A controlled trial to improve delivery of preventive care: physician or patient reminders? A computer-generated reminder system improves physician compliance with diabetes preventive care guidelines. A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease. Can just-in-time, evidence-based "reminders" improve pain management among home health care nurses and their patients? Reminders to physicians from an introspective computer medical record. A two-year randomized trial. Patients and computers as reminders to screen for diabetes in family practice. Randomized-controlled trial. Use of a computer to detect and respond to clinical events: its effect on clinician behavior. Effect of enhanced feedback and brief educational reminder messages on laboratory test requesting in primary care: a cluster randomised trial. Effect of mailed reminders on the response rate in surveys among patients in general practice. A computerized reminder system to increase the use of preventive care for hospitalized patients. Use of reminders for preventive procedures in family medicine. Protocol-based computer reminders, the quality of care and the non-perfectability of man. A randomized controlled trial of communication training with primary care providers to improve patient-centeredness and health risk communication. The use of text messaging to improve attendance in primary care: a randomized controlled trial. Computer-generated physician and patient reminders. Tools to improve population adherence to selected preventive services. Physician response to computer reminders. Telephone reminders are effective in recruiting nonresponding patients to randomized controlled trials. A randomized trial of the impact of telephone and recorded delivery reminders on the response rate to research questionnaires. Effectiveness of computer-generated reminders for increasing discussions about advance directives and completion of advance directive forms. A randomized, controlled trial. A large population-based randomized controlled trial to increase attendance at screening for cervical cancer. Can computer-generated evidence-based care suggestions enhance evidence-based management of asthma and chronic obstructive pulmonary disease? A randomized, controlled trial. Computerized medical records and preventive health care: success depends on many factors. The effect of microcomputer-generated reminders on influenza vaccination rates in a university-based family practice center. Implementation of evidence-based preventive services delivery processes in primary care: an Oklahoma Physicians Resource/Research Network (OKPRN) study. The impact of computerized clinical reminders on physician prescribing behavior: evidence from community oncology practice. How reminders given to patients and physicians affected pap smear use in a health maintenance organization: results of a randomized controlled trial. The effect of patient and physician reminders on use of screening mammography in a health maintenance organization. Results of a randomized controlled trial.
To improve the delivery of preventive care in a medical clinic, a controlled trial was conducted of two interventions that were expected to influence delivery of preventive services differently, depending on level of initiative required of the physician or patient to complete a service.
                A prospective, controlled trial of five-months' duration.
                A university hospital-based, general medical clinic.
                Thirty-nine junior and senior medical residents who saw patients in stable clinic teams throughout the study.
                A computerized reminder system for physicians and a patient questionnaire and educational hand-out on preventive care.
                Delivery of five of six audited preventive services improved significantly after the interventions were introduced. The computerized reminder alone increased completion rates of services that relied primarily on physician initiative; the questionnaire alone increased completion rate of the service that depended more on patient compliance as well as on some physician-dependent services. Both interventions used together were slightly less effective in improving performance of physician-dependent services than the computerized reminder used alone.
                These interventions can improve the delivery of preventive care but they differ in their impacts on physician and patient behaviors. Overall, the computer reminder was the more effective intervention. Computerized reminder systems have been shown to be effective in improving physician compliance with preventive services guidelines. Very little has been published about the use of computerized reminders for preventive care in diabetes. We implemented a computer-generated reminder system for diabetes care guidelines in a randomized controlled study in the outpatient clinics of 35 internal medicine residents at the University of Utah and Salt Lake Veterans Affairs Hospitals. After a six month study period, compliance with the recommended care significantly improved in both the intervention group that received patient-specific reminders about the guidelines (38.0% at baseline, 54.9% at follow-up) and the control group that received a nonspecific report (34.6% at baseline, 51.0% at follow-up). There was no significant difference between the two groups. Both clinic sites showed similar improvement over baseline levels of compliance. Residents who completed encounter forms used by the system showed a significantly greater improvement in compliance than those who did not complete encounter forms (19.7% vs. 7.6%, p = 0.006). The improvements in guideline compliance were seen in all areas of diabetes preventive care studied, and significant improvements were seen with recommended items from the medical history, physical exam, laboratory testing, referrals, and patient education. The use of encounter forms by the providers significantly improved documented compliance with the guidelines in almost all categories of preventive care. These results suggest that computerized reminder systems improve compliance with recommended care more by facilitating the documentation of clinical findings and the ordering of recommended procedures than by providing the clinician with patient-specific information about guideline compliance status. Further study is needed to understand the implications of these findings to the development of future computerized reminder systems for chronic diseases such as diabetes. The aim of this study was to evaluate the impact of an integrated patient-specific electronic clinical reminder system on diabetes and coronary artery disease (CAD) care and to assess physician attitudes toward this reminder system.
                We enrolled 194 primary care physicians caring for 4549 patients with diabetes and 2199 patients with CAD at 20 ambulatory clinics. Clinics were randomized so that physicians received either evidence-based electronic reminders within their patients' electronic medical record or usual care. There were five reminders for diabetes care and four reminders for CAD care.
                The primary outcome was receipt of recommended care for diabetes and CAD. We created a summary outcome to assess the odds of increased compliance with overall diabetes care (based on five measures) and overall CAD care (based on four measures). We surveyed physicians to assess attitudes toward the reminder system.
                Baseline adherence rates to all quality measures were low. While electronic reminders increased the odds of recommended diabetes care (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.01-1.67) and CAD (OR 1.25, 95% CI 1.01-1.55), the impact of individual reminders was variable. A total of three of nine reminders effectively increased rates of recommended care for diabetes or CAD. The majority of physicians (76%) thought that reminders improved quality of care.
                An integrated electronic reminder system resulted in variable improvement in care for diabetes and CAD. These improvements were often limited and quality gaps persist. The purpose of this randomized, controlled, home care intervention was to test the effectiveness of two nurse-targeted, e-mail-based interventions to increase home care nurses' adherence to pain assessment and management guidelines, and to improve patient outcomes. Nurses from a large urban non-profit home care organization were assigned to usual care or one of two interventions upon identification of an eligible cancer patient with pain. The basic intervention consisted of a patient-specific, one-time e-mail reminder highlighting six pain-specific clinical recommendations. The augmented intervention supplemented the initial e-mail reminder with provider prompts, patient education material, and clinical nurse specialist outreach. Over 300 nurses were randomized and outcomes of 673 of their patients were reviewed. Data collection involved clinical record abstraction of nurse care practices and patient interviews completed approximately 45 days after start of care. The intervention had limited effect on nurse-documented care practices but patient outcomes were positively influenced. Patients in the augmented group improved significantly over the control group in ratings of pain intensity at its worst, whereas patients in the basic group had better ratings of pain intensity on average. Other outcomes measures were also positively influenced but did not reach statistical significance. Our findings suggest that although reminders have some role in improving cancer pain management, a more intensive approach is needed for a generalized nursing workforce with limited recent exposure to state-of-the-art pain management practices. We developed a computer-stored medical record system containing a limited set of the total clinical data base--primarily diagnostic studies and treatments. This system responds to its own content according to physician-authored reminder rules. To determine the effect of the reminder messages generated by 1490 rules on physician behavior, we randomly assigned practitioners in a general medicine clinic to study or control groups. The computer found indications for six different actions per patient in 12 467 patients during a 2-year study: 61 study group residents who received computer reminders responded to 49% of these indications; 54 control group residents, to only 29% (p less than 0.0001). Preventive care (occult blood testing, mammographic screening, weight reduction diets, influenza and pneumococcal vaccines) was affected. The intentions of the study group to use a given action for an indication predicted their response to the indications (p less than 0.03, r2 = 0.33). The intentions of the control residents did not. In New Zealand, more than 5% of people aged 50 years and older have undiagnosed diabetes; most of them attend family practitioners (FPs) at least once a year.
                To test the effectiveness of patients or computers as reminders to screen for diabetes in patients attending FPs.
                A randomized-controlled trial compared screening rates in 4 intervention arms: patient reminders, computer reminders, both reminders, and usual care. The trial lasted 2 months. The patient reminder was a diabetes risk self-assessment sheet filled in by patients and given to the FP during the consultation. The computer reminder was an icon that flashed only for patients considered eligible for screening.
                One hundred and seven FPs.
                The primary outcome was whether each eligible patient, who attended during the trial, was or was not tested for blood glucose. Analysis was by intention to treat and allowed for clustering by FP.
                Patient reminders (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.21, 2.43), computer reminders (OR 2.55, 1.68, 3.88), and both reminders (OR 1.69, 1.11, 2.59) were all effective compared with usual care. Computer reminders were more effective than patient reminders (OR 1.49, 1.07, 2.07). Patients were more likely to be screened if they visited the FP repeatedly, if patients were non-European, if they were "regular" patients of the practice, and if their FP had a higher screening rate prior to the study.
                Patient and computer reminders were effective methods to increase screening for diabetes. However, the effects were not additive. A computer was used to prospectively detect and suggest responses to simple, medication-related events as reflected in a computerized record in a prospective, randomized study of a diabetes clinic with primary-care responsibility. There were two categories of event/suggestions: when the last observation of a test required for medication control was too old, the computer suggested a repeat; and when an abnormality with therapeutic implications was detected, the computer suggested a specific change in therapeutics. Clinicians responded to 36% of events in the first category with computer reminders and 11% without (P less than 0.0001); they responded to 28% of events in the second category with computer assistance and 13% without (P less than 0.026). For the most clinically significant of these second category events, the difference was even greater: 47% with and 4% without computer assistance (P less than 0.0004). I believe that computer detection and response (in the form of reminders) to simple clinical events will change clinician behavior. Laboratory services play an important part in screening, diagnosis, and management of patients within primary care. However, unnecessary use of laboratory tests is increasing. Our aim was to assess the effect of two interventions on the number of laboratory tests requested by primary-care physicians.
                We did a cluster randomised controlled trial using a 2x2 factorial design, involving 85 primary-care practices (370 family practitioners) that request all laboratory tests from one regional centre. The interventions were quarterly feedback of practice requesting rates for nine laboratory tests, enhanced with educational messages, and brief educational reminder messages added to the test result reports for nine laboratory tests. The primary outcome was the number of targeted tests requested by primary-care practices during the 12 months of the intervention. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN06490422.
                Practices that received either or both the enhanced feedback and the reminder messages were significantly less likely than the control group to request the targeted tests in total (enhanced feedback odds ratio 0.87, 95% CI 0.81-0.94; reminder messages 0.89, 0.83-0.93). The effect of the interventions varied across the targeted tests individually, although the number of tests requested for both interventions was generally reduced. Neither intervention was consistently better than the other.
                Enhanced feedback of requesting rates and brief educational reminder messages, alone and in combination, are effective strategies for reducing test requesting in primary care. Both strategies are feasible within most laboratory settings. Randomized trials were performed in Denmark and The Netherlands to determine the effect of mailed reminders on the response rate in surveys among patients in general practice. In both countries, general practitioners handed out questionnaires to 200 adult patients who came to visit them. An intervention group of 100 patients received reminders at 3 weeks after the visit, whereas a control group of the remaining 100 patients did not receive reminders. The response rate was significantly higher in the intervention groups than in the control group in The Netherlands (86% versus 55%, respectively) but not in Denmark (87% versus 81%, respectively). Mailed reminders can improve the response rate in surveys related to a general practice, but they are not effective in all situations. Although they are effective in outpatient settings, computerized reminders have not been proved to increase preventive care in inpatient settings.
                We conducted a randomized, controlled trial to determine the effects of computerized reminders on the rates at which four preventive therapies were ordered for inpatients. During an 18-month study period, a computerized system processed on-line information for all 6371 patients admitted to a general-medicine service (for a total of 10,065 hospitalizations), generating preventive care reminders as appropriate. Physicians who were in the intervention group viewed these reminders when they were using a computerized order-entry system for inpatients.
                The reminder system identified 3416 patients (53.6 percent) as eligible for preventive measures that had not been ordered by the admitting physician. For patients with at least one indication, computerized reminders resulted in higher adjusted ordering rates for pneumococcal vaccination (35.8 percent of the patients in the intervention group vs. 0.8 percent of those in the control group, P<0.001), influenza vaccination (51.4 percent vs. 1.0 percent, P< 0.001), prophylactic heparin (32.2 percent vs. 18.9 percent, P<0.001), and prophylactic aspirin at discharge (36.4 percent vs. 27.6 percent, P<0.001).
                A majority of hospitalized patients in this study were eligible for preventive measures, and computerized reminders significantly increased the rate of delivery of such therapies. To compare the effectiveness of three computerized reminder systems in the delivery of five preventive procedures in family practice.
                Prospective, randomized, controlled study.
                Ottawa Civic Hospital Family Medicine Centre.
                Of 8502 patients 15 years of age or more who were not in a hospital or institution 5883 were randomly assigned, by family, to a control group, a physician reminder group (passive) or a telephone or letter reminder group (active). The remaining 2619 patients were not included in the randomized portion of the study but were monitored.
                During 1 year the patients in the active reminder groups received a telephone call or letter reminding them of any overdue preventive procedures; for those in the passive reminder group the physician was reminded at an office visit to provide any overdue service.
                Rates of completion of the preventive procedures required.
                All three reminder systems significantly improved the delivery of preventive services (p less than 0.001). The procedure completion rates were 42.0% in the letter reminder group, 42.0% in the telephone reminder group, 33.7% in the physician reminder group and 14.1% in the randomized control group. The use of a letter was more cost-effective than the telephone system, but the physician reminder system was the most cost-effective.
                Computerized reminder systems do improve the delivery of preventive services in family practice. To determine whether clinical errors can be reduced by prospective computer suggestions about the management of simple clinical events, I studied the responses of nine physicians to computer suggestions generated by 390 protocols in a controlled crossover design. These protocols dealt primarily with conditions managed (e.g., elevated blood pressure) or caused (e.g., liver toxicity) by drugs. Physicians responded to 51 per cent of 327 events when given, and 22 per cent of 385 events when not given computer suggestions. Neither level of postgraduate training (first-year postgraduate or third-year post-graduate) nor the order in which physicians served as study and control subjects had statistically significant overall effect on the results. It appears that the prospective reminders do reduce errors, and that many of these errors are probably due to man's limitations as a data processor rather than to correctable human deficiencies. to determine the efficacy and effectiveness of training to improve primary care providers' patient-centered communication skills and proficiency in discussing their patients' health risks.
                twenty-eight primary care providers participated in a baseline simulated patient interaction and were subsequently randomized into intervention and control groups. Intervention providers participated in training focused on patient-centered communication about behavioral risk factors. Immediate efficacy of training was evaluated by comparing the two groups. Over the next 3 years, all providers participated in two more sets of interactions with patients. Longer term effectiveness was assessed using the interaction data collected at 6 and 18 months post-training.
                The intervention providers significantly improved in patient-centered communication and communication proficiencies immediately post-training and at both follow-up time points.
                this study suggests that the brief training produced significant and large differences in the intervention group providers which persisted 2 years after the training.
                the results of this study suggest that primary care providers can be trained to achieve and maintain gains in patient-centered communication, communication skills and discussion of adverse childhood events as root causes of chronic disease.
                2010 Elsevier Ireland Ltd. All rights reserved. Non-attendance is common in primary care and previous studies have reported that reminders were useful in reducing broken appointments.
                To determine the effectiveness of a text messaging reminder in improving attendance in primary care.
                Multicentre three-arm randomized controlled trial.
                Seven primary care clinics in Malaysia. Participants. Patients (or their caregivers) who required follow-up at the clinics between 48 hours and 3 months from the recruitment date. Interventions. Two intervention arms consisted of text messaging and mobile phone reminders 24-48 hours prior to scheduled appointments. Control group did not receive any intervention. Outcome measures. Attendance rates and costs of interventions.
                A total of 993 participants were eligible for analysis. Attendance rates of control, text messaging and mobile phone reminder groups were 48.1, 59.0 and 59.6%, respectively. The attendance rate of the text messaging reminder group was significantly higher compared with that of the control group (odds ratio 1.59, 95% confidence interval 1.17 to 2.17, P = 0.005). There was no statistically significant difference in attendance rates between text messaging and mobile phone reminder groups. The cost of text messaging reminder (RM 0.45 per attendance) was lower than mobile phone reminder (RM 0.82 per attendance).
                Text messaging reminder system was effective in improving attendance rate in primary care. It was more cost-effective compared with the mobile phone reminder. Despite an emerging consensus on appropriate preventive services, a minority of patients receive them. A study was undertaken to assess the impact of computer-generated reminders to adult patients, their physicians, or both patients and physicians on adherence to five recommended preventive services: cholesterol measurements, fecal occult blood testing, mammography, Papanicolaou smears, and tetanus immunization. During the academic year 1988-1989, all 7397 adult patients and their 49 physicians in a university family medicine clinical practice were randomized by practice group into one of four study groups: control, physician reminders, patient reminders, and both physician and patient reminders. Adherence was defined in community-oriented terms: the percentage of patients within each group who had received the preventive service in the recommended interval. During the study period, adherence to four of the five preventive services increased significantly, with the largest increases in the physician and patient reminder group: cholesterol measurements increased from 19.5% to 38.1%, fecal occult blood testing 9.3% to 27.0%, mammography 11.4% to 27.1%, and tetanus immunization 23.4% to 35.4% (for each increase, P less than .0001, McNemar's chi-square test). In general, increases were greater in blacks and in patients with any form of insurance coverage. Computer-based physician and patient reminder systems have great promise of improving adherence to preventive services in primary care settings. A computerized medical record system was designed to detect and remind the responsible clinician about clinical events that might need corrective action. These reminders significantly increased the clinician response rate (in terms of test orders and treatment changes) to the events in question. The addition of relevant medical literature citations to the reminders did not significantly change the clinician response rate as compared with that with reminders alone, nor did it stimulate the physicians to read any of the cited articles kept in an immediately available "library" of reprints. Studies investigating means of recruiting participants to randomized controlled trials (RCTs) are sparse. We investigated the effects of telephone reminders as a recruitment strategy.
                Sick-listed employees received a written invitation to participate in a study comparing standard treatments with a solution-focused follow-up and were randomly allocated to an intervention or control group (n=703). Those who did not respond within 2 weeks received either 'no reminder' (n=242) or 'attempted telephone reminder' (n=256). Outcome was enrollment to the RCT.
                An intention to recruit analysis revealed no significant differences between the groups (P=.229). An intention to phone analysis among nonresponders revealed significant differences between 'no reminder' (recruited 4.5%) and 'attempted telephone reminder' (recruited 12.1%) (P=.003, odds ratio 2.89, 95% confidence interval [CI] 1.42-5.90). An analysis of numbers needed to phone showed that to recruit one more person in this group of nonresponders, we needed to phone 13 persons (95% CI=8-33).
                Systematic use of telephone calls can increase the recruitment rate among nonresponders in RCTs. A range of factors have been shown to affect the response rate to mailed questionnaires, but particular strategies to improve patients' response in trials conducted in general practice require further study.
                Non-responders in a larger trial were randomized to receive a telephone or recorded delivery reminder on the third contact. The cost of administration of each method was estimated.
                Significantly more patients returned completed questionnaires when sent questionnaires by recorded delivery, although the cost per patient contacted was nearly three times more than for contact by telephone.
                Our study indicates that sending reminders by recorded delivery, although more expensive, is more effective than telephone reminders for recruiting patients to a study in general practice using research questionnaires. Physicians can increase the rate of completion of advance directive forms by discussing directives with their patients, but the means by which physicians can be induced to initiate these discussions are unclear. Computer-generated reminders have been shown to increase physician compliance with practice guidelines.
                To determine the effects of computer-generated reminders to physicians on the frequency of advance directive discussions between patients and their primary caregivers and the frequency of consequent establishment of advance directives.
                Randomized, controlled trial with a 2 x 2 factorial design.
                An outpatient general medicine practice associated with an urban public hospital.
                Participants were 1) 1009 patients who were at least 75 years of age or were at least 50 years of age with serious underlying disease and 2) 147 primary care physicians (108 housestaff and 39 faculty).
                Computer-generated reminders that recommended discussion of one or both of two types of advance directives compared with no reminders.
                Discussions about advance directives, determined by patient interviews after all scheduled patient-physician outpatient encounters, and completed advance directive forms. The study period was approximately 1 year.
                Physicians who did not receive reminders (controls) discussed advance directives with 4% of the study patients compared with 24% for physicians who received both types of reminders (adjusted odds ratio, 7.7 [95% CI, 3.4 to 18]; P < 0.001). Physicians who did not receive reminders completed advance directive forms with only 4% of their study patients compared with 15% for physicians who received both types of reminders (adjusted odds ratio, 7.0 [CI, 2.9 to 17]; P < 0.001). Overall, 45% of patients with whom advance directives were discussed completed at least one type of advance directive.
                Simple computer-generated reminders aimed at primary caregivers can increase the rates of discussion of advance directives and completion of advance directive forms among elderly outpatients with serious illnesses. Although cervical cancer is one of the potentially most preventable malignancies, it is still fairly common. In settings with established screening programs, increased compliance is important for future reduction in cervical cancer incidence, but it is presently unclear how this can be effectively achieved.
                We conducted a randomized controlled trial including all 12,240 women invited to organized screening in Sweden. To increase compliance, three successive interventions were tested: (a) modified invitation versus the standard invitation letter, (b) reminder letter to nonattenders after the first intervention versus no reminder letter, and (c) phone reminder to nonattenders after the reminder letter versus no phone reminder. We analyzed the proportion of women attending screening after each intervention and the cumulative proportion after the interventions as well as the cumulative proportions of cytologic abnormalities.
                The modified invitation did not increase attendance compared with the standard invitation letter [difference 1.3% 95% confidence interval (CI) -0.3 to 2.9]. In contrast, a reminder letter increased the proportion of women attending with 9.2% (95% CI 7.9-10.5) compared with women who did not receive a reminder letter, and a phone reminder increased the proportion of women attending with 31.4% (95% CI 26.9-35.9). Combinations of modified invitation, written reminder, and phone reminder almost doubled attendance within 12 months, and the number of detected cytologic abnormalities was more than tripled.
                Simple reminders by mail and phone can drastically increase women's participation in Papanicolaou smear screening and increase the number of detected precursor lesions and thereby save lives. Translation of evidence-based guidelines into clinical practice has been inconsistent. We performed a randomized, controlled trial of guideline-based care suggestions delivered to physicians when writing orders on computer workstations.
                Inner-city academic general internal medicine practice.
                Randomized, controlled trial of 246 physicians (25 percent faculty general internists, 75 percent internal medicine residents) and 20 outpatient pharmacists. We enrolled 706 of their primary care patients with asthma or chronic obstructive pulmonary disease. Care suggestions concerning drugs and monitoring were delivered to a random half of the physicians and pharmacists when writing orders or filling prescriptions using computer workstations. A 2 x 2 factorial randomization of practice sessions and pharmacists resulted in four groups of patients: physician intervention, pharmacist intervention, both interventions, and controls. DATA EXTRACTION/COLLECTION METHODS: Adherence to the guidelines and clinical activity was assessed using patients' electronic medical records. Health-related quality of life, medication adherence, and satisfaction with care were assessed using telephone questionnaires.
                During their year in the study, patients made an average of five scheduled primary care visits. There were no differences between groups in adherence to the care suggestions, generic or condition-specific quality of life, satisfaction with physicians or pharmacists, medication compliance, emergency department visits, or hospitalizations. Physicians receiving the intervention had significantly higher total health care costs. Physician attitudes toward guidelines were mixed.
                Care suggestions shown to physicians and pharmacists on computer workstations had no effect on the delivery or outcomes of care for patients with reactive airways disease. To study the effect of a computerized medical record and other practice factors on the delivery of preventive health care.
                Prospective, controlled trial.
                University general internal medicine teaching clinic.
                Forty-five internal medicine residents and their 4 supervising attending physicians.
                The study group used a computerized ambulatory medical record system that included health care maintenance reminders. The control group used a conventional paper record with a health care maintenance flow sheet.
                The computer reminders significantly increased health care maintenance recommendations made to patients for proctosigmoidoscopy, tetanus vaccination, influenza vaccination, and pneumococcal vaccination, but not for fecal occult blood testing, mammography, Pap smears, or serum thyroxine screening in the elderly. First-year residents were nearly twice as successful as third-year residents in overall health care maintenance. Success scores varied markedly depending on which attending physician was supervising the residents. We found a strong interaction among group assignment, supervising attending, and level of training such that the reminders doubled success scores among first-year residents supervised by two of the attending physicians but had little effect on other subgroups. The time of year and the format of the reminder also had important effects for some of the maneuvers.
                Although computerized medical records markedly improved the performance of prevention maneuvers by committed physicians, many physicians using computer systems failed to make use of the resource. The reasons for this were complex. Future work in this area should carefully control for personal behaviors and focus upon administrative changes that more effectively implement these potentially powerful tools. Less than 20 percent of elderly and other high-risk persons targeted for annual influenza vaccination are immunized each year. In most busy practice settings, it is difficult for primary care physicians to identify every patient in need of preventive health interventions. The purpose of this study was to assess the effect of microcomputer-generated reminders on influenza vaccination rates in a university-based family practice center. The practice uses an interactive encounter form system from which updated clinical information is routinely entered into a cumulative database. During a 2-month period, 686 patients were identified in the database as eligible to receive influenza vaccine according to accepted criteria. Practice physicians (n = 32) were stratified by level of training and randomized to one of three groups, thereby receiving printed reminders on the encounter forms of all, none, or half of their eligible patients. Patients of physicians who always received reminders were more likely to receive influenza vaccine during the study period than patients of the never-reminded physicians (51 percent versus 30 percent, P less than 0.001). Patients whose physicians received reminders for only half their patients had an intermediate likelihood of receiving a vaccination if a reminder was printed (38 percent) but were less likely than the patients of never-reminded physicians to receive the vaccine if no reminder was printed (20 percent, P less than 0.001). This study suggests that physicians learn to depend on reminders for preventive health activities and that reminders are most effective when they are provided at every patient encounter. Previous research has found that wellness visits, recall and reminder systems, and standing orders are associated with higher rates of delivery of preventive services in primary care practices. However, there is little information about how to help practices implement these processes.
                A 6-month randomized, controlled trial comparing a multicomponent quality improvement intervention to feedback and benchmarking. One clinician/nurse team from each of 24 practices was randomly assigned to one of 2 study arms. Intervention practices received performance feedback, peer-to-peer education (academic detailing), a practice facilitator, and computer (information technology) support. Implementation of the 3 targeted processes was determined by a blinded 3-clinician panel that reviewed transcribed clinician interviews before and after intervention using performance definitions. Rates of delivery of selected preventive services were determined by chart audit.
                Intervention practices implemented more of the processes than control practices overall (P = .003), for adults (P = .05), and for children (P = .04). They were also more likely to implement at least one of the processes for children (P = .04) and to implement standing orders for either children or adults (P = .02). Mammography rates increased significantly. Neither clinician and practice characteristics nor clinician readiness to change predicted implementation.
                A multicomponent implementation strategy consisting of feedback, benchmarking, academic detailing, facilitation, and IT support increased implementation of evidence-based processes for delivering preventive services to a greater extent than performance feedback and benchmarking alone. The objective of this study is to examine the impact of a clinical reminder generated by an electronic medical record (EMR) system on physician prescribing behavior in community oncology practice setting. A case-control trial assessing the prescribing rates of erythropoietin by physicians is used. The participants and setting involves a total of 11,644 physician-patient encounters in 2 community oncology practices in the United States during a 21-month period. The intervention is a clinical reminder generated in real time during a physician-patient encounter by an EMR identifying cancer patients with low hemoglobin (Hgb) levels (ie, anemic), that is, patients with Hgb less then 12 g/dL. The main outcome measure is to determine the frequency of erythropoietin prescription by physicians to cancer patients with low Hgb levels. Implementation of a clinical reminder generated by way of an EMR significantly improved the likelihood of low-Hgb patients receiving treatment with erythropoietin. Low-Hgb patients in the experimental clinic during the time that the clinical reminder system was in place were almost twice as likely (ie, adjusted odds ratio = 1.92, P = .008) to have been treated with erythropoietin. The data support the effectiveness of clinical reminders as a way to influence physician prescribing behaviors and potentially improve the quality of patient care. However, we feel that there is a need to investigate the use of reminders in other aspects of cancer care that may be undertreated or when new drugs may be available but are underused. Despite its effectiveness as a method of controlling cervical carcinoma, the use of Pap smear testing remains incomplete, and its promotion in the primary care setting provides an important opportunity for intervention.
                The authors conducted a randomized controlled trial that involved three sites of a health maintenance organization (HMO) serving an urban minority population. Their aim was to evaluate the impact of reminders given to patients and physicians on site visitation by patients and Pap smear use. Eligible women (n=5801) were randomly assigned to 1 of 4 intervention combinations (in which reminders were given to either the patient or the physician, to both, or to neither). If they were ineligible for patient reminder intervention, patients were randomized only to physician reminder intervention (the presence or absence of it). The letter of reminder mailed to the patient invited women due for Pap smears to visit the HMO site, and the reminder for physicians was a medical record notice that a Pap smear was due. Logistic and survival analyses were used to investigate the correlation of intervention status with visitation, interval of time to a visit, and Pap smear use.
                In the primary intent-to-treat analysis, there was no significant effect of either patient or physician reminder interventions on rates of visitation or Pap smear completion. The secondary efficacy analyses demonstrated no overall effect of either patient or physician reminders, but effects among subgroups of women at individual HMO sites were noted. At Site 3, there was an apparent increase in time to the next visit among the subgroup of women with a chronic illness (16 weeks with intervention vs. 9 weeks without). With the physician reminder, the odds that a Pap smear would be given during the study year were increased among women without a previous Pap smear at Site 1 (adjusted odds ratio=1.39) and those with a chronic illness at Site 2 (adjusted odds ratio=3.38).
                Reminders given to patients and physicians had a limited impact on visitation by patients to the HMO sites or Pap smear completion. Although some subgroups of women may benefit, the authors also observed a possibly unfavorable impact among other subgroups. These results emphasize the importance of identifying more effective interventions, targeting them to women most likely to benefit, and not overlooking the possibility that preventive intervention will have an unanticipated adverse effect. Despite its demonstrated efficacy in reducing breast carcinoma mortality, screening mammography remains underutilized and its promotion in the primary care setting provides an important opportunity for intervention.
                A randomized controlled trial was conducted in two sites of a health maintenance organization (HMO) serving an urban, minority population to evaluate the impact of patient and physician reminders on site visitation and mammography use. Eligible women (n = 2368) were randomly assigned to 1 of 4 intervention combinations (patient and physician reminders individually, together, or neither). The patient reminder letter invited mammography-due women to visit. The physician reminder was a notice placed in the medical record of mammography-due women. Logistic analysis and survival analysis were used to investigate the relationship of intervention status to visitation, time to a visit, and mammography use.
                The patient reminder intervention had no effect upon rates of study year visitation or mammography at either site. However, among HMO Site 2 enrollees with entitlement insurance, the median time to the next visit was reduced from 12 to 9 weeks in association with assignment to patient reminder intervention. The physician reminder intervention was also effective in increasing the rate of completed mammography at Site 2 among all assignees (36% vs. 22% for those with vs. those without physician reminders) and among assignees who visited (59% vs. 43%).
                Patient reminder letters had limited impact on visitation in this setting. Physician reminders are more effective but sites vary in their responsiveness. Further improvement in mammography utilization will require a better understanding of the determinants of patient and physician behavior.
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.