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BACKGROUND - Inadequate blood pressure control is a persistent gap in quality care.
OBJECTIVE - To evaluate provider and patient interventions to improve blood pressure control.
DESIGN - Cluster randomized, controlled trial.
SETTING - 2 hospital-based and 8 community-based clinics in the Veterans Affairs Tennessee Valley Healthcare System.
PATIENTS - 1341 veterans with essential hypertension cared for by 182 providers. Eligible patients had 2 or more blood pressure measurements greater than 140/90 mm Hg in a 6-month period and were taking a single antihypertensive agent.
INTERVENTION - Providers who cared for eligible patients were randomly assigned to receive an e-mail with a Web-based link to the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) guidelines (provider education); provider education and a patient-specific hypertension computerized alert (provider education and alert); or provider education, hypertension alert, and patient education, in which patients were sent a letter advocating drug adherence, lifestyle modification, and conversations with providers (patient education).
MEASUREMENTS - Proportion of patients with a systolic blood pressure less than 140 mm Hg at 6 months; intensification of antihypertensive medication.
RESULTS - Mean baseline blood pressure was 157/83 mm Hg with no differences between groups (P = 0.105). Six-month follow-up data were available for 975 patients (73%). Patients of providers who were randomly assigned to the patient education group had better blood pressure control (138/75 mm Hg) than those in the provider education and alert or provider education alone groups (146/76 mm Hg and 145/78 mm Hg, respectively). More patients in the patient education group had a systolic blood pressure of 140 mm Hg or less compared with those in the provider education or provider education and alert groups (adjusted relative risk for the patient education group compared with the provider education alone group, 1.31 [95% CI, 1.06 to 1.62]; P = 0.012).
LIMITATIONS - Follow-up blood pressure measurements were missing for 27% of study patients. The study could not detect a mechanism by which patient education improved blood pressure control.
CONCLUSIONS - A multifactorial intervention including patient education improved blood pressure control compared with provider education alone.
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.
BACKGROUND - Slow adaptation of new information by providers may result in suboptimal care.
OBJECTIVE - To evaluate changes in prescriptions for combination hormone replacement therapy (HRT) after a multicomponent intervention to deliver new information to patients and providers.
DESIGN - Quasi-experimental study with multiple baselines.
SETTING - Veterans Affairs Tennessee Valley Healthcare System (VA-TVHS).
PATIENTS - Female veterans age 50 to 79 years who had a prescription filled at the VA-TVHS for combination HRT between 1 January 2002 and 1 July 2002.
MEASUREMENTS - Discontinuation of HRT.
INTERVENTION - A 3-part intervention consisted of 1) notifying patients who were using combination HRT of the results of the Women's Health Initiative study (patient education component), 2) sending all providers an e-mail with the Women's Health Initiative study results (provider education component), and 3) placing an electronic alert in each eligible patient's chart (provider care component). The alert asked providers to reevaluate the need for combination HRT. The intervention was implemented at different VA-TVHS sites in a stepwise fashion to differentiate intervention effect from media effect. Study follow-up continued through 31 December 2002.
RESULTS - The total rate of discontinuation of combination HRT was 70.3% in 2002. The proportion of discontinuation from time of media release until intervention was 23.3%. After initiation of the intervention, an additional 43% of the original cohort discontinued use of HRT; this percentage represents a 59% relative decrease in HRT use among patients. After adjustment for time, the discontinuation rate per day was 4.9 times higher after the multifacted intervention than after the media release (95% CI, 1.8 to 13.1).
LIMITATIONS - A true control group is lacking.
CONCLUSION - A multifaceted approach in an integrated health care system with standardized methods of communication is an effective way to implement patient-centered, effective, and timely care with changing medical knowledge.
Compliance with outpatient practice guidelines is low and clinical reminders have had variable success in improving adherence rates. We surveyed primary care physicians (PCPs) regarding practice guidelines and the perceived utility of electronic reminders for both routine health maintenance (HM) items and chronic disease management. Most PCPs preferred receiving reminders in an electronic format rather than a paper format. Electronic reminders were felt to be more useful for HM items than for diabetes management. The majority of clinicians felt that electronic reminders significantly improved overall health care quality.
Decision support is an important area of medical informatics research. Computer-based decision-support tools facilitate diagnosis and the management of patients after a diagnosis has been established. Diagnostic decision-support tools, such as Meditel, Quick Medical Reference, DXplain, Iliad, and PEM-DXP are potentially useful "expert systems." Other management-support tools, such as systems that use clinical practice guidelines to create reminders and alerts, also have been developed and evaluated. We do the following: (1) to provide an overview of diagnostic and management decision-support systems; (2) explore the background of and motivation behind these systems; (3) survey the uses of decision-support technology in office-based and inpatient pediatric practices; and (4) discuss the virtues and problems associated with some of these tools, and current controversies and future goals for computer-based decision support.