Randomized study of online vaccine reminders in adult primary care

Information Systems Department, University of Iowa Hospitals and Clinics, Iowa City, USA.
Proceedings / AMIA ... Annual Symposium. AMIA Symposium 02/1999; 1999:755-9.
Source: PubMed


Online immunization reminders were implemented in an adult medicine setting in which all immunization history, vaccine ordering and charting were required online. Physicians were randomized to one of two arms in a cross-over design. Each arm was shown online recommendations for vaccines indicated by nationally accepted guidelines either during the first or during the second part of the study period. The main purpose of the study was to assess the impact of reminders on correct decisions related to prescribing vaccines. Online reminders had the following impact on physician behavior: 1) Physicians used the application almost 3 times as often when shown reminders. 2) Physicians in the reminder group were 27% less likely to order a vaccine in the reminder group (P- value 0.0005). 3) Compliance with guidelines was improved significantly for Tetanus and for Hepatitis B in several analyses. No such effects were found for Pneumoccocal, Measles, or Influenza vaccines.

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Available from: Susan E Beekmann, Oct 09, 2015
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    • "Additional file 2 Table S2 shows that 20/41 (49%) CCDSSs were integrated with an electronic medical record [1,17,25,27,29,31,32,34-36,39,41-46,49,50,52,56,59] including at least five also integrated with a computerized order entry system [1,32,42,49,56] and 21/41 (51%) were stand-alone computer systems [15,16,18-22,24,26,28,30,33,37,38,40,47,48,51,53-55,57,58]. The data entry method varied across systems, with a non-practitioner decision-maker entering data on 29/39 (74%) studies [1,15,17,21,23-25,27,29,31,32,34-55,59] and automatic entry through electronic health records in 15/39 (38%) cases [1,17,27,29,31,34-36,41,42,46,49,50,56,59]. In all but one study [26], physicians used all PPC CCDSSs, either solely or shared with other healthcare providers including trainees [1,25,28,29,39,41,42,46-48,52], advanced practice nurses [1,17-19,30,50,59], physician assistants [18,19,33], and social workers [26]. "
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    ABSTRACT: Computerized clinical decision support systems (CCDSSs) are claimed to improve processes and outcomes of primary preventive care (PPC), but their effects, safety, and acceptance must be confirmed. We updated our previous systematic reviews of CCDSSs and integrated a knowledge translation approach in the process. The objective was to review randomized controlled trials (RCTs) assessing the effects of CCDSSs for PPC on process of care, patient outcomes, harms, and costs. We conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid's EBM Reviews Database, Inspec, and other databases, as well as reference lists through January 2010. We contacted authors to confirm data or provide additional information. We included RCTs that assessed the effect of a CCDSS for PPC on process of care and patient outcomes compared to care provided without a CCDSS. A study was considered to have a positive effect (i.e., CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive. We added 17 new RCTs to our 2005 review for a total of 41 studies. RCT quality improved over time. CCDSSs improved process of care in 25 of 40 (63%) RCTs. Cumulative scientifically strong evidence supports the effectiveness of CCDSSs for screening and management of dyslipidaemia in primary care. There is mixed evidence for effectiveness in screening for cancer and mental health conditions, multiple preventive care activities, vaccination, and other preventive care interventions. Fourteen (34%) trials assessed patient outcomes, and four (29%) reported improvements with the CCDSS. Most trials were not powered to evaluate patient-important outcomes. CCDSS costs and adverse events were reported in only six (15%) and two (5%) trials, respectively. Information on study duration was often missing, limiting our ability to assess sustainability of CCDSS effects. Evidence supports the effectiveness of CCDSSs for screening and treatment of dyslipidaemia in primary care with less consistent evidence for CCDSSs used in screening for cancer and mental health-related conditions, vaccinations, and other preventive care. CCDSS effects on patient outcomes, safety, costs of care, and provider satisfaction remain poorly supported.
    Implementation Science 08/2011; 6(1):87. DOI:10.1186/1748-5908-6-87 · 4.12 Impact Factor
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    • "All four used system-initiated advice to prompt physicians about the therapeutic management of patients determined to be 'at risk' of cardiovascular events. [21,24,26,28] Five of the nine studies targeting vaccinations demonstrated statistically significant benefits in favour of CDSS for the majority of outcomes [20,21,36,40,41], and they too used system-initiated advice to increase vaccination rates. There were too few studies across the other clinical domains to draw any conclusions about the impact of CDSS in specific clinical areas. "
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    ABSTRACT: Computerised clinical decision support systems (CDSSs) are used widely to improve quality of care and patient outcomes. This systematic review evaluated the impact of CDSSs in targeting specific aspects of prescribing, namely initiating, monitoring and stopping therapy. We also examined the influence of clinical setting (institutional vs ambulatory care), system- or user-initiation of CDSS, multi-faceted vs stand alone CDSS interventions and clinical target on practice changes in line with the intent of the CDSS. We searched Medline, Embase and PsychINFO for publications from 1990-2007 detailing CDSS prescribing interventions. Pairs of independent reviewers extracted the key features and prescribing outcomes of methodologically adequate studies (experiments and strong quasi-experiments). 56 studies met our inclusion criteria, 38 addressing initiating, 23 monitoring and three stopping therapy. At the time of initiating therapy, CDSSs appear to be somewhat more effective after, rather than before, drug selection has occurred (7/12 versus 12/26 studies reporting statistically significant improvements in favour of CDSSs on = 50% of prescribing outcomes reported). CDSSs also appeared to be effective for monitoring therapy, particularly using laboratory test reminders (4/7 studies reporting significant improvements in favour of CDSSs on the majority of prescribing outcomes). None of the studies addressing stopping therapy demonstrated impacts in favour of CDSSs over comparators. The most consistently effective approaches used system-initiated advice to fine-tune existing therapy by making recommendations to improve patient safety, adjust the dose, duration or form of prescribed drugs or increase the laboratory testing rates for patients on long-term therapy. CDSSs appeared to perform better in institutional compared to ambulatory settings and when decision support was initiated automatically by the system as opposed to user initiation. CDSSs implemented with other strategies such as education were no more successful in improving prescribing than stand alone interventions. Cardiovascular disease was the most studied clinical target but few studies demonstrated significant improvements on the majority of prescribing outcomes. Our understanding of CDSS impacts on specific aspects of the prescribing process remains relatively limited. Future implementation should build on effective approaches including the use of system-initiated advice to address safety issues and improve the monitoring of therapy.
    BMC Health Services Research 09/2009; 9(1):154. DOI:10.1186/1472-6963-9-154 · 1.71 Impact Factor
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    • "Within CPOE system, reminders about corollary orders presented when ordering 1 of 87 tests or treatments; written guidelines made available as in control % immediate compliance with relevant corollary orders 46.3% vs 21.9%, p < 0.0001 Tierney et al., 1993 18 68 teams/ 5219/17 Usual inpatient care, including use of computerized patient record system CPOE system, which displayed problem -specific menus of cost -effective orders and recommended against certain expensive orders Total charge per admission ($) Mean length of stay (days) 6077 vs 6964, p = 0.02 7.6 vs 8.5, p = 0.11 Tierney et al., 1988 19 112/~6077/6 Usual outpatient care, including use of CPOE system For 8 common outpatient tests, display of predicted probabilities of test abnormalities during order entry Patient study test charges per scheduled visit ($) Estimated probability of abnormality among ordered tests 11.18 vs 12.27, p < 0.05 24% vs 18%, p < 0. 0001 Flanagan et al., 1999 20 89/817/9 Usual outpatient care, including optional use of computer-based immunization charting and ordering system Computer-generated reminders for tetanus, hepatitis B, influenza, pneumococcal, and MMR vaccines presented in optional immunization charting and ordering system % of immunization charting system sessions resulting in the appropriate administration of tetanus, hepatitis B, influenza, pneumococcal, and MMR vaccines NS Rotman et al., 1996 21 37/2645 prescriptions/3 "
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    ABSTRACT: Computerized physician order entry (CPOE) systems represent an important tool for providing clinical decision support. In undertaking this systematic review, our objective was to identify the features of CPOE-based clinical decision support systems (CDSSs) most effective at modifying clinician behavior. For this review, two independent reviewers systematically identified randomized controlled trials that evaluated the effectiveness of CPOE-based CDSSs in changing clinician behavior. Furthermore, each included study was assessed for the presence of 14 CDSS features. We screened 10,023 citations and included 11 studies. Of the 10 studies comparing a CPOE-based CDSS intervention against a non-CDSS control group, 7 reported a significant desired change in professional practice. Moreover, meta-regression analysis revealed that automatic provision of the decision support was strongly associated with improved professional practice (adjusted odds ratio, 23.72; 95% confidence interval, 1.75-infiniti). Thus, we conclude that automatic provision of decision support is a critical feature of successful CPOE-based CDSS interventions.
    AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium 02/2003; 2003:361-5.
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