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PubMed2003

Interventions to improve medication compliance in older patients living in the community: a systematic review of the literature.

Noncompliance affects all age groups, but older patients have specific barriers against effective medication use and can be more vulnerable to the incorrect use of medication. Some age-related barriers are vision loss and cognitive impairment. In people aged 60 years or older, noncompliance with medication regimens varies from 26-59%. In this article we review randomised controlled trials (RCTs) on interventions aimed to improve compliance with medication regimens in older patients living in the community. It is known from other reviews that multifaceted interventions, a combination of interventions, are more often effective than single-focus interventions, probably because these address a wider range of barriers. Also, an individual approach with specifically tailored interventions is effective at improving compliance. In this review the following two hypotheses are evaluated: i) multifaceted interventions improve compliance more successfully than single interventions; and ii) interventions that are tailored to patients improve compliance more successfully than generalised interventions. A systematic literature search in four databases produced 14 suitable RCTs with 23 interventions that we categorised as single or multifaceted, and generalised or tailored. Differences in medication compliance between the intervention group and the control group were in less than half of the comparisons in favour of the intervention group. Telephone-linked reminder systems achieved the most striking effect, looking at differences between the intervention and control group, and deserve further attention. Overall, multifaceted interventions and tailored interventions seemed to result more often in differences in compliance rates in older adults in favour of the intervention group compared with a control group than single and generalised interventions.

Aged↗

PubMed1990

Computerized follow-up of abnormalities detected at mammography screening.

Obtaining follow-up information after abnormal interpretations is an important aspect of a mammography practice, but it can be tedious, time-consuming, and produce suboptimal results. This study demonstrates the effect of computer-generated reminders on the collection of follow-up data for patients in whom abnormalities were detected at mammography screening. From April 1985 until December 1987, follow-up data for 1009 abnormal examinations were collected by using standard procedures, supplemented by occasional searches of pathology records and sporadic letters and telephone calls to referring physicians. Results showed that follow-up was limited to a normal physical examination in 104 women (10.3%); eight other women (0.8%) were lost to follow-up. For over 90% of these inadequately followed cases, referring physicians were first contacted more than 3 months after screening. Since December 1987, follow-up data for 777 abnormal examinations were collected, supplemented by computer-generated reminders sent to referring physicians for cases apparently unresolved 3 months after screening. Only four (0.5%) of these women have had inadequate follow-up (normal physical examination alone). We conclude that use of a computer-generated reminder system prompts more timely and more appropriate patient management. It also makes follow-up data collection much less onerous.

Appointments and Schedules↗

PubMed1994

Computerized tracking of mammography patients: value of a radiology information system integrated with a personal-computer data base.

OBJECTIVE. We investigated the advantages of using a radiology information system as the primary data source for a mammographic patient-tracking system that is based on a personal-computer local-area network and that requires almost no data entry. HARDWARE AND SOFTWARE. Our mammographic data base is maintained on a file server that provides cross-platform access to both Macintosh and IBM-compatible personal computers. Locally developed software automatically transfers mammographic data from our radiology information system to the file server's mammographic data base. The data transferred include patients' demographics (e.g., hospital identification number, address, referring physician) and the complete mammographic report. With the use of specific terminology, the need for follow-up can be automatically gleaned from the mammographic report and coded within the data base. Graphically oriented, commercially available software provides easy access to this information from any personal computer on our department's network. The software provides considerable flexibility for searching and manipulating the data without the need for customized data-base programming. Redundant data entry and associated errors are drastically reduced, as are personnel requirements for maintaining the system. Relative to most commercial radiology information systems, a personal computer facilitates the steps involved in tracking patients and obtaining highly customized analyses of the mammographic data base. The data in the mammographic data base exactly match those in the hospital's registration data and are easily transferred to other personal-computer programs for ancillary processing. CONCLUSION. This technique is ideal for departments that use a general-purpose radiology information system for mammographic reporting, yet need a more powerful but user-friendly and low-cost method for tracking their mammography patients.

Female↗

PubMedDate not supplied

Efforts to improve the follow-up of patients with abnormal Papanicolaou test results.

BACKGROUND: We describe and evaluate efforts to improve the follow-up care of patients with abnormal Papanicolaou test results at an academic family practice center at Shadyside Hospital in Pittsburgh. METHODS: From 1994 to 1996, 1796 patients received Papanicolaou testing; 147 (8 percent) of the smears had abnormal findings--16 percent had atypia, 83 percent had dysplasia, and 1 percent had carcinoma in situ. Patients received follow-up care based on a formalized protocol using educational input, logistic aids, and automated prompting. RESULTS: Overall follow-up success rates and colposcopy completion rates increased dramatically. Whereas 36 percent of patients with abnormal findings on Papanicolaou smears had been overdue for follow-up in 1990, only 13 percent were overdue in 1996 after our interventions. Patients assigned to Papanicolaou testing for follow-up of abnormal findings failed to receive a test in 9 of 45 (20 percent) cases, but those assigned to colposcopy follow-up failed to receive a test in only 10 of 102 (10 percent) of cases. Appointment failure rates at colposcopy clinic dropped from 56 percent in 1993 to 12 percent in 1996. Colposcopic biopsy was far superior to Papanicolaou test for detecting precursors of cervical cancer at follow-up. CONCLUSIONS: Educational programs, formalized approaches to care, transportation assistance, and reminder systems are not only practical but also can dramatically improve the outcome of cervical cancer screening programs.

Adolescent↗

PubMedDate not supplied

Improving female preventive health care delivery through practice change: an Every Woman Matters study.

BACKGROUND: The levels of breast and cervical cancer screening in Nebraska primary care remain suboptimal despite awareness of their importance, and despite implementation of the Every Woman Matters program to assist low-income women. The GAPS model was used to develop a practice-based intervention to identify and reduce barriers to delivery of breast and cervical cancer screening services. METHODS: Seven primary care practices actively participated in this multimethod case study. A research nurse collected data and facilitated the intervention process at each site. Qualitative data from field notes, patient encounters, and in-depth interviews of physicians and key informants were collected to describe the process of Papanicolaou and mammogram service delivery, and to identify barriers/facilitators to screening, and potential change areas. Chart reviews provided information regarding the preintervention and postintervention identification/execution of Papanicolaou smears and mammograms. Qualitative and quantitative analyses led to individual practice case studies. Cross case comparisons identified common themes. RESULTS: The individual practice plans for change had many commonalities, ie, developing screening databases and reminder systems. The biggest differences involved practice contexts. Despite use of the GAPS model and a financial incentive to obtain "buy in" from providers and staff, change was difficult for all but 2 of the practices. CONCLUSION: The complexity of practice context and its effect on change cannot be underestimated. Individual practice providers and staff are often unaware of the potential challenges, and unable/unwilling to overcome them.

Breast Neoplasms↗

PubMed1999

Immunisation coverage in Australian children: a systematic review 1990-1998.

The Australian Childhood Immunisation Register (ACIR) commenced operation in January 1996 and provides a comprehensive database of children's immunisations in Australia. The ACIR enables implementation of an immunisation recall and reminder system and improved surveillance and reporting of immunisation coverage. Before the introduction of the ACIR, the methods used in assessing coverage varied widely in design and quality, with few studies measuring coverage at national or statewide level. This is a systematic review of the scope and reliability of estimates of immunisation coverage available in Australia from 1990 to 1998. A total of 108 studies were identified of which 51 were classified as higher quality based on a range of criteria including whether they had a response rate of 50% or better.

Adolescent↗

PubMed2000

Clinical preventive medicine in primary care: background and practice: 2. Delivering primary preventive services.

Strategies to incorporate preventive services into primary care settings have been underutilized. The first component of delivering preventive services in the primary care setting is the health risk assessment followed by establishment of practice guidelines and protocols for preventive services--who is eligible for what service (based on age, sex, and other clinical characteristics) and when. A computerized reminder system can be useful to track past and currently due preventive services for each patient and can also serve as a follow-up system for test results. Well-trained paramedical personnel can perform appropriate patient counseling and education. The goal of counseling and education is to change patient behavior. The first step in this difficult process is once again to ascertain health risks and then to determine the patient's stage of readiness--defined as precontemplation, contemplation, preparation, action, and maintenance. The counselor assists in identification of target behavior, advocates and commends behavior change, reinforces health benefits of behavior change, offers resources, strategies, and support, and creates a plan of action and monitoring mechanisms. Improved implementation of preventive services in primary care could have a major impact on the health of the population.

Counseling↗

PubMed2004

A multifaceted health-service intervention in remote Aboriginal communities: 3-year follow-up of the impact on diabetes care.

OBJECTIVE: To examine the trends in processes of diabetes care and in participant outcomes after an intervention in two remote regions of Australia. DESIGN: Follow-up study over 3 years. SETTING: Seven health centres in the Tiwi Islands and the Katherine West region of the Northern Territory. PARTICIPANTS: 137 Aboriginal people with type 2 diabetes. INTERVENTION: Implementation of a multifaceted trial, including transfer of purchasing and planning responsibility to local health boards, the development and dissemination of clinical guidelines supported by electronic registers, recall and reminder systems and associated staff training, and audit and feedback. MAIN OUTCOME MEASURES: Trends in the proportion of Aboriginal people receiving services in accordance with clinical guidelines and in the proportion for whom specified levels of blood pressure and glycosylated haemoglobin (HbA(1c)) were achieved; health staff perceptions of barriers to effective service delivery. RESULTS: An initial improvement in overall service levels from 40% to 49% was not fully sustained over the 3-year period. The overall proportion of services delivered varied from 22% to 64% between communities and over time. The proportion of participants whose most recent HbA(1c) level was less than 7% improved from 19% to 32%, but there was little change in blood pressure control. Perceived barriers to service delivery included discontinuities in staffing, lack of work-practice support and patients' acceptance of services. CONCLUSIONS: Multifaceted interventions can improve quality of care in this environment, but achieving sustainable, high-quality care in a range of services and local conditions presents particular challenges. Developing and testing strategies for consistent and sustained improvement should be a priority for service providers and researchers.

Adult↗

PubMed1999

Immunisation initiatives in general practice. Important lessons from division projects.

AIM: To examine immunisation projects undertaken by divisions of general practice through the Divisions and Project Grants Program in the period from 1993 to mid 1997. METHOD: A simple descriptive frequency analysis was conducted of information from the National Information Service Divisions Project database and evaluation reports of the project characteristics and methodology such as: year commenced; duration; location; funding; target groups; intervention; needs assessment; aim(s); study design; measurement (assessment) and outcome(s). RESULTS: Forty-four funded immunisation projects were identified and of these, 12 projects with completed evaluation reports were analysed. Most projects were of 12-14 months duration, and were funded for a mean of $56,349 and median of $46,348 for the 44 funded projects and a mean $44,348 and median $40,318 for the 12 with evaluation reports. Most projects included a needs assessment. The main target groups were general practitioners, the general community, and children. Of the wide spectrum of interventions used, education and/or promotion and register and/or reminder systems were the most common. Study designs, the quality of measurement and outcomes were variable. CONCLUSION: In the future with the move to outcome based block funding, it will be important for projects to adopt broader target groups, refine and develop interventions and develop greater sustainability through responding to local needs, improving design and evaluation and ongoing funding.

Australia↗

PubMed2000

Preventive services in the primary care practices of the Practice Partner Research Network.

Despite the emphasis of primary care on preventive services over the past decade, and the reminder systems that are available to promote the provision of these services, many patients still do not receive needed services. This study describes the preventive services that the primary care practices of the Practice Partner Research Network (PPRNet) monitors, and documents adherence to them. Preventive services monitored in PPRNet practices and the levels of adherence to them vary by practice and service. The lower-than-desired levels of adherence offer opportunities for improvement interventions.

Data Collection↗

PubMed2000

Explaining physician rates of providing flexible sigmoidoscopy.

Colorectal cancer is the third most frequent cancer, yet screening rates for this cancer remain low. This study was designed to identify factors associated with family physicians' rates of recommending or providing flexible sigmoidoscopy. We applied a behavioral model consisting of three components: physician attitude toward providing the test, facilitating conditions, and reinforcing conditions. Qualitative interviews identified relevant measures of each model component and guided the design of the survey. The survey was administered to 60 randomly selected family physicians in Washington State. Chart reviews were conducted to measure physician rates of providing flexible sigmoidoscopy. All three model components were significantly correlated with sigmoidoscopy rate. Multiple regression found physician attitude, facilitating conditions, and their interaction to be significant determinants of sigmoidoscopy rate (multiple R = 0.72). Analyses of specific items used to measure physician attitude found that physician beliefs about cost, time, income, degree of distaste, risk of complications, and screening effectiveness were significantly correlated with sigmoidoscopy rate. Specific facilitating conditions found to be correlated with rate of providing the test included physician and staff training, availability of a reminder system, and clinic structural conditions. This study provides strong support for application of a theory-based model to understand physician provision of flexible sigmoidoscopy testing for colorectal cancer. The findings provide very specific information to guide development of educational and motivational efforts and modification of facilitating conditions to increase physician provision of sigmoidoscopy to control colorectal cancer.

Adult↗

PubMedDate not supplied

Barriers to immunization in a relatively affluent community.

BACKGROUND: Although Healthy People 2000 calls for the complete immunization of at least 90% of children by age 20 months, few communities can claim such success. We wanted to determine the parent-reported barriers associated with underimmunization of infants in a relatively affluent midwestern population. METHODS: We undertook a case-control study of a population-based sample of parents and guardians of children who were either fully immunized or underimmunized at 20 months of age in Olmsted County, Minn. RESULTS: In this study, 596 of 1,216 parents (46%) of both immunized and underimmunized children participated. Of these participants, 281 (47%) reported barriers to immunizations, but only 15 (3%) reported major barriers. Whereas the most commonly reported barriers were barriers of inconvenience (waiting too long, inconvenient office hours), only delays caused by a sick child, fear of reactions, trouble remembering an appointment, not knowing when the next shot was due, and transportation problems were significantly associated with underimmunization when controlling for demographic factors. Fear of reactions, sick child delays, and not knowing when the next shot was due had the highest attributable risk for underimmunization. Taken together, parent-reported barriers and demographic factors explained less than 30% of the underimmunization status of children. Parents' most common recommendations for improving immunization status were the use of a recall or reminder system and a single unified schedule for immunizations. CONCLUSIONS: In this relatively affluent community, barriers to immunization were commonly reported but few (fear of reactions, sick child delays, and not knowing when the next shot was due) were associated with underimmunization. The types of barriers reported were similar to those reported in other communities, but unlike many populations studied, cost was not reported as an important barrier.

Case-Control Studies↗

PubMed2001

Improving depression care: barriers, solutions, and research needs.

Potential solutions for barriers to improved organization of care of depressive illness were identified. These included (1) aligning efforts to improve depression care with broader strategies for improving care of other chronic conditions; (2) increasing the availability of depression case management services in primary care; (3) developing registries and reminder systems to ensure active follow-up of depressed patients; (4) achieving agreement on how depression outcomes should be measured to provide outcomes-based performance standards; (5) providing greater support from mental health specialists for management of depressed patients by primary care providers; (6) campaigns to reduce the stigma associated with treatment of depressive illness; (7) increased dissemination of interventions that activate and empower patients managing a depressive illness; (8) redefining the lack of time of primary care providers for high-quality depression care as issues in organization of care and provider training; and (9) development of incentives (organizational or financial) for high-quality depression care. Research needs were identified according to what has been learned to date. Identified research needs included: studies of approaches to organization of case management, research in new populations (e.g., new diagnostic groups, rural populations, the disadvantaged, the elderly, and those with chronic medical illnesses), research on stepped care and relapse prevention strategies, evaluation of the societal benefits of improved depression care, and multisite trials and meta-analytic approaches that can provide adequate statistical power to assess societal benefits of improved care.

Case Management↗

PubMedDate not supplied

Time and money: effects of no-shows at a family practice residency clinic.

BACKGROUND: When patients fail to appear for scheduled appointments, the flow of patient care is interrupted, and clinic productivity declines. This study investigated the impact of failed appointments on a clinic by measuring time and money lost after taking into account same-day treatment patients (walk-ins). METHODS: Schedule information was retrieved for 4,055 visits over 20 business days. Data were collected on appointment status (show, no-show, cancel, walk-in), time allocated for the appointment, charges for visit, date and time of the visit, and other appointment information. RESULTS: No-shows and cancellations represented 31.1% of scheduled appointments and 32.2% of scheduled time. Rates of failed appointments varied by type of provider, patient demographics, and patient status (new versus established). Walk-in patients replaced 61.0% of failed appointments but only 42.4% of the time blocked for those appointments. Walk-in visits generated 89.5% of the charges associated with scheduled visits. Over the course of a year, total revenue shortfalls could range from 3% to 14% of total clinic income. CONCLUSIONS: Failed appointments pose financial as well as administrative problems for residency practices. Proactive reminder systems are needed to promote patient attendance.

Adult↗

PubMed2002

Accuracy of computerized outpatient diagnoses in a Veterans Affairs general medicine clinic.

BACKGROUND: Electronically available data, both administrative, such as outpatient encounter diagnostic data, and clinical, such as problem lists, are being used increasingly for outcome and quality assessment, risk adjustment, and clinical reminder systems. OBJECTIVE: To determine the accuracy of outpatient primary care diagnostic information recorded in administrative and clinical files in a Veterans Affairs VISTA (Veterans Health Information Systems and Technology Architecture) database compared with medical chart notes. STUDY DESIGN: Cross-sectional medical chart review of 148 patients attending a general medicine clinic at a university-affiliated Veterans Affairs hospital for 9 diagnoses relevant to the choice of drug therapy for hypertension. PATIENTS AND METHODS: An administrative file of encounter diagnoses, for a 2-year period, and a clinical file of the problem list maintained by the clinician were the sources of electronic diagnoses. We compared these sources with diagnoses abstracted by medical chart review. We estimated the sensitivity and specificity of each electronic data source for detecting medical chart note diagnoses. RESULTS: The sensitivity for 8 of the 9 study diagnoses was greater than 80% in the administrative file and 49% in the clinical problem list. The specificity was good for the administrative file (91% to 100%) and even better for the clinical file (98% to 100%). CONCLUSIONS: Outpatient encounter diagnoses relevant to hypertension recorded as electronic data had high specificity, and some codes had high sensitivity when collected over multiple visits. The administrative file was more sensitive but less specific than the clinical file. Administrative vs clinical files can be selected to minimize either the false-negative or the false-positive designations, respectively, as dictated by the needs of the quality assessment review.

California↗

PubMed2002

Screening for colorectal cancer: the business case.

Colorectal cancer screening is advocated by expert groups based on strong evidence of effectiveness, yet only approximately 1 in 3 Americans are screened. For a screening program to be effective, it is necessary for providers to offer and patients to accept screening, insurers to pay for screening, and provider groups to have monitoring and reminder systems and the expertise and facilities to perform the tests well. Whether and when such screening programs become successful depends on the priorities of healthcare decision makers as much as on the efforts of individual physicians and patients. There are strong arguments for decision makers giving colorectal cancer screening programs high priority: it saves as many lives as other services now in common use; it is a good use of scarce resources, costing less than $20,000 per year of life saved; and members of insurance programs increasingly expect screening benefits and programs, and failure to offer them might lead to member dissatisfaction and malpractice claims. Screening is costly, however, taking into account the cost of screening, follow-up tests, and treatments, and the costs occur many years before the benefits. Programs that are promoted to members but not fully implemented could create disappointment and backlash. Also, this screening can cause medical complications. Nevertheless, successful programs have been developed, proving that they are feasible in today's cost-conscious environment. We believe that colorectal cancer screening programs are integral to any organization purporting to provide high-quality care. Organizations without such programs should give them high priority for implementation.

Aged↗

PubMed2002

Successful colorectal cancer screening starts with primary care.

Colorectal cancer screening is effective. Screening rates remain low, but that will change. All guidelines now recommend colorectal cancer screening, the value of screening is being promoted in the popular media, and insurers are beginning to pay for screening tests. For screening programs to be successful, good intentions must be backed by reminder systems, readily available patient information, and other changes in office practice. Currently recommended screening options accommodate a broad range of patient preferences and save lives, but none is ideal. Newer tests, such as virtual colonoscopy and stool-based DNA tests, will help if they offer greater sensitivity, specificity, or patient acceptability than current screening options.

Barium Sulfate↗

PubMedDate not supplied

Impact of a physician intervention program to increase breast cancer screening.

In order to improve compliance with the National Cancer Institute's breast cancer screening guidelines, we developed a multifaceted intervention designed to alter physician screening practice. A pre-post test, two-community design was used. Primary care physicians in one community served as the control. Data were collected by two mailed surveys (1987 and 1990). Response rates were 61% and 64%, respectively. The physician intervention program consisted of a hospital-based continuing medical education program and an outreach component which focused on implementing a reminder system. Outcome measures were self-reported attitudinal, knowledge, and screening practices changes. In spite of an impressive change in comparison community physicians' practice, the difference in change over time in the intervention community physicians' ordering of annual mammography compared to the change in the comparison community physicians' ordering was significant (P = 0.04). The adjusted odds ratio is nearly 8. We conclude that our in-service continuing medical education program was successful in improving breast cancer screening practices among primary care physicians.

Education, Medical, Continuing↗