention in that review were combined with studies identified through an updated search (January 2011-October 2012). Data analysis was conducted in 2013.

EVIDENCE SYNTHESIS

A total of 45 studies qualified for inclusion in the review. Improvements were seen for recommended screening and other preventive care services completed by clinicians, recommended clinical tests completed by clinicians, and recommended treatments prescribed by clinicians (median increases of 3.8, 4.0, and 2.0 percentage points, respectively). Results were inconsistent for changes in CVD risk factors such as systolic and diastolic blood pressure, total and low-density lipoprotein cholesterol, and hemoglobin A1C levels.

CONCLUSIONS

CDSSs are effective in improving clinician practices related to screening and other preventive care services, clinical tests, and treatments. However, more evidence is needed from implementation of CDSSs within the broad context of comprehensive service delivery aimed at reducing CVD risk and CVD-related morbidity and mortality.

The forgotten risk? A systematic review of the effect of reminder systems for postpartum screening for type 2 diabetes in women with previous gestational diabetes

Background

Screening for type 2 diabetes is recommended for women with previous gestational diabetes (GDM). However, the screening rates remain low. We aimed to evaluate the reminders and reminder systems for women with previous GDM and the health professionals in primary and secondary health care with screening rate among postpartum women as primary outcome.

Methods

Observational and intervention studies were included and the PRISMA guidelines were followed for the literature extraction.

Results

Six studies were included: two long-term follow up studies and four early terms. Five studies focused on secondary care settings and one on primary care. Three studies focused on reminders to postpartum women only, two studies to both the women and health care professional, and one study on the health care provider only. Types of reminders varied from letters, emails, and personal telephone calls to the women to register-based reminders or letters to the health care professionals. Reminders were efficient but efficiency varied between studies. Two studies found that direct telephone calls strengthened the reminding of the women. The effect of reminding both the women and the health professional screening rates decreased compared to reminding either health professionals or reminding the women separately.

Conclusions

Reminders have a potential for early detection and prevention of type 2 diabetes in this high risk group of women; however, the kind of reminder and the frequency of reminders should be carefully considered accordingly to the target group.

An early evaluation of implementation of brief intervention for unhealthy alcohol use in the US Veterans Health Administration

AIMS

The US Veterans Health Administration [Veterans Affairs (VA)] used performance measures and electronic clinical reminders to implement brief intervention for unhealthy alcohol use. We evaluated whether documented brief intervention was associated with subsequent changes in drinking during early implementation.

DESIGN

Observational, retrospective cohort study using secondary clinical and administrative data.

SETTING

Thirty VA facilities.

PARTICIPANTS

Outpatients who screened positive for unhealthy alcohol use [Alcohol Use Disorders Identification Test Consumption (AUDIT-C ≥ 5)] in the 6 months after the brief intervention performance measure (n = 22 214) and had follow-up screening 9-15 months later (n = 6210; 28%).

MEASUREMENTS

Multi-level logistic regression estimated the adjusted prevalence of resolution of unhealthy alcohol use (follow-up AUDIT-C <5 with ≥2 point reduction) for patients with and without documented brief intervention (documented advice to reduce or abstain from drinking).

FINDINGS

Among 6210 patients with follow-up alcohol screening, 1751 (28%) had brief intervention and 2922 (47%) resolved unhealthy alcohol use at follow-up. Patients with documented brief intervention were older and more likely to have other substance use disorders, mental health conditions, poor health and more severe unhealthy alcohol use than those without (P-values < 0.05). Adjusted prevalences of resolution were 47% [95% confidence interval (CI) = 42-52%] and 48% (95% CI = 42-54%) for patients with and without documented brief intervention, respectively (P = 0.50).

CONCLUSIONS

During early implementation of brief intervention in the US Veterans Health Administration, documented brief intervention was not associated with subsequent changes in drinking among outpatients with unhealthy alcohol use and repeat alcohol screening.

Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes

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.

Community-based, interdisciplinary geriatric care team satisfaction with an electronic health record: a multimethod study

This multimethod study measured the impact of an electronic health record (EHR) on clinician satisfaction with clinical process. Subjects were 39 clinicians at a Program of All-inclusive Care for Elders (PACE) site in Philadelphia utilizing an EHR. Methods included the evidence-based evaluation framework, Health Information Technology Research-Based Evaluation Framework, which guided assessment of clinician satisfaction with surveys, observations, follow-up interviews, and actual EHR use at two points in time. Mixed-methods analysis of findings provided context for interpretation and improved validity. The study found that clinicians were satisfied with the EHR; however, satisfaction declined between time periods. Use of EHR was universal and wide and was differentiated by clinical role. Between time periods, EHR use increased in volume, with increased timeliness and decreased efficiency. As the first EHR evaluation at a PACE site from the perspective of clinicians who use the system, this study provides insights into EHR use in the care of older people in community-based healthcare settings.

General health checks in adults for reducing morbidity and mortality from disease

BACKGROUND

General health checks are common elements of health care in some countries. These aim to detect disease and risk factors for disease with the purpose of reducing morbidity and mortality. Most of the commonly used screening tests offered in general health checks have been incompletely studied. Also, screening leads to increased use of diagnostic and therapeutic interventions, which can be harmful as well as beneficial. It is, therefore, important to assess whether general health checks do more good than harm.

OBJECTIVES

We aimed to quantify the benefits and harms of general health checks with an emphasis on patient-relevant outcomes such as morbidity and mortality rather than on surrogate outcomes such as blood pressure and serum cholesterol levels.

SEARCH METHODS

We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, MEDLINE, EMBASE, Healthstar, CINAHL, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) to July 2012. Two authors screened titles and abstracts, assessed papers for eligibility and read reference lists. One author used citation tracking (Web of Knowledge) and asked trialists about additional studies.

SELECTION CRITERIA

We included randomised trials comparing health checks with no health checks in adults unselected for disease or risk factors. We did not include geriatric trials. We defined health checks as screening general populations for more than one disease or risk factor in more than one organ system.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed the risk of bias in the trials. We contacted authors for additional outcomes or trial details when necessary. For mortality outcomes we analysed the results with random-effects model meta-analysis, and for other outcomes we did a qualitative synthesis as meta-analysis was not feasible.

MAIN RESULTS

We included 16 trials, 14 of which had available outcome data (182,880 participants). Nine trials provided data on total mortality (155,899 participants, 11,940 deaths), median follow-up time nine years, giving a risk ratio of 0.99 (95% confidence interval (CI) 0.95 to 1.03). Eight trials provided data on cardiovascular mortality (152,435 participants, 4567 deaths), risk ratio 1.03 (95% CI 0.91 to 1.17) and eight trials on cancer mortality (139,290 participants, 3663 deaths), risk ratio 1.01 (95% CI 0.92 to 1.12). Subgroup and sensitivity analyses did not alter these findings.We did not find an effect on clinical events or other measures of morbidity but one trial found an increased occurrence of hypertension and hypercholesterolaemia with screening and one trial found an increased occurence of self-reported chronic disease. One trial found a 20% increase in the total number of new diagnoses per participant over six years compared to the control group. No trials compared the total number of prescriptions, but two out of four trials found an increased number of people using antihypertensive drugs. Two out of four trials found small beneficial effects on self-reported health, but this could be due to reporting bias as the trials were not blinded. We did not find an effect on admission to hospital, disability, worry, additional visits to the physician, or absence from work, but most of these outcomes were poorly studied. We did not find useful results on the number of referrals to specialists, the number of follow-up tests after positive screening results, or the amount of surgery.

AUTHORS' CONCLUSIONS

General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased. Important harmful outcomes, such as the number of follow-up diagnostic procedures or short term psychological effects, were often not studied or reported and many trials had methodological problems. With the large number of participants and deaths included, the long follow-up periods used, and considering that cardiovascular and cancer mortality were not reduced, general health checks are unlikely to be beneficial.

Improving delivery of EPSDT well-child care at acute visits in an academic pediatric practice

BACKGROUND AND OBJECTIVE

Many patients with Medicaid do not receive timely, comprehensive well-child care through the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. Missed opportunities for EPSDT well-child check-ups (WCCs) at acute visits contribute to this problem. The authors sought to reduce missed opportunities for WCCs at acute visits for patients overdue for those services.

METHODS

A quality improvement team developed key drivers and used a people-process-technology framework to devise 3 interventions: (1) an electronic indicator based on novel definitions of EPSDT status (up-to-date, due, overdue, no EPSDT), (2) a standardized scheduling process for acute visits based on EPSDT status, and (3) a dedicated nurse practitioner to provide WCCs at acute visits. Data were collected for 1 year after full implementation.

RESULTS

At baseline, 10.3 acute visits per month were converted to WCCs. After intervention, 86.7 acute visits per month were converted. Of 13801 acute visits during the project, 31.2% were not up-to-date. Of those overdue for WCCs, 51.4% (n = 552) were converted to a WCC in addition to the acute visit. Including all patients who were not up-to-date, a total of 1047 acute visits (7.6% of all acute visits) were converted to comprehensive WCCs. Deferring needed WCCs at acute visits resulted in few patients who scheduled or completed future WCC visits.

CONCLUSIONS

Implementation of interventions focused on people-process-technology significantly increased WCCs at acute visits within a feasible and practical model that may be replicated at other academic general pediatrics practices.

Analysis of the EHR systems in Spanish Primary Public Health System: the lack of interoperability

This paper presents the impact of the Electronic Health Records (EHRs) systems jointly in the Spanish Primary Public Health System. Different EHRs that exist in each of the Spanish regions are discussed. Moreover, other purpose of this analysis is to identify the current state of knowledge about health information systems adoption in primary care in Spain. For the analysis and study of EHRs systems in Spain we have relied on the use of different sources, mostly items related to the study of EHRs systems in different areas. We will analyze some technical aspects of these and some of their major implications, both positive and negative. Moreover, we have resorted to make direct contact with the organizations that have implemented the EHRs systems. The result of this study leads to a main idea, the need for interoperability between different systems. We will delve into how we have reached this conclusion and that is the key to EHRs systems homogenization of Spanish territory. EHR systems used in different regions of Spain offer the access to medical information as well as provide a clinical analysis of each patient more quickly. The adoption of health information systems is seen world wide as one method to mitigate the widening health care demand and supply gap.

The development of a highly constrained health level 7 implementation guide to facilitate electronic laboratory reporting to ambulatory electronic health record systems

Electronic laboratory interfaces can significantly increase the value of ambulatory electronic health record (EHR) systems by providing laboratory result data automatically and in a computable form. However, many ambulatory EHRs cannot implement electronic laboratory interfaces despite the existence of messaging standards, such as Health Level 7, version 2 (HL7). Among several barriers to implementing laboratory interfaces is the extensive optionality within the HL7 message standard. This paper describes the rationale for and development of an HL7 implementation guide that seeks to eliminate most of the optionality inherent in HL7, but retain the information content required for reporting outpatient laboratory results. A work group of heterogeneous stakeholders developed the implementation guide based on a set of design principles that emphasized parsimony, practical requirements, and near-term adoption. The resulting implementation guide contains 93% fewer optional data elements than HL7. This guide was successfully implemented by 15 organizations during an initial testing phase and has been approved by the HL7 standards body as an implementation guide for outpatient laboratory reporting. Further testing is required to determine whether widespread adoption of the implementation guide by laboratories and EHR systems can facilitate the implementation of electronic laboratory interfaces.

Strategies for facilitating change in alcohol and other drugs (AOD) professional practice: a systematic review of the effectiveness of reminders and feedback

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.

Outcomes assessment of clinical information system implementation: a practical guide

Healthcare information systems (HIS) play a vital role in quality of care and the organization's daily operations. Consequently, increasing numbers of clinicians have been involved in HIS implementation, particularly for clinical information systems (CIS). Implementation of these systems is a major organizational investment, and its outcomes must be assessed. The purpose of this article is to provide clinicians and frontline informaticians with a practical guide to assess these outcomes, focusing on outcome variables, assessment methods, and timing of assessment. Based on in-depth literature reviews and their empirical experiences, the authors identified 3 frequently used outcomes: user satisfaction, clinical outcomes, and financial impact. These outcomes have been assessed employing various methods, including randomized controlled trials, pre- and post-test studies, time and motion studies, surveys, and user testing. The timing for outcomes assessments varied depending on several factors, such as learning curves or patients conditions. In conclusion, outcomes assessment is essential for the success of healthcare information technology, and the CIS implementation team members must be prepared to conduct and/or facilitate these studies.

Information systems for patient follow-up and chronic management of HIV and tuberculosis: a life-saving technology in resource-poor areas

Background

The scale-up of treatment for HIV and multidrug-resistant tuberculosis (MDR-TB) in developing countries requires a long-term relationship with the patient, accurate and accessible records of each patient’s history, and methods to track his/her progress. Recent studies have shown up to 24% loss to follow-up of HIV patients in Africa during treatment and many patients not being started on treatment at all. Some programs for prevention of maternal–child transmission have more than 80% loss to follow-up of babies born to HIV-positive mothers. These patients are at great risk of dying or developing drug resistance if their antiretroviral therapy is interrupted. Similar problems have been found in the scale-up of MDR-TB treatment.

Objectives

The aim of the study was to assess the role of medical information systems in tracking patients with HIV or MDR-TB, ensuring they are promptly started on high quality care, and reducing loss to follow-up.

Methods

A literature search was conducted starting from a previous review and using Medline and Google Scholar. Due to the nature of this work and the relative lack of published articles to date, the authors also relied on personal knowledge and experience of systems in use and their own assessments of systems.

Results

Functionality for tracking patients and detecting those lost to follow-up is described in six HIV and MDR-TB treatment projects in Africa and Latin America. Preliminary data show benefits in tracking patients who have not been prescribed appropriate drugs, those who fail to return for follow-up, and those who do not have medications picked up for them by health care workers. There were also benefits seen in providing access to key laboratory data and in using this data to improve the timeliness and quality of care. Follow-up was typically achieved by a combination of reports from information systems along with teams of community health care workers. New technologies such as low-cost satellite Internet access, personal digital assistants, and cell phones are helping to expand the reach of these systems.

Conclusions

Effective information systems in developing countries are a recent innovation but will need to play an increasing role in supporting and monitoring HIV and MDR-TB projects as they scale up from thousands to hundreds of thousands of patients. A particular focus should be placed on tracking patients from initial diagnosis to initiation of effective treatment and then monitoring them for treatment breaks or loss to follow-up. More quantitative evaluations need to be performed on the impact of electronic information systems on tracking patients.

Improving osteoporosis screening: results from a randomized cluster trial

BACKGROUND

Despite recommendations, osteoporosis screening rates among women aged 65 years and older remain low. We present results from a clustered, randomized trial evaluating patient mailed reminders, alone and in combination with physician prompts, to improve osteoporosis screening and treatment.

METHODS

Primary care clinics (n = 15) were randomized to usual care, mailed reminders alone, or mailed reminders with physician prompts. Study patients were females aged 65-89 years (N = 10,354). Using automated clinical and pharmacy data, information was collected on bone mineral density testing, pharmacy dispensings, and other patient characteristics. Unadjusted/adjusted differences in testing and treatment were assessed using generalized estimating equation approaches.

RESULTS

Osteoporosis screening rates were 10.8% in usual care, 24.1% in mailed reminder, and 28.9% in mailed reminder with physician prompt. Results adjusted for differences at baseline indicated that mailed reminders significantly improved testing rates compared to usual care, and that the addition of prompts further improved testing. This effect increased with patient age. Treatment rates were 5.2% in usual care, 8.4% in mailed reminders, and 9.1% in mailed reminders with prompt. No significant differences were found in treatment rates between those receiving mailed reminders alone or in combination with physician prompts. However, women receiving usual care were significantly less likely to be treated.

CONCLUSIONS

The use of mailed reminders, either alone or with physician prompts, can significantly improve osteoporosis screening and treatment rates among insured primary care patients (Clinical Trials.gov number NCT00139425).

Provider knowledge and practice regarding hepatitis B screening in Chinese-speaking patients

BACKGROUND

The extent to which academic general medicine providers screen Chinese-speaking patients for hepatitis B virus (HBV) is not known.

METHODS

Retrospective cohort study of Chinese-speaking patients' HBV screening status and survey of providers' HBV knowledge/screening.

RESULTS

Most patients (65%) received HBV screening. Being screened was independently associated with marital status and years in the clinic. Providers with Asian language abilities and greater knowledge of HBV risk factors/guidelines were more likely to screen.

CONCLUSIONS

Chinese-speaking patients in this setting were underscreened for HBV. Providers underestimated the risks associated with Chinese ethnicity. Education is needed to improve risk assessment and guideline awareness.

It Ain't Necessarily So: The Electronic Health Record And The Unlikely Prospect Of Reducing Health Care Costs

Electronic health record (EHR) advocates argue that EHRs lead to reduced errors and reduced costs. Many reports suggest otherwise. The EHR often leads to higher billings and declines in provider productivity with no change in provider-to-patient ratios. Error reduction is inconsistent and has yet to be linked to savings or malpractice premiums. As interest in patient-centeredness, shared decision making, teaming, group visits, open access, and accountability grows, the EHR is better viewed as an insufficient yet necessary ingredient. Absent other fundamental interventions that alter medical practice, it is unlikely that the U.S. health care bill will decline as a result of the EHR alone.

Factors associated with improved completion of computerized clinical reminders across a large healthcare system

OBJECTIVE

To analyze the relationship of completion rates for a standardized set of computerized clinical reminders across a large healthcare system to practice and provider characteristics.

METHODS

The relationship between completion rate for 13 standardized reminders at 49 primary care practices in the VA New England Healthcare System for a 30-day period and practice characteristics, provider demographics and, via survey, provider attitudes was analyzed.

RESULTS

There was no difference in clinical reminder completion rate between staff physicians versus nurse practitioners/physician assistants (87.6% versus 88.1%) but both were better than residents (76.6%, p<0.0001). With residents excluded, there were no differences between hospital and community-based clinics or between teaching and non-teaching sites. Clinical reminder completion rate was lower for sites that did not fully utilize support staff in completion process versus sites that did (82.4% versus 88.1%, p<0.0001). Analysis of survey results showed no correlation of completion rate with provider demographics or attitudes towards reminders. However there was significant correlation with frequency of receiving individual feedback on reminder completion (r=0.288, p=0.004).

CONCLUSION

Completion of computerized clinical reminders was not affected by a variety of provider characteristics, including professional training, demographics and provider attitude, although was lower among residents than staff providers. However incorporation of support staff into clinic processes and individualized feedback to providers were strongly associated with improved completion. These findings demonstrate the importance of considering practice and provider factors and not just technical elements when implementing informatics tools.

Individualization, globalization and health--about sustainable information technologies and the aim of medical informatics

This paper discusses aspects of information technologies for health care, in particular on transinstitutional health information systems (HIS) and on health-enabling technologies, with some consequences for the aim of medical informatics. It is argued that with the extended range of health information systems and the perspective of having adequate transinstitutional HIS architectures, a substantial contribution can be made to better patient-centered care, with possibilities ranging from regional, national to even global care. It is also argued that in applying health-enabling technologies, using ubiquitous, pervasive computing environments and ambient intelligence approaches, we can expect that in addition care will become more specific and tailored for the individual, and that we can achieve better personalized care. In developing health care systems towards transinstitutional HIS and health-enabling technologies, the aim of medical informatics, to contribute to the progress of the sciences and to high-quality, efficient, and affordable health care that does justice to the individual and to society, may be extended to also contributing to self-determined and self-sufficient (autonomous) life. Reference is made and examples are given from the Yearbook of Medical Informatics of the International Medical Informatics Association (IMIA) and from the work of Professor Jochen Moehr.

Hypertension: trends in prevalence, incidence, and control

Hypertension is the leading cause of cardiovascular disease worldwide. Prior to 1990, population data suggest that hypertension prevalence was decreasing; however, recent data suggest that it is again on the rise. In 1999-2002, 28.6% of the U.S. population had hypertension. Hypertension prevalence has also been increasing in other countries, and an estimated 972 million people in the world are suffering from this problem. Incidence rates of hypertension range between 3% and 18%, depending on the age, gender, ethnicity, and body size of the population studied. Despite advances in hypertension treatment, control rates continue to be suboptimal. Only about one third of all hypertensives are controlled in the United States. Programs that improve hypertension control rates and prevent hypertension are urgently needed.

Protocol for the 'e-Nudge trial': a randomised controlled trial of electronic feedback to reduce the cardiovascular risk of individuals in general practice [ISRCTN64828380]

Background

Cardiovascular disease (including coronary heart disease and stroke) is a major cause of death and disability in the United Kingdom, and is to a large extent preventable, by lifestyle modification and drug therapy. The recent standardisation of electronic codes for cardiovascular risk variables through the United Kingdom's new General Practice contract provides an opportunity for the application of risk algorithms to identify high risk individuals. This randomised controlled trial will test the benefits of an automated system of alert messages and practice searches to identify those at highest risk of cardiovascular disease in primary care databases.

Design

Patients over 50 years old in practice databases will be randomised to the intervention group that will receive the alert messages and searches, and a control group who will continue to receive usual care. In addition to those at high estimated risk, potentially high risk patients will be identified who have insufficient data to allow a risk estimate to be made. Further groups identified will be those with possible undiagnosed diabetes, based either on elevated past recorded blood glucose measurements, or an absence of recent blood glucose measurement in those with established cardiovascular disease.

Outcome measures

The intervention will be applied for two years, and outcome data will be collected for a further year. The primary outcome measure will be the annual rate of cardiovascular events in the intervention and control arms of the study. Secondary measures include the proportion of patients at high estimated cardiovascular risk, the proportion of patients with missing data for a risk estimate, and the proportion with undefined diabetes status at the end of the trial.

Strategies to enhance effectiveness of individual based nutrition communications

Lifestyle modifications, including dietary and physical activity, are treatments for many chronic health conditions. Therefore, there is continued interest in improving the quantity and quality of nutrition information provided to the patient by the physician. This paper reviews the evidence to support motivational interviewing and other similar strategies for nutrition communications. Limited but positive data were found.