Randomized Controlled Trial of Electronic Care Plan Alerts and Resource Utilization by High Frequency Emergency Department Users with Opioid Use Disorder

Effectiveness of emergency department based interventions for frequent users with mental health issues: A systematic review

Frequent emergency department (ED) users with mental health issues are particularly vulnerable patients, who often receive insufficient or inadequate outpatient care. This systematic review identified and evaluated studies on ED-based interventions to reduce acute care use by this population, while improving outpatient service use and patient outcomes. Searches were conducted in five databases for studies published between January 1, 2000, and April 30, 2022. Eligibility criteria included: patients with mental health issues who made 2+ ED visits in the previous 6 months or were high ED users (3+ visits/year), and who received ED-based interventions to reduce ED use. The review included 12 studies of 11,082 articles screened. Four intervention groups were identified: care plan (n = 4), case management (n = 4), peer-support (n = 2) and brief interventions (n = 2). The definitions of frequent users varied considerably, while the quality assessment rated studies from moderate to good and risk of bias from low to high. Eight studies used pre-post design, and four were randomized controlled trials. Ten studies assessed outcomes related to use of other services than ED, mainly hospitalizations, while five assessed patients' clinical conditions and three, social conditions (e.g., housing status). This review revealed that case management and care plan interventions, based in ED, decrease ED use among frequent users, while case management also showed promising results for outpatient service use and clinical and social outcomes. Thus, the results support continued deployment of intensive ED-based interventions for frequent ED users with mental health issues although firm conclusions regarding the effectiveness of these interventions, particularly outcomes related to services other than ED, require further investigation.

What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review

OBJECTIVES

Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide.

DESIGN

A mixed-methods scoping review was conducted using the Arksey and O'Malley framework.

DATA SOURCES

Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022.

ELIGIBILITY CRITERIA

Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied.

DATA EXTRACTION AND SYNTHESIS

Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment.

RESULTS

The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care.

CONCLUSION

High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.

Opioid Prescribing for Chronic Musculoskeletal Conditions: Trends over Time and Implementation of Safe Opioid-Prescribing Practices

OBJECTIVES

This study aimed (1) to determine the impact of a clinical decision support (CDS) tool on rate of opioid prescribing and opioid dose for patients with chronic musculoskeletal conditions and (2) to identify prescriber and facility characteristics associated with adherence to the Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain in this population.We conducted an interrupted time series analysis to assess trends in percentage of patients from 2016 to 2020, receiving an opioid and the average opioid dose, as well as the change associated with implementation of the CDS toolkit. We conducted a retrospective cohort study to assess the association between prescriber and facility characteristics and safe opioid-prescribing practices.

METHODS

We assessed the impact of the CDS intervention on percent of patients receiving an opioid and average opioid dose (morphine milligram equivalents). We operationalized safe opioid prescribing as a composite score of several behaviors (i.e., prescribing naloxone, initiating a pain agreement, prescribing <90 MME, avoiding extended-release prescriptions for opioid-naïve patients, and avoiding coprescribing opioids and benzodiazepines) and used a hierarchical linear regression model to assess associations between prescriber and facility characteristics and safe opioid prescribing.

RESULTS

This CDS intervention had a modest but statistically significant 1.6% reduction on the percent of patients (n = 1,290,746) receiving an opioid (mean: 15% preintervention; 10% postintervention). The average dose of opioid prescriptions did not significantly change. Advanced practice providers and prescribers with higher percentages of patients aged 18 to 64 exhibited safer opioid prescribing, while prescribers with higher percentages of white patients and larger numbers of patients on opioids exhibited less safe opioid prescribing.

CONCLUSION

A CDS intervention was associated with a small improvement in percent of patients receiving an opioid, but not on average dose. Clinicians are not prescribing opioids for chronic musculoskeletal conditions frequently, when they do, they are generally adhering to guidelines.

The influence of electronic reminders on recording diagnoses in a primary health care emergency department: a register-based study in a Finnish town

OBJECTIVE

This study examines whether implementation of electronic reminders is associated with a change in the amount and content of diagnostic data recorded in primary health care emergency departments (ED).

DESIGN

A register-based 12-year follow-up study with a before-and-after design.

SETTING

This study was performed in a primary health care ED in Finland. An electronic reminder was installed in the health record system to remind physicians to include the diagnosis code of the visit to the health record.

SUBJECTS AND MAIN OUTCOME MEASURES

The report generator of the electronic health record-system provided monthly figures for the number of different recorded diagnoses by using the International Classification of Diagnoses (ICD-10th edition) and the total number of ED physician visits, thus allowing the calculation of the recording rate of diagnoses on a monthly basis and the comparison of diagnoses before and after implementing electronic reminders.

RESULTS

The most commonly recorded diagnoses in the ED were acute upper respiratory infections of various and unspecified sites (5.8%), abdominal and pelvic pain (4.8%), suppurative and unspecified otitis media (4.5%) and dorsalgia (4.0%). The diagnosis recording rate in the ED doubled from 41.2 to 86.3% (p < 0.001) after the application of electronic reminders. The intervention especially enhanced the recording rate of symptomatic diagnoses (ICD-10 group-R) and alcohol abuse-related diagnoses (ICD-10 code F10). Mental and behavioural disorders (group F) and injuries (groups S-Y) were also better recorded after this intervention.

CONCLUSION

Electronic reminders may alter the documentation habits of physicians and recording of clinical data, such as diagnoses, in the EDs. This may be of use when planning resource managing in EDs and planning their actions.KEY POINTSElectronic reminders enhance recording of diagnoses in primary care but what happens in emergency departments (EDs) is not known.Electronic reminders enhance recording of diagnoses in primary care ED.Especially recording of symptomatic diagnoses and alcohol abuse-related diagnoses increased.

Association between supportive interventions and healthcare utilization and outcomes in patients on long-term prescribed opioid therapy presenting to acute healthcare settings: a systematic review and meta-analysis

BACKGROUND

Long-term prescription of opioids by healthcare professionals has been linked to poor individual patient outcomes and high resource utilization. Supportive strategies in this population regarding acute healthcare settings may have substantial impact.

METHODS

We performed a systematic review and meta-analysis of primary studies. The studies were included according to the following criteria: 1) age 18 and older; 2) long-term prescribed opioid therapy; 3) acute healthcare setting presentation from a complication of opioid therapy; 4) evaluating a supportive strategy; 5) comparing the effectiveness of different interventions; 6) addressing patient or healthcare related outcomes. We performed a qualitative analysis of supportive strategies identified. We pooled patient and system related outcome data for each supportive strategy.

RESULTS

A total of 5664 studies were screened and 19 studies were included. A total of 9 broad categories of supportive strategies were identified. Meta-analysis was performed for the "supports for patients in pain" supportive strategy on two system-related outcomes using a ratio of means. The number of emergency department (ED) visits were significantly reduced for cohort studies (n = 6, 0.36, 95% CI [0.20-0.62], I2 = 87%) and randomized controlled trials (RCTs) (n = 3, 0.71, 95% CI [0.61-0.82], I2 = 0%). The number of opioid prescriptions at ED discharge was significantly reduced for RCTs (n = 3, 0.34, 95% CI [0.14-0.82], I2 = 78%).

CONCLUSION

For patients presenting to acute healthcare settings with complications related to long-term opioid therapy, the intervention with the most robust data is "supports for patients in pain".

Impact of Electronic Medical Record Alerts on Emergency Physician Workflow and Medical Management

BACKGROUND

Electronic medical record (EMR) alerts are automated messages that notify the physician of important information. However, little is known about how EMR alerts affect the workflow and decision-making of emergency physicians (EPs).

STUDY OBJECTIVES

This study aimed to quantify the number of EMR alerts EPs receive, the time required to resolve alerts, the types of alerts EPs receive, and the impact of alerts on patient management.

METHODS

We performed a prospective observational study at a tertiary care ED with 130,000 visits annually. Research assistants observed EPs on shift from May to December 2018. They recorded the number of EMR alerts received, time spent addressing the alerts, the types of alerts received, and queried the EP to determine if the alert impacted patient management.

RESULTS

Seven residents and six attending physicians were observed on a total of 17 shifts and 153 patient encounters; 78% (119) of patient encounters involved alerts. These 119 patients triggered 530 EMR alerts. EPs spent a mean of 7.06 s addressing each alert and addressed 3.46 alerts per total patient seen. In total, EPs spent approximately 24 s per patient resolving alerts. Only 12 alerts (2.26%) changed clinical management.

CONCLUSION

EPs frequently receive EMR alerts, however, most alerts were not perceived to impact patient care. These alerts contribute to the high volume of interruptions EPs must contend with in the clinical environment of the ED.

The Characteristics and Effectiveness of Interventions for Frequent Emergency Department Utilizing Patients With Chronic Noncancer Pain: A Systematic Review

BACKGROUND

Patients with chronic noncancer pain (CNCP) present unique challenges to emergency department (ED) care providers and administrators. Their conditions lead to frequent ED visits for pain relief and symptom management and are often poorly addressed with costly, low-yield care. A systematic review has not been performed to inform the management of frequent ED utilizing patients with CNCP. Therefore, we synthesized the available evidence on interventional strategies to improve care-associated outcomes for this patient group.

METHODS

We searched Medline, EMBASE, CINAHL, CENTRAL, SCOPUS, and Web of Science from database inception to June 2018 for eligible interventional studies aimed at reducing frequent ED utilization among adult patients with CNCP. Articles were assessed in duplicate in accordance with methodologic recommendations from the Cochrane Handbook for Systematic Reviews of Interventions. Outcomes of interest were the frequency of subsequent ED visits, type and amount of opioids administered in the ED and prescribed at discharge, and costs. Methodologic quality was assessed using the Cochrane Risk of Bias in Non-Randomized Studies of Interventions and Risk of Bias tools for nonrandomized and randomized studies, respectively.

RESULTS

Thirteen studies including 1,679 patients met the inclusion criteria. Identified interventions implemented pain policies (n = 4), individualized care plans (n = 5), ED care coordination (n = 2), chronic pain management pathways (n = 1), and behavioral health interventions (n = 1). All of the studies reported a decrease in ED visit frequency following their respective interventions. These reductions were especially pronounced in studies whose interventions were focused around individualized care plans and primary care involvement. Interventions implementing opioid restriction and pain management policies were largely successful in reducing the amounts of opioid medications administered and prescribed in the ED.

CONCLUSIONS

Multifaceted interventions, especially those employing individualized care plans, can successfully reduce subsequent ED visits, ED opioid administration and prescription, and care-associated costs for frequent ED utilizing patients with CNCP.

Impact of a Prescription Drug Monitoring Program on Health Information Exchange Utilization, Prescribing Behaviors, and Care Coordination in an Emergency Department

Timely access to patient data is critical in patient care. The utilization of health information exchange and prescription drug monitoring programs can make pertinent data readily accessible for emergency department providers to coordinate care. A quasi-experimental preintervention-postintervention design, with 62 providers and 53 554 emergency department visits linked to a health information exchange and prescription drug monitoring program, was used to evaluate rates for utilization, laboratory/imaging orders, narcotic prescribing and readmission. Health information exchange utilization increased significantly after the drug monitoring program was implemented (mean = 119.33 to mean = 231.33, t2 = -15.79, P < .001). There was no significant effect postprescription drug monitoring program for laboratory/imaging orders or narcotics at discharge, although narcotic orders during emergency visits increased (F1,23 = 7.953, P = .010), which may suggest the data confirmed the immediate need to control acute or chronic conditions. In addition, readmission rates decreased from 14.64% to 12.58%. Through streamlining processes, health information exchange and prescription drug monitoring program usage were increased, which can improve care. As organizations promote interoperability of health information, the nurse informaticist plays a significant role in managing access to systems that can assist all providers in coordinating care.

The Comprehensive Care Plan: A Patient-Centered, Multidisciplinary Communication Tool for Frequently Hospitalized Patients

Comprehensive care plans are dynamic documents maintained by an interdisciplinary team that contain specific, actionable information for clinicians and staff across multiple care settings. They promote communication and continuity of care by suggesting communication strategies, medical plans, and psychosocial resources. This article describes the structure and development process of comprehensive care plans for frequently hospitalized patients enrolled in a program designed to improve care for this vulnerable population. These care plans are widely used, with inpatient physicians referring to the care plan in their notes during 92.0% of admissions.

Interventions to manage use of the emergency and urgent care system by people from vulnerable groups: a mapping review

Background

The NHS currently faces increasing demands on accident and emergency departments. Concern has been expressed regarding whether the needs of vulnerable groups are being handled appropriately or whether alternative methods of service delivery may provide more appropriate emergency and urgent care services for particular groups.

Objective

Our objective was to identify what interventions exist to manage use of the emergency and urgent care system by people from a prespecified list of vulnerable groups. We aimed to describe the characteristics of these interventions and examine service delivery outcomes (for patients and the health service) resulting from these interventions.

Review methods

We conducted an initial mapping review to assess the quantity and nature of the published research evidence relating to seven vulnerable groups (socioeconomically deprived people and families, migrants, ethnic minority groups, the long-term unemployed/inactive, people with unstable housing situations, people living in rural/isolated areas and people with substance abuse disorders). Databases, including MEDLINE and the Cumulative Index to Nursing and Allied Health Literature, and other sources were searched between 2008 and 2018. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion. In addition, we searched for UK interventions and initiatives by examining press reports, commissioning plans and casebooks of ‘good practice’. We carried out a detailed intervention analysis, using an adapted version of the TIDieR (Template for Intervention Description and Replication) framework for describing interventions, and an analysis of current NHS practice initiatives.

Results

We identified nine different types of interventions: care navigators [three studies – moderate GRADE (Grading of Recommendations, Assessment, Development and Evaluations)], care planning (three studies – high), case finding (five studies – moderate), case management (four studies – high), front of accident and emergency general practice/front-door streaming model (one study – low), migrant support programme (one study – low), outreach services and teams (two studies – moderate), rapid access doctor/paramedic/urgent visiting services (one study – low) and urgent care clinics (one systematic review – moderate). Few interventions had been targeted at vulnerable populations; instead, they represented general population interventions or were targeted at frequent attenders (who may or may not be from vulnerable groups). Interventions supported by robust evidence (care navigators, care planning, case finding, case management, outreach services and teams, and urgent care clinics) demonstrated an effect on the general population, rather than specific population effects. Many programmes mixed intervention components (e.g. case finding, case management and care navigators), making it difficult to isolate the effect of any single component. Promising UK initiatives (front of accident and emergency general practice/front-door streaming model, migrant support programmes and rapid access doctor/paramedic/urgent visiting services) lacked rigorous evaluation. Evaluation should therefore focus on the clinical effectiveness and cost-effectiveness of these initiatives.

Conclusions

The review identified a limited number of intervention types that may be useful in addressing the needs of specific vulnerable populations, with little evidence specifically relating to these groups. The evidence highlights that vulnerable populations encompass different subgroups with potentially differing needs, and also that interventions seem particularly context sensitive. This indicates a need for a greater understanding of potential drivers for varying groups in specific localities.

Limitations

Resources did not allow exhaustive identification of all UK initiatives; the examples cited are indicative.

Future work

Research is required to examine how specific vulnerable populations differentially benefit from specific types of alternative service provision. Further exploration, using primary mixed-methods data and potentially realist evaluation, is required to explore what works for whom under what circumstances. Rigorous evaluation of UK initiatives is required, including a specific need for economic evaluations and for studies that incorporate effects on the wider emergency and urgent care system.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

PURPOSE

We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.

METHODS

A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018.

RESULTS

We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy.

CONCLUSIONS

Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.

Interventions to Decrease Use in Prehospital and Emergency Care Settings Among Super-Utilizers in the United States: A Systematic Review

Interest in high users of acute care continues to grow as health care organizations look to deliver cost-effective and high-quality care to patients. Since “super-utilizers” of acute care are responsible for disproportionately high health care spending, many programs and interventions have been implemented to reduce medical care use and costs in this population. This article presents a systematic review of the peer-reviewed and grey literature on evaluations of interventions to decrease prehospital and emergency care use among U.S. super-utilizers. Forty-six distinct evaluations were included in the review. The most commonly evaluated intervention was case management. Although a number of interventions reported reductions in prehospital and emergency care utilization and costs, methodological and study design weaknesses—especially regression to the mean—were widespread and call into question reported positive findings. More high-quality research is needed to accurately assess the impact of interventions to reduce prehospital and emergency care use in the super-utilizer population.

Real-Time Emergency Department Electronic Notifications Regarding High-Risk Patients: A Systematic Review

Background: To systematically review evidence on the feasibility and efficacy of real-time electronic notifications about patients at high risk of emergency department (ED) recidivism. Methods: Eight electronic databases were searched for empirical studies of real-time ED-based electronic tools, identifying adult patients at high risk of frequent utilization. Study selection and data extraction were performed independently by two reviewers. Qualitative data synthesis and assessment of strength of evidence were conducted through consensus discussion. Results: Of 2,256 records found through the search, 210 were duplicates, 2,004 were excluded based on abstract review, and 31 were excluded after full text review. The final sample consisted of 10 studies described in 11 articles describing the effect of real-time ED-based electronic notifications for high-risk patients. Three were randomized controlled trials (RCTs). All notifications were based on prespecified markers of risk. Seven studies integrated complex care plans into the electronic health record. Effect on ED use and length of stay (LOS) was mixed: nine studies reported decreased ED use, although results were statistically significant in only three studies; for LOS, one study reported a statistically significant reduction. Impact on cost and financial metrics was promising, with three (of three studies reporting this metric) showing improved organizational financial metrics. Three RCTs reported a reduction in opioid prescriptions. Conclusions: Real-time electronic notifications of ED providers regarding patients at high risk of ED recidivism are feasible. They may help reduce resource utilization and costs. Large knowledge gaps remain regarding patient- and provider-centered outcomes.

Review of implementation strategies to change healthcare provider behaviour in the emergency department

OBJECTIVES

Advances in emergency medicine research can be slow to make their way into clinical care, and implementing a new evidence-based intervention can be challenging in the emergency department. The Canadian Association of Emergency Physicians (CAEP) Knowledge Translation Symposium working group set out to produce recommendations for best practice in the implementation of a new science in Canadian emergency departments.

METHODS

A systematic review of implementation strategies to change health care provider behaviour in the emergency department was conducted simultaneously with a national survey of emergency physician experience. We summarized our findings into a list of draft recommendations that were presented at the national CAEP Conference 2017 and further refined based on feedback through social media strategies.

RESULTS

We produced 10 recommendations for implementing new evidence-based interventions in the emergency department, which cover identifying a practice gap, evaluating the evidence, planning the intervention strategy, monitoring, providing feedback during implementation, and desired qualities of future implementation research.

CONCLUSIONS

We present recommendations to guide future emergency department implementation initiatives. There is a need for robust and well-designed implementation research to guide future emergency department implementation initiatives.

The effects of on-screen, point of care computer reminders on processes and outcomes of care

BACKGROUND

The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering 'computer reminders'.

OBJECTIVES

To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care.

SEARCH STRATEGY

We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles.

SELECTION CRITERIA

Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care.

DATA COLLECTION AND ANALYSIS

Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome.

MAIN RESULTS

Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering. In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase).

AUTHORS' CONCLUSIONS

Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.