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PubMed2000

Improving residents' compliance with standards of ambulatory care: results from the VA Cooperative Study on Computerized Reminders.

CONTEXT: Computerized systems to remind physicians to provide appropriate care have not been widely evaluated in large numbers of patients in multiple clinical settings. OBJECTIVE: To examine whether a computerized reminder system operating in multiple Veterans Affairs (VA) ambulatory care clinics improves resident physician compliance with standards of ambulatory care. DESIGN, SETTING, AND PARTICIPANTS: A total of 275 resident physicians at 12 VA medical centers were randomly assigned in firms or half-day clinic blocks to either a reminder group (n = 132) or a control group (n = 143). During a 17-month study period (January 31, 1995-June 30, 1996), the residents cared for 12,989 unique patients for whom at least 1 of the studied standards of care (SOC) was applicable. MAIN OUTCOME MEASURES: Compliance with 13 SOC, tracked using hospital databases and encounter forms completed by residents, compared between residents in the reminder group vs those in the control group. RESULTS: Measuring compliance as the proportion of patients in compliance with all applicable SOC by their last visit during the study period, the reminder group had statistically significantly higher rates of compliance than the control group for all standards combined (58.8% vs 53.5%; odds ratio [OR], 1.24; 95% confidence interval [CI], 1.08-1.42; P =.002) and for 5 of the 13 standards examined individually. Measuring compliance as the proportion of all visits for which care was indicated in which residents provided proper care, the reminder group also had statistically significantly higher rates of compliance than the control group for all standards combined (17.9% vs 12.2%; OR, 1.57; 95% CI, 1.45-1.71; P<.001) and for 9 of the 13 standards examined individually. The benefit of reminders, however, declined throughout the course of the study, even though the reminders remained active. CONCLUSIONS: Our data indicate that reminder systems installed at multiple sites can improve residents' compliance to multiple SOC. The benefits of such systems, however, appear to deteriorate over time. Future research needs to explore methods to better sustain the benefits of reminders. JAMA. 2000;284:1411-1416.

Adult↗

PubMed2002

Colorectal cancer screening: physician attitudes and practices.

PURPOSE: The American Cancer Society (ACS) set a nationwide goal to increase to 75% by 2015 the proportion of people aged 50 and older who have colorectal cancer (CRC) screening consistent with ACS guidelines. Little is known about current physician screening practices and attitudes. The purpose of this study was to document current physician attitudes and practices regarding CRC screening, and to formulate appropriate interventions to meet the ACS screening goal. METHODS: Questionnaires were sent to a random sample of 600 primary care physicians in Wisconsin. The survey measured 1) screening preferences; 2) estimates of patients screened by each method; 3) agreement to statements regarding screening guidelines and practices, patient compliance, effectiveness in reducing mortality, factors regarding colonoscopy as a screening tool; 4) use of reminder systems; 5) demographics. RESULTS: Physicians prefer combining fecal occult blood testing (FOBT) with flexible sigmoidoscopy for CRC screening, while they believe patients prefer FOBT alone. Only 1.5% view colonoscopy as their preferred method of screening. There is discrepancy between physicians' beliefs that patients should be screened and estimated numbers they screen. Only 38.2% of respondents would screen a moderate-risk patient at the ACS recommended age. Physicians perceive screening compliance to be low. Cost, availability, risks, and lack of proof of effectiveness influence physician decisions. Fewer than half have any reminder system for CRC screening. CONCLUSIONS: CRC screening rates are currently lower than the 2015 ACS goal. Influential factors include physician attitudes and beliefs about effectiveness, familiarity with guidelines, perception of patient preferences and compliance, and lack of adequate reminder systems. Targeting interventions to these factors may increase the rate of CRC screening. Despite increased consensus from professional societies on colonoscopy as the best choice for screening, few primary care physicians would choose this option.

Colonoscopy↗

PubMed2002

A national survey of physician practices regarding influenza vaccine.

OBJECTIVE: To characterize U.S. physicians' practices regarding influenza vaccine, particularly regarding the capacity to identify high-risk patients, the use of reminder systems, and the typical period of administration of vaccine. DESIGN: Cross-sectional mail survey administered in October and November 2000. PARTICIPANTS: National random sample of internists and family physicians (N = 1,606). RESULTS: Response rate was 60%. Family physicians are significantly more likely than internists to administer influenza vaccine in their practices (82% vs 76%; P <.05). Eighty percent of physicians typically administer influenza vaccine for 3 to 5 months, but only 27% continue administering vaccine after the typical national peak of influenza activity. Only one half of physicians said their practices are able to generate lists of patients with chronic illnesses at high risk for complications of influenza, and only one quarter had used mail or telephone reminder systems to contact high-risk patients. Physicians working in a physician network (including managed care organizations) are more than twice as likely to use reminders as physicians in other practice settings (odds ratio, 2.04; 95% confidence interval, 1.17 to 3.55). CONCLUSIONS: Over three quarters of U.S. internists and family physicians routinely administer influenza vaccine, but few continue immunization efforts past the typical national peak of influenza activity. Many physicians may be limited by their practice data systems' capacity to identify high-risk patients. Despite the known effectiveness and cost-effectiveness of reminder systems, few physicians use reminders for influenza vaccination efforts. These findings raise concerns about meeting domestic influenza vaccination goals-especially for individuals with chronic illness and during periods of delayed vaccine availability-and the possibility of increased morbidity and mortality attributable to influenza as a result.

Attitude of Health Personnel↗

PubMed2004

The use of patient and physician reminders for preventive services: results from a National Study of Physician Organizations.

BACKGROUND: Clinical preventive services improve patient health, and reminder systems can increase the use of such services. However, physician organizations often underutilize clinical preventive service reminders. Little is known about the incentives, capabilities, and organizational characteristics associated with the use of reminders by physician organizations. METHODS: The predictors of patient and physician reminder system use were examined in a sample of 1,104 US physician organizations. The cross-sectional sample was obtained through a telephone survey with a 70% response rate. RESULTS: Fifty-one percent of physician organizations used mammogram reminders, 41% used influenza immunization reminders, and 26% used eye exam reminders for patients. Eighteen percent of physician organizations used computer-generated reminders to physicians. Required reporting of data (P = 0.0006), public recognition for quality (P = 0.0002), and IT capabilities (P < 0.0001) were strongly associated with patient reminder use. Medical groups were more likely to use patient-level reminders than independent practice associations (IPAs) (P < 0.0001). Physician reminder use was related to required reporting of data (P < 0.0001) and IT capabilities (P < 0.0001). CONCLUSIONS: Physician organizations have relatively low use of preventive service reminders to patients and physicians. Offering quality incentives to physician organizations and improving their IT capabilities may increase the use of preventive service reminders and improve the delivery of preventive care.

Adult↗

PubMed2005

Prompting clinicians: a systematic review of preventive care reminders.

Prompting clinicians to offer preventive care procedures has been shown to increase the use of these procedures. This study is an update of a systematic review examining the effect of reminder systems on offers of preventive care to patients. Of 1,404 eligible studies, 23 were included. The studies were evaluated according to their intervention type and use of computerized methods. We found that although computerized reminder systems have become more common, paper-based reminders were the most effective reminder strategy.

Humans↗

PubMed1995

Effectiveness of interventions to enhance physician screening for breast cancer.

BACKGROUND: Physician recommendation is one of the strongest predictors of mammography use. This study was designed to review research articles assessing the effectiveness of interventions to enhance physician breast cancer screening behavior. METHODS: A MEDLINE search was conducted to identify intervention studies published from January 1980 to April 1993. The search was supplemented by review of all related bibliographic references and recent listings in Current Contents. RESULTS: Effect sizes and 95% confidence intervals were calculated for the 20 controlled trials identified by the search. The majority of studies were conducted in academic settings; two were community-based. Interventions included physician reminder systems, other office systems, audit with feedback, and physician education. The majority of trials included two or more intervention modalities; 65% included physician reminder systems. In university settings, physician reminders and audit with feedback each significantly increased use of mammography and clinical breast examination by approximately 5% to 20%. In community-based settings, the effects of physician education also had a positive impact on mammography and clinical breast examination rates, which ranged from 6% to 14%. Using patient education to influence physician behavior was not effective in university settings, but had a modest impact in community trials. Generally, reminders were more cost-efficient than audit with feedback. CONCLUSIONS: Physician-based interventions can be effective in increasing screening use. Interventions should emphasize community practices and practices caring for underserved and older populations.

Breast Neoplasms↗

PubMed2003

Use of an on-line pager system to increase adherence to antiretroviral medications.

Adherence to antiretroviral therapy is critical for treatment success. Antiretroviral therapy typically requires multiple pills at multiple dosing times. To address this, we tested the feasibility, utility, and efficacy of a customizable reminder system using pagers, which were programmed using web-based technology, to increase and maintain proper adherence in patients with pre-existing adherence problems. After a two-week monitoring period with an electronic pill-cap, participants with less than 90% adherence were randomized to continue monitoring or to receive a pager. The group who received the pagers had greater improvements in adherence from baseline to Week 2 and Week 12 than those who monitored their medications only. However, adherence in both groups at the outcome assessments points was still poor. While the provision of a reminder system helped improve adherence, it is likely that more intensive interventions are required for patients with pre-existing problems.

Anti-HIV Agents↗

PubMed1999

Chart reminders increase referrals for inpatient smoking cessation intervention.

The purpose of this study was to test the effect of a chart reminder system on referral of inpatients to a hospital smoking cessation intervention pilot program. An A1-B-A2 reversal design was used to test the hypothesis that a chart reminder to nursing staff would increase the proportion of smokers referred for smoking cessation intervention over the usual method of posted memos. In Condition A1, memos reminding nursing staff to refer smokers were posted prominently on a cardiopulmonary unit for 4 weeks. In Condition B, a reminder containing the same message was placed in the front of every patient chart for 4 weeks. Finally, in Condition A2, chart reminders were removed and posted memos were reinstated for 4 additional weeks. During Condition A1 (posted memo), only one patient out of 29 eligible smokers was referred, for a referral rate of 3.4%. In Condition B (chart reminders), 18 patients out of 52 (34.6%) were referred (chi 2 = 10.07, p < 0.01). In Condition A2, the referral rate returned to below baseline (2.1%) (chi 2 = 16.80, p < 0.001). The findings support the use of a chart reminder system for screening and referral as an important component for comprehensive smoking cessation programs in the acute care setting.

Adult↗

PubMedDate not supplied

Postcard and telephone reminders for unclaimed prescriptions: a comparative evaluation using survival analysis.

OBJECTIVE: This study investigated unclaimed prescription reminders with the goal of developing practical and useful recommendations for pharmacies interested in reminding patients to pick up unclaimed prescriptions. Based on the recipient and mode of the reminder notification, this study measured differences in unclaimed prescription pickup time. DESIGN: This study was conducted using a convenience sample of three independent pharmacies in a large Midwestern city. A total of 120 subjects with prescriptions remaining unclaimed after 3 or 4 working days were included in the study. Once identified as unclaimed, these prescriptions were randomly assigned into a control group or one of the following four intervention groups: (1) a telephone reminder to the patient, (2) telephone notification to the prescribing physician, (3) a postcard reminder to the patient, and (4) postcard notification to the prescribing physician. RESULTS: The results suggest that different methods of pharmacist-initiated reminder systems may affect time to prescription pickup in community pharmacy practice. Marginally significant differences were found among the five study groups and the time to prescription pickup (P = .09). Compared with the control group, neither telephone nor postcard reminders--to patients or physicians--significantly decreased the mean number of days to pickup of potentially abandoned prescriptions. CONCLUSION: The actual value of an unclaimed prescription reminder program may reside in improved relationships with customers and with the medical community. The effort and expense of implementing and maintaining an unclaimed prescription reminder system should be balanced against the opportunity to establish and improve pharmacist-patient and pharmacist-physician relationships. Further research in different pharmacy settings should investigate the effectiveness of (1) postcard versus telephone reminders, (2) physician versus patient notification, and (3) the effects of reminders on patient outcomes.

Community Pharmacy Services↗

PubMed1995

Using belief networks to enhance sharing of medical knowledge between sites with variations in data accuracy.

Differences in data definition between sites are a known obstacle to sharing of reminder-system rule sets. We identify another data characteristic--data accuracy--with implications for sharing. We reviewed the literature on data accuracy and found reports of high error rates for many data classes used by reminder systems (e.g., problem lists). The accuracy of other, equally important, data classes had not been characterized. Wide variations in accuracy between sites has been observed, suggesting that such differences may pose a previously unrecognized barrier to sharing of reminder rules. We propose a belief-network model for encoding reminder rules that explicitly models site-specific data accuracy and we discuss how encoding knowledge in this format may lower the cost and effort required to share reminder rules between sites.

Artificial Intelligence↗

PubMed1992

Use of reminders to increase compliance with tetanus booster vaccination.

OBJECTIVE: To assess the effect of three computerized reminder systems on compliance with tetanus vaccination. DESIGN: Prospective randomized controlled trial. SETTING: Ottawa Civic Hospital Family Medicine Centre. PARTICIPANTS: Of 8069 patients 20 years of age or more who were not in a hospital or institution 5589 were randomly assigned, by family, to a control group, a physician reminder group, a telephone reminder group or a letter reminder group. The remaining 2480 patients were not included in the randomized portion of the study but were monitored. Results are presented for the 5242 randomized patients and the 2369 nonrandomized patients for whom there was no up-to-date record of tetanus vaccination at the start of the trial. INTERVENTIONS: For the patients in the physician reminder group the physician was reminded at an office visit to assess the patient's tetanus vaccination status and to recommend vaccination; those in the other two reminder groups received a telephone call or letter enquiring about their tetanus vaccination status and recommending a booster dose. MAIN OUTCOME MEASURE: Proportion of patients who received tetanus toxoid during the study year or who had a claim of vaccination in the previous 10 years. MAIN RESULTS: The rate of recorded tetanus vaccination in the randomized control group was 3.2%. The difference between that rate and those for the three reminder groups was 19.6% in the physician reminder group (95% confidence interval [CI] 17.1% to 22.2%, p less than 0.00001), 20.8% in the telephone reminder group (95% CI 18.3% to 23.5%, p less than 0.00001) and 27.4% in the letter reminder group (95% CI 24.8% to 30.2%, p less than 0.00001)). The letter reminders were more effective than either the telephone reminders (p = 0.00013) or the physician reminders (p less than 0.00001) in improving compliance. The cost to the practice per additional vaccination recorded was 43 for the physician reminders, $5.43 for the telephone reminders and $6.05 for the letter reminders. CONCLUSIONS: Although all three reminder systems increased the rate of recorded tetanus vaccination they fell far short of achieving complete population coverage. More intensive interventions would be required to approach that goal. However, such interventions do not appear to be justified given the rarity of tetanus.

Adult↗

PubMed2006

Modelling the costs and outcomes of changing rates of screening for alcohol misuse by GPs in the Australian context.

AIM: To assess the relative cost effectiveness of four strategies (academic detailing, computerised reminder systems, target payments and interactive continuing medical education) to increase the provision of screening and brief interventions by Australian GPs with the ultimate goal of decreasing risky alcohol consumption among their patients. METHODS: This project used a modelling approach to combine information on the effectiveness and costs of four separate strategies to change GP behaviours to estimate their relative cost effectiveness. RESULTS: The computerised reminder system and academic detailing appear most effective in achieving a decrease in the number of standard drinks consumed by risky drinkers. CONCLUSION: Regardless of the assumptions made, the targeted payment strategy appeared to be the least cost-effective method to achieve a decrease in risky alcohol consumption while the other three strategies appear reasonably comparable.

Adult↗

PubMed1995

A retrospective cohort study of childhood immunisation status in northern Sydney.

A survey of their children's immunisation status was conducted among mothers of babies from a three-month birth cohort (January to March 1990) in the Northern Sydney Area in 1992. Its aims were to determine the uptake of immunisation in the area, to examine factors associated with immunisation status, and to assess agreement between the parent's reporting of this status and records of councils and general practitioners. Fifty-eight per cent of the questionnaires (1004) were returned. The full immunisation rate was 86 per cent, 14 per cent were partially immunised and only four children had received no immunisations. Between 74 per cent and 82 per cent of vaccinations were on time at two, four and six months; the rate dropped to 21 per cent at 12 months. Logistic regression analysis showed that premature babies are significantly more likely to be fully immunised, whereas children who have had a serious childhood illness, those with a single mother, or whose mothers are more highly educated, are significantly less likely to be fully immunised. There was 60 per cent agreement between the parent's report of immunisation status and a subgroup of 197 council and 82 general practitioner records. Although all councils in the Northern Sydney Area have a reminder system, most immunisations were found to be done in general practices (64 per cent), where reminder systems are not common.

Child, Preschool↗

PubMed1998

A computerized reminder for prophylaxis of deep vein thrombosis in surgical patients.

OBJECTIVE: To measure the effect of a computerized reminder system on the rate of deep vein thrombosis (DVT) prophylaxis in surgical patients. DESIGN: A prospective trial to measure change in compliance compared to historic controls. MEASUREMENTS: LDS Hospital surgeons developed local consensus as to which procedures should have DVT prophylaxis. The historic rate of prophylaxis for the procedures was measured through a database search of patient records. A computerized reminder system was then implemented which utilized an expert knowledge base and a time drive mechanism to flag surgical cases for DVT prophylaxis. For eligible patients, a DVT reminder appeared on the operating room schedule; surgical staff used this as a guide to apply prophylaxis. During the 3 month trial the rate of DVT prophylaxis was remeasured and compared to the pre-intervention rate. RESULTS: The pre-intervention rate of DVT prophylaxis over a 3 month period was 85.2% (785 of 921 eligible cases). For the 3 months following the introduction of the computerized reminder, compliance with DVT prophylaxis increased to 99.3% (1084 of 1092 eligible cases). The difference between the historic controls and the study subjects was highly significant (p < 0.001). CONCLUSION: A computerized reminder is an effective method of increasing the rate of DVT prophylaxis in surgical patients.

Anticoagulants↗

PubMed1994

Promoting screening mammography in inner-city settings: a randomized controlled trial of computerized reminders as a component of a program to facilitate mammography.

In a one-year randomized controlled trial, we assessed the effectiveness of a computerized mammography reminder system as a component of a program to increase the use of screening mammography in three health care organizations serving inner-city women in Detroit, Michigan (two sites of a health department, one HMO site, and two sites of a private hospital). Four thousand four hundred and one women older than 40 who had visited a study site in the preceding year were randomly assigned to one of two treatment groups. Limited intervention (LI) included physician and staff breast cancer control education, facilitated mammography appointment scheduling procedures, and elimination of out-of-pocket patient cost for mammography (at three of five sites). Full intervention (FI) included all components of limited intervention plus an additional series of "cues-to-action." These included a mammography reminder form inserted in the medical record of women who were due to have mammography, intended to increase physician referral for mammography appointments, and patient reminders intended to increase completion of mammography among referred women. During the one-year intervention period 2,725 randomized women visited a study site. The 6-month mammography appointment rates among FI women vary from 38% to 65% and the FI rate exceeds the LI rate at each site with differences from 13% (95% CI, 6 to 20) to 29% (21 to 38). The annual completed mammography rate among FI women extends from 43% to 64% and exceeds the LI rate at each site by 12% (5 to 19) to 25% (16 to 34). After age-adjustment, the mammography intervention effect sizes among the five sites were not significantly different. The average increase in FI compared to LI was 18%. The computerized reminder system is effective in increasing the use of mammography in each of the study institutions and the major effect is on physician referral for mammography.

Adult↗

PubMed2005

Computerized reminders to improve isolation rates of patients with drug-resistant infections: design and preliminary results.

Infections with multi-drug resistant organisms (MDROs) are a steadily increasing threat to inpatients as they move through the hospital. We constructed a computerized reminder system, integrated with existing data sources maintained by the infection control service. We tested the hypothesis that computerized reminders from a centralized infection control expert system can improve rates of barrier isolation in patients with MDROs. Immediately after institution of this reminder system, isolation of eligible ward patients increased from a baseline rate of 33% to 95% (p<0.0001). The median time to isolation decreased from 16.6 hours to 0 hours, indicating that the majority of patients post-intervention had isolation orders written prior to arrival on the ward. We conclude that a computerized reminder system can dramatically increase the clinical impact of data sources maintained by hospital Infection Control services.

Drug Resistance, Multiple↗

PubMed2004

Child Health Improvement through Computer Automation: the CHICA system.

Clinical guidelines are prevalent but frequently not used. Computer reminder systems can improve adherence to guidelines but have not been widely adopted. We present a computer-based decision support system that combines these elements: 1) pediatric preventive care guidelines encoded in Arden Syntax; 2) a dynamic, scannable paper user interface; and 3) a HL7-compliant interface to existing electronic medical record systems. The result is a system that both delivers "just in time" patient-relevant guidelines to physicians during the clinical encounter and accurately captures structured data from all who interact with the system. The system performs these tasks while remaining sensitive to the workflow constraints of a busy outpatient pediatric practice.

Algorithms↗

PubMed1993

Office systems for promoting screening mammography. A survey of primary care practices.

BACKGROUND: Office tracking, scheduling, and reminder systems have been shown to improve utilization of screening mammography, but little is known about the use of these systems by primary care physicians. METHODS: We surveyed 132 primary care and obstetrics and gynecology practices affiliated with an independent practice association model health maintenance organization in central Massachusetts to determine their use of reminder, scheduling, and follow-up systems, and education and counseling services aimed at increasing screening mammography rates. RESULTS: The use of chart flags to remind physicians of a patient's need for mammography screening was reported by 30% of practices. Thirty-one percent reported the use of flow sheets, and 27% reported the use of mail or telephone patient reminders. At least one of these three systems was used by 57% of the practices, whereas 43% reported having none of these three systems. Variations in the use of these office systems were related to specialty type, physician number, and clinical staffing. The majority of practices (77%) reported using written educational materials, and 42% offered prevention counseling with nonphysician staff. Very few offices (8%) reported using mail or telephone reminders for previously scheduled appointments. CONCLUSIONS: Despite the proven effectiveness of reminder systems for screening mammography, many practices do not have a system in place. Promotion of reminder systems in primary care practices could have a substantial impact on mammography utilization.

Ambulatory Care Information Systems↗