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The efficacy of computer reminders on external quality assessment for point-of-care testing in Danish general practice: rationale and methodology for two randomized trials.

ABSTRACT: Point-of-care testing (POCT) is increasingly being used in general practice to assist general practitioners (GPs) in their management of patients with diseases. However, low adherence to quality guidelines in terms of split test procedures has been observed among GPs in parts of the Capital Region in Denmark. Computer reminders embedded in GPs electronic medical records (ComRem) may facilitate improved quality control behaviour, but more research is needed to identify what types of reminders work and when. The overall aim of this study is to evaluate the efficacy of ComRem to improve GPs adherence to quality guidelines. This article describes the rationale and methods of the study that constitute this research project.The study is conducted as two randomised controlled trials (RCTs) among general practices in two districts of the Capital Region in Denmark. These districts contain a total of 739 GPs in 567 practices with a total of 1.1 million patients allocated to practice lists. In the first RCT (RCT A), ComRem is compared to postal reminder letters. In the second RCT (RCT B), ComRem is compared to usual activities (no reminders) with a crossover approach. In both of these studies, outcomes are measured by the number of split tests received by the laboratory.This study will contribute to knowledge on the efficacy of ComRem in primary care. Because the study does not explore GPs' perceptions and experiences with regard to ComRem, we will subsequently conduct a qualitative survey focusing on these aspects.Study A: ClinicalTrials.gov identifier: NCT01152151Study B: ClinicalTrials.gov identifier: NCT01152177.

SUBMITTER: Waldorff FB

PROVIDER: S-EPMC3158743 | biostudies-literature | 2011 Jul

REPOSITORIES: biostudies-literature

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The efficacy of computer reminders on external quality assessment for point-of-care testing in Danish general practice: rationale and methodology for two randomized trials.

Waldorff Frans B FB Siersma Volkert V Ertmann Ruth R Kousgaard Marius Brostrøm MB Nielsen Anette Sonne AS Felding Peter P Mosbæk Niels N Hjortsø Else E Reventlow Susanne S

Implementation science : IS 20110723

<h4>Background</h4>Point-of-care testing (POCT) is increasingly being used in general practice to assist general practitioners (GPs) in their management of patients with diseases. However, low adherence to quality guidelines in terms of split test procedures has been observed among GPs in parts of the Capital Region in Denmark. Computer reminders embedded in GPs electronic medical records (ComRem) may facilitate improved quality control behaviour, but more research is needed to identify what typ ...[more]

PMID: 21781338

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Project description:Computer reminders are increasingly being applied in efforts to improve quality and patient safety. However, research is still needed to establish the effectiveness of different kinds of reminders in various settings. This study aimed to evaluate the effectiveness of computer reminders for improving adherence to a quality assessment scheme for point-of-care testing in general practice.The study was conducted as a randomized controlled crossover trial among general practices in the Capital Region of Denmark. The intervention consisted of sending computer reminders (ComRem) to practices not adhering to the guideline recommendations of split testing for hemoglobin and glucose. Practices were randomly allocated into two groups. During the first follow-up period, one of the groups received the ComRem intervention together with the general implementation activities (GIA), while the other group only received the GIA. For the second follow-up period, the intervention was switched between the two groups. Outcomes were measured as split test procedure adherence.A total of 142 practices were randomly allocated to the early intervention group and 144 practices to the late intervention group (the control group in the first follow-up period). In the first intervention period, the mean number of split tests performed in the group receiving ComRem group increased from 1.22 to 3.76 (out of eight possible tests) while the mean number of split tests increased from 1.11 to 2.35 in the group targeted by GIA only (p = 0.0059). After the crossover, a similar effect of reminders was observed. Furthermore, the developments in outcome measures over time showed a strong effect of computer reminders beyond the intervention periods.There was a significant effect of computer reminders on adherence to the quality assessment scheme for point-of-care testing. Thus, computer reminders seem to be useful for supporting the implementation of relatively simple procedures for quality and safety.ClinicalTrials.gov: http://NCT01152177.

Project description:Interventions: Eligible general practice patients will complete a brief (approximately 5 to 10 minutes) touchscreen computer survey on a tablet device while in the waiting room prior to their appointment. The survey will assess the patient’s potential health risks related to under-screening for bowel cancer, cervical (women only) and breast cancer (women only), smoking, risky alcohol consumption and depression. For intervention participants, preferences for help with identified health risks will be elicited as part of the survey. Upon completion of the survey, intervention participants will receive printed feedback on health risks identified from their survey along with recommended self-management actions as endorsed by a range of Australian Government-supported organisations aimed at promoting health in these areas. Participants who report being under-screened for cancer (bowel, breast, cervical) will be encouraged to discuss screening options with their doctor. Participants identified as smokers will be presented with self-management options such as referral to Quitline (a telephone-based smoking cessation intervention), talking to their doctor, and nicotine replacement therapy etc. Participants identified as drinking above recommended levels will be presented with options for reducing alcohol intake such as choosing alcoholic drinks with lower alcohol content, and discussing approaches with their doctor etc. Participants who report depressed mood will be presented with options such as attending counselling, contacting Beyondblue (a telephone-based emotional support service), and discussing with their GP etc. The printed feedback will be given to patients in an envelope by a research assistant immediately after completion of the baseline survey in the primary care clinic. This f Primary outcome(s): The primary outcome will be the proportion of patients within each group who report undertaking one or more self-management actions in relation to health risk factors identified at baseline. Self management actions will be elicited by a survey specifically designed for this study.[1-month follow-up.] Study Design: Purpose: Prevention; Allocation: Randomised controlled trial; Masking: Open (masking not used);Assignment: Parallel;Type of endpoint: Efficacy

Project description:BackgroundPoint of care testing (PoCT) may be a useful adjunct in the management of chronic conditions in general practice (GP). The provision of pathology test results at the time of the consultation could lead to enhanced clinical management, better health outcomes, greater convenience and satisfaction for patients and general practitioners (GPs), and savings in costs and time. It could also result in inappropriate testing, increased consultations and poor health outcomes resulting from inaccurate results. Currently there are very few randomised controlled trials (RCTs) in GP that have investigated these aspects of PoCT.Design/methodsThe Point of Care Testing in General Practice Trial (PoCT Trial) was an Australian Government funded multi-centre, cluster randomised controlled trial to determine the safety, clinical effectiveness, cost effectiveness and satisfaction of PoCT in a GP setting.The PoCT Trial covered an 18 month period with the intervention consisting of the use of PoCT for seven tests used in the management of patients with diabetes, hyperlipidaemia and patients on anticoagulant therapy. The primary outcome measure was the proportion of patients within target range, a measure of therapeutic control. In addition, the PoCT Trial investigated the safety of PoCT, impact of PoCT on patient compliance to medication, stakeholder satisfaction, cost effectiveness of PoCT versus laboratory testing, and influence of geographic location.DiscussionThe paper provides an overview of the Trial Design, the rationale for the research methodology chosen and how the Trial was implemented in a GP environment. The evaluation protocol and data collection processes took into account the large number of patients, the broad range of practice types distributed over a large geographic area, and the inclusion of pathology test results from multiple pathology laboratories.The evaluation protocol developed reflects the complexity of the Trial setting, the Trial Design and the approach taken within the funding provided. The PoCT Trial is regarded as a pragmatic RCT, evaluating the effectiveness of implementing PoCT in GP and every effort was made to ensure that, in these circumstances, internal and external validity was maintained.Trial registration12612605000272695.

Project description:BACKGROUND:The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering 'computer reminders'. OBJECTIVES:To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care. SEARCH STRATEGY:We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles. SELECTION CRITERIA:Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care. DATA COLLECTION AND ANALYSIS:Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome. MAIN RESULTS:Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering. In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase). AUTHORS' CONCLUSIONS:Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.

Project description:BackgroundAnaemia can be a pointer of underlying severe disease, including undiagnosed malignancy. Subsequent blood tests are essential to classify the anaemia into subtypes and to facilitate targeted diagnostic investigation to ensure timely diagnosis of underlying disease.ObjectiveWe aimed to describe and classify anaemia based on laboratory tests from patients with new-onset anaemia detected in general practice. An additional aim was to analyse associations between patient characteristics and unclassified anaemia (not classifiable according to an algorithm).DesignPopulation-based cross-sectional study.SettingDanish general practice.SubjectsA total of 62,731 patients (age: 40-90 years) with new-onset anaemia were identified in Danish laboratory information systems and nationwide registries, and data were obtained for 2014-2018.Main outcome measuresWe measured the proportion of patients classified into subtypes of anaemia based on blood tests requested by general practitioners within 31 days of the anaemia index date.ResultsOf the 62,731 patients with new-onset anaemia, we identified unclassified anaemia in 78.9% (95% confidence interval (CI): 77.3-80.5) of men and 65.1% (CI: 63.4-66.9) of women. The likelihood of unclassified anaemia increased with age, increasing comorbidity and decreasing severity of anaemia.ConclusionThe majority of patients with new-onset anaemia could not be classified through a simple algorithm due to missing blood tests, which highlights a potential missed opportunity for diagnosis. Standardised laboratory testing of patients with anaemia is warranted to ensure adequate follow-up and early detection of underlying severe disease.KEY POINTSAnaemia can be a sign of malignancy, and anaemia classification is an important step in the diagnosis of underlying disorders.The majority of patients with anaemia could not be classified according to a simple algorithm due to missing blood tests.Some patient characteristics were associated with a high risk of unclassified anaemia: high age, high comorbidity, and severe anaemia.Standardised laboratory testing in patients with anaemia is needed to inform targeted diagnostic investigation to ensure timely diagnosis.

Dataset Information

The efficacy of computer reminders on external quality assessment for point-of-care testing in Danish general practice: rationale and methodology for two randomized trials.

Publications

The efficacy of computer reminders on external quality assessment for point-of-care testing in Danish general practice: rationale and methodology for two randomized trials.

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