A design model for computer-based guideline implementation based on information management services. (1/1168)

Clinical practice guidelines must be implemented effectively if they are to influence the behavior of clinicians. The authors describe a model for computer-based guideline implementation that identifies eight information management services needed to integrate guideline-based decision support with clinical workflow. Recommendation services determine appropriate activities in specific clinical circumstances. Documentation services involve data capture. Registration services integrate demographic and administrative data. Explanation services enhance the credibility of automated recommendations by providing supportive evidence and rating the quality of evidence. Calculation services measure time intervals, suggest medication dosages, and perform other computational tasks. Communication services employ standards for information transfer and provide data security. Effective presentation services facilitate understanding of complex data, clarify trends, and format written materials (including prescriptions) for patients. Aggregation services associate outcomes with specific guideline interventions. The authors provide examples of the eight services that make up the model from five evidence-based practice parameters developed by the American Academy of Pediatrics.  (+info)

Computer-based guideline implementation systems: a systematic review of functionality and effectiveness. (2/1168)

In this systematic review, the authors analyze the functionality provided by recent computer-based guideline implementation systems and characterize the effectiveness of the systems. Twenty-five studies published between 1992 and January 1998 were identified. Articles were included if the authors indicated an intent to implement guideline recommendations for clinicians and if the effectiveness of the system was evaluated. Provision of eight information management services and effects on guideline adherence, documentation, user satisfaction, and patient outcome were noted. All systems provided patient-specific recommendations. In 19, recommendations were available concurrently with care. Explanation services were described for nine systems. Nine systems allowed interactive documentation, and 17 produced paper-based output. Communication services were present most often in systems integrated with electronic medical records. Registration, calculation, and aggregation services were infrequently reported. There were 10 controlled trials (9 randomized) and 10 time-series correlational studies. Guideline adherence improved in 14 of 18 systems in which it was measured. Documentation improved in 4 of 4 studies.  (+info)

Gastrointestinal illness in managed care: healthcare utilization and costs. (3/1168)

Identification of inefficiencies is a first step to improving the quality of gastrointestinal (GI) care at the most reasonable cost. This analysis used administrative data to examine the healthcare utilization and associated costs of the management of GI illnesses in a 2.5 million-member private managed care plan containing many benefit designs. An overall incidence of 10% was found for GI conditions, with a preponderance in adults (patients older than 40 years) and women. The most frequently occurring conditions were abdominal pain, nonulcer peptic diseases, lower GI tract diseases, and other GI tract problems. These conditions, along with gallbladder/biliary tract disease, were also the most costly. Claims submitted for care during GI episodes averaged $17 per member per month. Increasing severity of condition was associated with substantial increases in utilization and costs (except for medication use). For most GI conditions, approximately 40% of charges were for professional services (procedures, tests, and visits) and 40% of charges were for facility admissions. The prescription utilization analysis indicated areas where utilization patterns may not match accepted guidelines, such as the low use of anti-Helicobacter pylori therapy, the possible concomitant use of nonsteroidal anti-inflammatory drugs in patients with upper GI diseases, and the use of narcotics in treating patients with lower GI disease and abdominal pain. Also, there was no clear relationship between medication utilization and disease severity. Thus, this analysis indicated that GI disease is a significant economic burden to managed care, and identified usage patterns that potentially could be modified to improve quality of care.  (+info)

A cost-effectiveness clinical decision analysis model for schizophrenia. (4/1168)

A model was developed to estimate the medical costs and effectiveness outcomes of three antipsychotic treatments (olanzapine, haloperidol, and risperidone) for patients with schizophrenia. A decision analytic Markov model was used to determine the cost-effectiveness of treatments and outcomes that patients treated for schizophrenia may experience over a 5-year period. Model parameter estimates were based on clinical trial data, published medical literature, and, when needed, clinician judgment. Direct medical costs were incorporated into the model, and outcomes were expressed by using three effectiveness indicators: the Brief Psychiatric Rating Scale, quality-adjusted life years, and lack of relapse. Over a 5-year period, patients on olanzapine had an additional 6.8 months in a disability-free health state based on Brief Psychiatric Rating Scale scores and more than 2 additional months in a disability-free health state based on quality-adjusted life years, and they experienced 13% fewer relapses compared with patients on haloperidol. The estimated 5-year medical cost associated with olanzapine therapy was $1,539 less than that for haloperidol therapy. Compared with risperidone therapy, olanzapine therapy cost $1,875 less over a 5-year period. Patients on olanzapine had approximately 1.6 weeks more time in a disability-free health state (based on Brief Psychiatric Rating Scale scores) and 2% fewer relapses compared with patients on risperidone. Sensitivity analyses indicated the model was sensitive to changes in drug costs and shortened hospital stay. Compared with both haloperidol and risperidone therapy, olanzapine therapy was less expensive and provided superior effectiveness outcomes even with conservative values for key parameters such as relapse and discontinuation rates.  (+info)

A population-based approach to diabetes management in a primary care setting: early results and lessons learned. (5/1168)

OBJECTIVE: To determine the effect of a multifaceted program of support on the ability of primary care teams to deliver population-based diabetes care. DESIGN: Ongoing evaluation of a population-based intervention. SETTING/PARTICIPANTS: Group Health Cooperative of Puget Sound, a staff model HMO in which more than 200 primary care providers treat approximately 15,000 diabetic patients. INTERVENTION: A program of support to improve the ability of primary care teams to deliver population-based diabetes care was implemented. The elements of the program are based on an integrated model of well-validated components of delivery of effective care to chronically ill populations. These elements have been introduced since the beginning of 1995, and some aspects of the program were pilot-tested in a few practice sites before being implemented throughout the organization. The program elements include 1) a continually updated on-line registry of diabetic patients; 2) evidence-based guidelines on retinal screening, foot care, screening for microalbuminuria, and glycemic management; 3) improved support for patient self-management; 4) practice redesign to encourage group visits for diabetic patients in the primary care setting; and 5) decentralized expertise through a diabetes expert care team (a diabetologist and a nurse certified diabetes educator) seeing patients jointly with primary care teams. MAIN OUTCOME MEASURES: Patient and provider satisfaction through existing system-wide measurement processes; process measures, health outcomes, and costs are tracked continuously. RESULTS: Patient and provider satisfaction have improved steadily. Interest in and use of the electronic Diabetes Registry have grown considerably. Rates of retinal eye screening, documented foot examinations, and testing for microalbuminuria and hemoglobin A1c have increased substantially. CONCLUSIONS: Providing support to primary care teams in several key areas has made a population-based approach to diabetes care a practical reality in the setting of a staff model HMO. It may be an important mechanism for improving standards of care for many diabetic patients.  (+info)

The impact of computerized physician order entry on medication error prevention. (6/1168)

BACKGROUND: Medication errors are common, and while most such errors have little potential for harm they cause substantial extra work in hospitals. A small proportion do have the potential to cause injury, and some cause preventable adverse drug events. OBJECTIVE: To evaluate the impact of computerized physician order entry (POE) with decision support in reducing the number of medication errors. DESIGN: Prospective time series analysis, with four periods. SETTING AND PARTICIPANTS: All patients admitted to three medical units were studied for seven to ten-week periods in four different years. The baseline period was before implementation of POE, and the remaining three were after. Sophistication of POE increased with each successive period. INTERVENTION: Physician order entry with decision support features such as drug allergy and drug-drug interaction warnings. MAIN OUTCOME MEASURE: Medication errors, excluding missed dose errors. RESULTS: During the study, the non-missed-dose medication error rate fell 81 percent, from 142 per 1,000 patient-days in the baseline period to 26.6 per 1,000 patient-days in the final period (P < 0.0001). Non-intercepted serious medication errors (those with the potential to cause injury) fell 86 percent from baseline to period 3, the final period (P = 0.0003). Large differences were seen for all main types of medication errors: dose errors, frequency errors, route errors, substitution errors, and allergies. For example, in the baseline period there were ten allergy errors, but only two in the following three periods combined (P < 0.0001). CONCLUSIONS: Computerized POE substantially decreased the rate of non-missed-dose medication errors. A major reduction in errors was achieved with the initial version of the system, and further reductions were found with addition of decision support features.  (+info)

Effects of a decision support system on physicians' diagnostic performance. (7/1168)

PURPOSE: This study examines how the information provided by a diagnostic decision support system for clinical cases of varying diagnostic difficulty affects physicians' diagnostic performance. METHODS: A national sample of 67 internists, 35 family physicians, and 6 other physicians used the Quick Medical Reference (QMR) diagnostic decision support system to assist them in the diagnosis of written clinical cases. Three sets of eight cases, stratified by diagnostic difficulty and the potential of QMR to produce high-quality information, were used. The effects of using QMR on three measures of physicians' diagnostic performance were analyzed using analyses of variance. RESULTS: Physicians' diagnostic performance was significantly higher (p < 0.01) on the easier cases and the cases for which QMR could provide higher-quality information. CONCLUSIONS: Physicians' diagnostic performance can be strongly influenced by the quality of information the system produces and the type of cases on which the system is used.  (+info)

Influence of case and physician characteristics on perceptions of decision support systems. (8/1168)

OBJECTIVE: This study examines how characteristics of clinical cases and physician users relate to the users' perceptions of the usefulness of the Quick Medical Reference (QMR) and their confidence in their diagnoses when supported by the decision support system. METHODS: A national sample (N = 108) of 67 internists, 35 family physicians, and 6 other U.S. physicians used QMR to assist in the diagnosis of written clinical cases. Three sets of eight cases stratified by diagnostic difficulty and the potential of QMR to produce high-quality information were used. A 2 x 2 repeated-measures analysis of variance was used to test whether these factors were associated with perceived usefulness of QMR and physicians' diagnostic confidence after using QMR. Correlations were computed among physician characteristics, ratings of QMR usefulness, and physicians' confidence in their own diagnoses, and between usefulness or confidence and actual diagnostic performance. RESULTS: The analyses showed that QMR was perceived to be significantly more useful (P < 0.05) on difficult cases, on cases where QMR could provide high-quality information, by non-board-certified physicians, and when diagnostic confidence was lower. Diagnostic confidence was higher when comfort with using certain QMR functions was higher. The ratings of usefulness or diagnostic confidence were not consistently correlated with diagnostic performance. CONCLUSIONS: The results suggest that users' diagnostic confidence and perceptions of QMR usefulness may be associated more with their need for decision support than with their actual diagnostic performance when using the system. Evaluators may fail to find a diagnostic decision support system useful if only easy cases are tested, if correct diagnoses are not in the system's knowledge base, or when only highly trained physicians use the system.  (+info)