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Biomedical subjects

Steven M Asch

Publications and source records attributed to Steven M Asch.

At least 37 records · Page 2Linked to original sources
PubMed2005

Differences in education, knowledge, self-management activities, and health outcomes for patients with heart failure cared for under the chronic disease model: the improving chronic illness care evaluation.

BACKGROUND: The objective of this study was to determine whether participation in a quality improvement (QI) collaborative for heart failure (HF) was associated with better interpersonal aspects of care and health outcomes. METHODS AND RESULTS: We conducted a cross-sectional telephone survey of patients in 6 organizations who participated in a QI collaborative for HF (participants, n = 387) and 6 comparable control organizations (controls, n = 414) and measured provider-patient communication, education received, knowledge of HF, self-management behaviors, satisfaction, and quality of life. The participant group patients were more likely to report their doctor and nurse discussed treatment options and reviewed self-management (P < .01 for both). A total of 88% of participants were told to weigh themselves daily and record their weight compared with 34% of controls (P < .01). Participants were more likely to know how often to check their weight (P < .01), recognize symptoms of worsening HF (P < or = .01 for all), have a scale (P = .002), and monitor their weight daily (P < .001). Participants had similar quality of life but fewer emergency department visits and hospitalizations. CONCLUSION: Participation in a QI collaborative for HF was associated with better communication, education, and knowledge, and lower health care use. Collaboratives may be a useful method for disseminating quality improvement strategies.

Adolescent↗
PubMed2005

Negotiating end-of-life decision making: a comparison of Japanese and U.S. residents' approaches.

PURPOSE: To compare Japanese and U.S. resident physicians' attitudes, clinical experiences, and emotional responses regarding making disclosures to patients facing incurable illnesses. METHOD: From September 2003 to June 2004, the authors used a ten-item self-administered anonymous questionnaire in a cross-sectional survey of 103 internal medicine residents at two U.S. sites in Los Angeles, California, and 244 general medical practice residents at five Japanese sites in Central Honshu, Kyushu, Okinawa, Japan. RESULTS: The Japanese residents were more likely to favor including the family in disclosing diagnosis (95% versus 45%, p<.001) and prognosis (95% versus 51%, p<.001) of metastatic gastric cancer. Of residents who favored diagnostic or prognostic disclosure to both the patient and family, Japanese residents were more likely to prefer discussion with the family first. Trainees in Japan expressed greater uncertainty about ethical practices related to disclosure of diagnosis or prognosis. Many Japanese and U.S. residents indicated that they had deceived a patient at the request of a family (76% versus 18 %, p<.001), or provided nonbeneficial care (56% versus 72%, p<.05), and many expressed guilt about these behaviors. CONCLUSIONS: The residents' approaches to end-of-life decision making reflect known cultural preferences related to the role of patients and their families. Although Japanese trainees were more likely to endorse the role of the family, they expressed greater uncertainty about their approach. Difficulty and uncertainty in end-of-life decision making were common among both the Japanese and U.S. residents. Both groups would benefit from ethical training to negotiate diverse, changing norms regarding end-of-life decision making.

Adult↗
PubMed2005

Does the collaborative model improve care for chronic heart failure?

BACKGROUND: Organizationally based, disease-targeted collaborative quality improvement efforts are widely applied but have not been subject to rigorous evaluation. We evaluated the effects of the Institute of Healthcare Improvement's Breakthrough Series (IHI BTS) on quality of care for chronic heart failure (CHF). RESEARCH DESIGN: We conducted a quasi-experiment in 4 organizations participating in the IHI BTS for CHF in 1999-2000 and 4 comparable control organizations. We reviewed a total of 489 medical records obtained from the sites and used a computerized data collection tool to measure performance on 23 predefined quality indicators. We then compared differences in indicator performance between the baseline and post-intervention periods for participating and non-participating organizations. RESULTS: Participating and control patients did not differ significantly with regard to measured clinical factors at baseline. After adjusting for age, gender, number of chronic conditions, and clustering by site, participating sites showed greater improvement than control sites for 11 of the 21 indicators, including use of lipid-lowering and angiotensin converting enzyme inhibition therapy. When all indicators were combined into a single overall process score, participating sites improved more than controls (17% versus 1%, P < 0.0001). The improvement was greatest for measures of education and counseling (24% versus -1%, P < 0.0001). CONCLUSIONS: Organizational participation in a common disease-targeted collaborative provider interaction improved a wide range of processes of care for CHF, including both medical therapeutics and education and counseling. Our data support the use of programs like the IHI BTS in improving the processes of care for patients with chronic diseases.

Chi-Square Distribution↗
PubMed2005

Sins of omission: getting too little medical care may be the greatest threat to patient safety.

BACKGROUND: Little is known about the relative incidence of serious errors of omission versus errors of commission. OBJECTIVE: To identify the most common substantive medical errors identified by medical record review. DESIGN: Retrospective cohort study. SETTING: Twelve Veterans Affairs health care systems in 2 regions. PARTICIPANTS: Stratified random sample of 621 patients receiving care over a 2-year period. MAIN OUTCOME MEASURE: Classification of reported quality problems. METHODS: Trained physicians reviewed the full inpatient and outpatient record and described quality problems, which were then classified as errors of omission versus commission. RESULTS: Eighty-two percent of patients had at least 1 error reported over a 13-month period. The average number of errors reported per case was 4.7 (95% confidence intervals [CI]: 4.4, 5.0). Overall, 95.7% (95% CI: 94.9%, 96.4%) of errors were identified as being problems with underuse. Inadequate care for people with chronic illnesses was particularly common. Among errors of omission, obtaining insufficient information from histories and physicals (25.3%), inadequacies in diagnostic testing (33.9%), and patients not receiving needed medications (20.7%) were all common. Out of the 2,917 errors identified, only 27 were rated as being highly serious, and 26 (96%) of these were errors of omission. CONCLUSIONS: While preventing iatrogenic injury resulting from medical errors is a critically important part of quality improvement, we found that the overwhelming majority of substantive medical errors identifiable from the medical record were related to people getting too little medical care, especially for those with chronic medical conditions.

Acute Disease↗
PubMed2005

Organization and management of care for military veterans with human immunodeficiency virus/acquired immunodeficiency syndrome in Department of Veterans Affairs Medical Centers.

OBJECTIVE: As the largest provider of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome health care services, the Department of Veterans Affairs (VA) has launched a national quality improvement program. As a first step, an assessment of how care for veterans with HIV/acquired immunodeficiency syndrome was organized was conducted. METHODS: Structured surveys were administered to senior HIV clinicians in 118 VA facilities, about local approaches to structuring, staffing, and delivering HIV health services. RESULTS: HIV care was chiefly delivered in special VA-based HIV clinics. HIV-related services were widely available on site, with non-VA referrals being more commonly needed to meet long-term care needs. Urban VA facilities had greater HIV caseloads, were more likely to have separate HIV clinics, and had greater access to HIV expertise, whereas rural practices focused on primary care-based models and tended to rely on off-site VA HIV experts. CONCLUSIONS: Understanding the organization and management of VA-based HIV services will help design systematic quality improvement efforts and meet the treatment needs of HIV-infected veterans.

Data Collection↗
PubMed2005

Do the incentives in 3-tier pharmaceutical benefit plans operate as intended? Results from a physician leadership survey.

BACKGROUND: Three-tier pharmaceutical benefit systems use graded co-payments to steer patients toward "preferred" formulary medications. OBJECTIVES: To evaluate physicians' knowledge of formularies and out-of-pocket costs in such systems, as well as their perceived responsibility for helping patients manage out-of-pocket costs. STUDY DESIGN: Self-administered written survey. METHODS: Physician leaders participating in the California Medical Association Leadership Conference were surveyed. RESULTS: A total of 133 responses were received from 205 participants (65% response rate). Physicians reported that they were often unaware of patients' out-of-pocket costs at the time of prescribing. Fifty-nine percent of physicians reported that they never or seldom were aware of patients' "preferred" (lower cost) formulary options when prescribing, and 70% never or seldom were aware of patients' out-of-pocket costs when prescribing. Although 88% of physicians agreed that it is important that patients' out-of-pocket costs for prescription drugs are managed, only 25% strongly or somewhat agreed that it is their "responsibility" to help. Instead, 69% of physicians believed that it is the responsibility of the pharmacist to be familiar with patients' out-of-pocket costs. Physicians reported that they receive phone calls from pharmacists concerning formulary issues after 18.6% of the prescriptions they write. CONCLUSIONS: Physician leaders reported that they often do not possess the knowledge to assist patients in managing out-of-pocket costs for prescription drugs and they depend on pharmacists to communicate patient preferences in making prescribing decisions. As a result, price preferences are communicated indirectly, likely less efficiently, rather than intentionally when prescribing decisions are made.

Data Collection↗
PubMed2004

Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample.

BACKGROUND: The Veterans Health Administration (VHA) has introduced an integrated electronic medical record, performance measurement, and other system changes directed at improving care. Recent comparisons with other delivery systems have been limited to a small set of indicators. OBJECTIVE: To compare the quality of VHA care with that of care in a national sample by using a comprehensive quality-of-care measure. DESIGN: Cross-sectional comparison. SETTING: 12 VHA health care systems and 12 communities. PATIENTS: 596 VHA patients and 992 patients identified through random-digit dialing. All were men older than 35 years of age. MEASUREMENTS: Between 1997 and 2000, quality was measured by using a chart-based quality instrument consisting of 348 indicators targeting 26 conditions. Results were adjusted for clustering, age, number of visits, and medical conditions. RESULTS: Patients from the VHA scored significantly higher for adjusted overall quality (67% vs. 51%; difference, 16 percentage points [95% CI, 14 to 18 percentage points]), chronic disease care (72% vs. 59%; difference, 13 percentage points [CI, 10 to 17 percentage points]), and preventive care (64% vs. 44%; difference, 20 percentage points [CI, 12 to 28 percentage points]), but not for acute care. The VHA advantage was most prominent in processes targeted by VHA performance measurement (66% vs. 43%; difference, 23 percentage points [CI, 21 to 26 percentage points]) and least prominent in areas unrelated to VHA performance measurement (55% vs. 50%; difference, 5 percentage points [CI, 0 to 10 percentage points]). LIMITATIONS: Unmeasured residual differences in patient characteristics, a lower response rate in the national sample, and differences in documentation practices could have contributed to some of the observed differences. CONCLUSIONS: Patients from the VHA received higher-quality care according to a broad measure. Differences were greatest in areas where the VHA has established performance measures and actively monitors performance.

Cross-Sectional Studies↗
PubMed2004

Identifying barriers to the effective use of clinical reminders: bootstrapping multiple methods.

Advances in electronic medical record capabilities enable clinical reminders to inform providers when recommended actions are "due" for a patient. Despite evidence that they improve adherence to guidelines, the Veteran's Health Administration (VHA) has experienced challenges in having providers consistently use clinical reminders as intended. In this paper, we describe how multiple methods were used to opportunistically triangulate, or "bootstrap," an understanding of barriers to the effective use of clinical reminders in the VHA. In an initial study using ethnographic observations and semi-structured interviews of HIV clinical reminders, we identified six barriers to effective use: workload, time to remove inapplicable reminders, false alarms, training, reduced eye contact, and the use of paper forms rather than software. In a second study, we collected open-ended and closed-ended data regarding barriers and facilitators to the use of clinical reminders in general in the VHA through a survey of 261 participants at a national informatics meeting, where 104 of 142 VHA health care facilities were represented. The findings from the second study extended our understanding of the previously identified barriers. In addition, four new barriers were identified: ease of use issues, accessibility of workstations, resident physicians and trainees, and administration benefiting more than providers from clinical reminder use. We discuss potential implications regarding the similarities and differences in study findings for factors to consider in planning interventions to improve clinical reminder use.

Appointments and Schedules↗
PubMed2004

Profiling quality of care: Is there a role for peer review?

BACKGROUND: We sought to develop a more reliable structured implicit chart review instrument for use in assessing the quality of care for chronic disease and to examine if ratings are more reliable for conditions in which the evidence base for practice is more developed. METHODS: We conducted a reliability study in a cohort with patient records including both outpatient and inpatient care as the objects of measurement. We developed a structured implicit review instrument to assess the quality of care over one year of treatment. 12 reviewers conducted a total of 496 reviews of 70 patient records selected from 26 VA clinical sites in two regions of the country. Each patient had between one and four conditions specified as having a highly developed evidence base (diabetes and hypertension) or a less developed evidence base (chronic obstructive pulmonary disease or a collection of acute conditions). Multilevel analysis that accounts for the nested and cross-classified structure of the data was used to estimate the signal and noise components of the measurement of quality and the reliability of implicit review. RESULTS: For COPD and a collection of acute conditions the reliability of a single physician review was quite low (intra-class correlation = 0.16-0.26) but comparable to most previously published estimates for the use of this method in inpatient settings. However, for diabetes and hypertension the reliability is significantly higher at 0.46. The higher reliability is a result of the reviewers collectively being able to distinguish more differences in the quality of care between patients (p < 0.007) and not due to less random noise or individual reviewer bias in the measurement. For these conditions the level of true quality (i.e. the rating of quality of care that would result from the full population of physician reviewers reviewing a record) varied from poor to good across patients. CONCLUSIONS: For conditions with a well-developed quality of care evidence base, such as hypertension and diabetes, a single structured implicit review to assess the quality of care over a period of time is moderately reliable. This method could be a reasonable complement or alternative to explicit indicator approaches for assessing and comparing quality of care. Structured implicit review, like explicit quality measures, must be used more cautiously for illnesses for which the evidence base is less well developed, such as COPD and acute, short-course illnesses.

Acute Disease↗
PubMed2004

Racial and ethnic differences in patients' preferences for initial care by specialists.

PURPOSE: To examine racial and ethnic differences in patients' preferences for initial care by specialists, and to determine whether trust in the physician and health beliefs account for these differences. METHODS: We conducted a cross-sectional study of 646 patients in the waiting room of three academic-based internal medicine outpatient practices. We asked subjects about their preference to see their primary care provider or a specialist first regarding the actual health problem that had brought them to see their physician as well as regarding three hypothetical scenarios (2 weeks of new-onset exertional chest pain, 2 months of knee pain, and rash for 4 weeks). We examined the relation among patients' preference for initial care by a specialist and their demographic characteristics, global ratings of their primary care physician and health plan, trust in their primary care physician, and other health beliefs and attitudes. RESULTS: Averaged for the three scenarios and actual health problem, 13% of patients preferred to see a specialist first. Adjusting for all other covariates, blacks (risk ratio [RR] = 0.55; 95% confidence interval [CI]: 0.20 to 0.92) and Asians (RR = 0.46; 95% CI: 0.19 to 0.75) were much less likely to prefer a specialist than were whites. Patients with less confidence in their primary care physician and greater certainty about needed tests and treatments were more likely to prefer a specialist. These variables, however, did not explain the difference in preference for specialist care among blacks, Asians, and whites. CONCLUSION: Blacks and Asians are less likely than whites to prefer initial care by a specialist. Future studies should examine whether differences in preference for care lead minorities to underutilize appropriate specialty care or lead whites to overuse specialty care.

Adult↗
PubMed2004

Lipid screening in HIV-infected veterans.

BACKGROUND: Lipid screening is recommended for patients taking protease inhibitors (PIs). METHODS: We examined data from the Veterans Administration Immunology Case Registry to assess lipid screening among HIV-infected veterans who received PIs for at least 6 consecutive months during 1999 and 2001. We estimated crude and adjusted associations between lipid screening and patient characteristics (age, gender, HIV exposure, and race/ethnicity), comorbidities (AIDS, cardiovascular disease, diabetes, hypertension, smoking, and hyperlipidemia), and facility characteristics (urban location, case management, guidelines, and quality improvement programs). RESULTS: Among 4065 patients on PIs, clinicians screened 2395 (59%) for lipids within 6 months of initiating treatment. Adjusting for patient characteristics, comorbidities, facility traits, and clustering, lipid screening was more common among patients who were cared for in urban areas (relative risk [RR] = 1.3, confidence limits: 1.0-1.5), diabetic (RR = 1.2, confidence limits: 1.1-1.3), or previously hyperlipidemic (RR = 1.4, confidence limits: 1.3-1.5) and less common among patients with a history of intravenous drug use (IVDU) (RR = 0.90, confidence limits: 0.79-1.0) or unknown HIV risk (RR = 0.85, confidence limits: 0.75-0.95). CONCLUSIONS: Six in 10 patients taking PIs receive lipid screening within 6 months of PI use. Systemic interventions to improve overall HIV quality of care should also address lipid screening, particularly among patients with unknown or IVDU HIV risk and those cared for in nonurban areas.

Adolescent↗
PubMed2004

Symptom-based framework for assessing quality of HIV care.

OBJECTIVE: To evaluate HIV quality of care using a symptom-based, patient-centered framework. METHODS: An expert panel developed 13 quality indicators for three common symptoms: cough with fever and/or shortness of breath; severe or persistent diarrhea; and significant weight loss. A nationally representative probability sample of HIV-infected adults was interviewed between 1996 and 1997. PARTICIPANTS: were asked about the presence and severity of HIV symptoms during the preceding 6 months, and care received. Variation in adherence to the indicators was assessed by symptom type and patient characteristics. RESULTS: In all, 2864 (71%) patients completed interviews and 920 reported being at least moderately bothered with one of the three symptoms. Of these, 41, 74, and 65% of patients with a symptom of cough, weight loss, or diarrhea, respectively, reported receiving all indicated care. Performance was better for patients with more severe HIV, measured as a CD4 cell count <50 cells/microliter, compared with those with less severe HIV, measured as CD4 cell count >500 cells/microliter (43% versus 60%; P = 0.02). Uninsured patients had worse performance than Medicare patients (45% versus 62%; P = 0.04), but care did not differ by patient's age, gender, ethnicity, HIV risk factor, providers' HIV patient load, or region. Only CD4 count remained significantly associated with performance in the multivariate analyses. CONCLUSIONS: Symptom-based quality indicators may provide a useful supplement to conventional measures. Patients with HIV reported substantial underuse of services for common, burdensome symptoms. Although adherence to quality indicators was better for patients with more advanced HIV disease, many still received suboptimal care. Vulnerable patient groups generally did not receive worse quality of care, suggesting that symptom-based measures of quality may measure domains that are distinct from those captured by conventional indicators.

Adult↗
PubMed2004

Accommodating ethnic diversity: a study of California hospice programs.

BACKGROUND: Studies have confirmed ethnic disparities in the use of hospice services and identified barriers that minorities face in accessing care. OBJECTIVES: We sought to determine whether hospices provide services that might affect minority participation. RESEARCH DESIGN: We surveyed California hospices to determine whether programs use diverse health care providers and volunteers, offer translation, diverse spiritual care, or outreach materials and whether they plan to expand such services. Linking the data to the California Office of Statewide Health Planning and Development annual home care and hospice survey and 2000 US Census, we used multivariate linear regression to evaluate the relationship of program characteristics (profit status, size, chain/freestanding status, urban/rural location, and proportion of nonwhite residents) to services that might affect minority participation. SUBJECTS: One hundred of 149 programs that we surveyed responded. RESULTS: Many programs offer translation (81%), diverse providers (63%) and volunteers (64%), and culturally diverse spiritual services (52%). Few (21%) were conducting outreach, but 23/25 programs expanding services reported plans to improve outreach. In multivariate models adjusted for program size, chain status, profit status, urban/rural location, proportion of nonwhite residents, we found that larger hospices and those in ethnically diverse zip codes were more likely to offer such services. Larger hospices are more likely to report expanding such services. CONCLUSIONS: Many hospices are making efforts to accommodate ethnically diverse patients, but a substantial number are not. Culturally appropriate care and outreach should be addressed in efforts to improve the acceptability and experience of hospice care among minorities.

California↗
PubMed2004

Hospice admission practices: where does hospice fit in the continuum of care?

OBJECTIVES: To evaluate selected hospice admission practices that could represent barriers to hospice use and the association between these admission practices and organizational characteristics. DESIGN: From December 1999 to March 2000, hospices were surveyed about selected admission practices, and their responses were linked to the 1999 California Office of Statewide Health Planning and Development's Home and Hospice Care Survey that describes organizational characteristics of California hospices. SETTING: California statewide. PARTICIPANTS: One hundred of 149 (67%) operational licensed hospices. MEASUREMENTS: Whether hospices admit patients who lack a caregiver; would not forgo hospital admissions; or are receiving total parenteral nutrition (TPN), tube feedings, radiotherapy, chemotherapy, or transfusions. RESULTS: Sixty-three percent of hospices restricted admission on at least one criterion. A significant minority of hospices would not admit patients lacking a caregiver (26%). Patients unwilling to forgo hospitalization could not be admitted to 29% of hospices. Receipt of complex medical care, including TPN (38%), tube feedings (3%), transfusions (25%), radiotherapy (36%), and chemotherapy (48%), precluded admission. Larger program size was significantly associated with a lower likelihood of all admission practices except restricting the admission of patients receiving TPN or tube feedings. Hospice programs that were part of a hospice chain were less likely to restrict the admission of patients using TPN, radiotherapy, or chemotherapy than were freestanding programs. CONCLUSION: Patients who are receiving complex palliative treatments could face barriers to hospice enrollment. Policy makers should consider the clinical capacity of hospice providers in efforts to improve access to palliative care and more closely incorporate palliation with other healthcare services.

Caregivers↗
PubMed2004

Surgery for hepatocellular carcinoma: does it improve survival?

BACKGROUND: The incidence and mortality of hepatocellular carcinoma (HCC) are increasing in the United States. Whether surgery is associated with improved survival at the population level is relatively unknown. To address this question, we used a population-based cancer registry to compare survival outcomes between patients receiving and not receiving surgery with similar tumor sizes and health status. METHODS: By using the Surveillance, Epidemiology, and End Results database, we identified HCC patients who had surgically resectable disease as defined by published expert guidelines. After excluding patients with contraindications to surgery, we performed both survival analysis and Cox regression to identify predictors of improved survival. RESULTS: Of the 4008 patients diagnosed with HCC between 1988 and 1998, 417 were candidates for surgical resection. The mean age was 63.6 years; mean tumor size was 3.3 cm. The 5-year overall survival with surgery was 33% with a mean of 47.1 months; without surgery, the 5-year overall survival was 7% with a mean of 17.9 months (P <.001). In the multivariate Cox regression, surgery was significantly associated with improved survival (P <.001). Specifically, patients who received surgery had a 55% decreased rate of death compared with patients who did not have surgery, even after controlling for tumor size, age, sex, and race. CONCLUSIONS: This study shows that surgical therapy is associated with improved survival in patients with unifocal, nonmetastatic HCC tumors <5 cm. If this is confirmed in future studies, efforts should be made to ensure that appropriate patients with resectable HCC receive high-quality care, as well as the opportunity for potentially curative surgery.

Aged↗
PubMed2004

Controversies and legal issues of prescribing and dispensing medications using the Internet.

Online pharmacies fall into 3 major categories: independent Internet-only sites, online branches of "brick-and-mortar" pharmacies, and sites representing partnership among neighborhood pharmacies. Potential benefits of online pharmacies include increased access, lower transaction and product costs, and greater anonymity. However, online pharmacies have generated controversies, including the use of "cyberdoctors" on some sites, the dispensing of drugs without prescriptions from other sites, and the importation of prescription medications. Although some online pharmacies are legitimate and likely provide benefits to patients, other online pharmacies engage in questionable practices. Numerous state and federal regulations and laws have tried to address controversies surrounding rogue Internet pharmacies. Because online pharmacies are increasingly common, clinicians may encounter patients asking for advice and information about online pharmacies. We review the regulatory framework governing online pharmacies and the potential risks and benefits of using online pharmacies.

Drug Prescriptions↗
PubMed2004

Variation in implementation and use of computerized clinical reminders in an integrated healthcare system.

OBJECTIVES: To identify patterns of use of computerized clinical reminders (CCRs) across an integrated healthcare system and describe institutional factors associated with their implementation. STUDY DESIGN: Cross-sectional study. METHODS: At a national electronic health record (EHR) meeting, we surveyed 261 participants from 104 Veterans Health Administration (VHA) healthcare facilities regarding the number and types of CCRs available at each facility. Potential explanatory measures included perceived utility and ease of use of CCRs, training and personnel support for computer use, EHR functionalities, and performance data feedback to providers at each facility. RESULTS: The number of conditions with CCRs in use at a facility ranged from 1 to 15; most reported implementation of reminders for 10 of the 15 conditions surveyed. The most commonly implemented CCRs, used in more than 85% of facilities, were for conditions with VHA national performance measures (eg, tobacco cessation, immunizations, diabetes mellitus). The least commonly implemented CCRs were for post-deployment health evaluation and management, medically unexplained symptoms, and erectile dysfunction. Facilities that had implemented greater numbers of clinical reminders had providers who reported greater ease of use and utility of the reminders (P= .01). CONCLUSIONS: VHA facilities vary markedly in their implementation of CCRs. This effect may be partly explained by greater incorporation of clinical reminders for conditions with performance measures. Further study is needed to determine how to best implement clinical reminders and the institutional factors important in their use.

Attitude of Health Personnel↗