title: The impact of a decision aid about heart disease prevention on patients' discussions with their doctor and their plans for prevention: a pilot randomized trial Outcomes of a home telehealth intervention for patients with diabetes and hypertension. Can computerized risk profiles help patients improve their coronary risk? The results of the Coronary Health Assessment Study (CHAS). Shared electronic vascular risk decision support in primary care: Computerization of Medical Practices for the Enhancement of Therapeutic Effectiveness (COMPETE III) randomized trial. TeleHealth Improves Diabetes Self-Management in an Underserved Community Assessment of an electronic daily diary in patients with overactive bladder Impact of Interview Mode on Accuracy of Child and Parent Report of Adherence With Asthma-Controller Medication A randomized trial of an intervention to improve use and adherence to effective coronary heart disease prevention strategies Adolescent sexual behavior, drug use, and violence: increased reporting with computer survey technology. Differences in young people's reports of sexual behaviors according to interview methodology: a randomized trial in India. A clinical trial comparing interviewer and computer-assisted assessment among clients with severe mental illness. Electronic Risk Alerts to Improve Primary Care Management of Chest Pain: A Randomized, Controlled Trial Cholgate - A Randomized Controlled Trial Comparing The Effect Of Automated And On-Demand Decision Support On The Management Of Cardiovascular Disease Factors In Primary Care Randomised controlled trial of computer-held medical records in hypertensive patients. Medical Information Systems: Assessing Impact in the Areas of Hypertension, Obesity and Renal Disease Effect of Preventive Messages Tailored to Family History on Health Behaviors: The Family Healthware Impact Trial Impact of decision support in electronic medical records on lipid management in primary care. Data Collection Outcomes Comparing Paper Forms With PDA Forms in an Office-Based Patient Survey
abstract: Abstract Background Low utilization of effective coronary heart disease ( CHD ) prevention strategies may be due to many factors , but chief among them is the lack of patient involvement in prevention decisions . We undertook this study to test the effectiveness of an individually-tailored , computerized decision aid about CHD on patients ' discussion s with their doctor and their plans for CHD prevention . Methods We conducted a pilot r and omized trial in a convenience sample of adults with no previous history of cardiovascular disease to test the effectiveness of an individually-tailored , computerized decision aid about CHD prevention against a risk factor list that patients could present to their doctor . Results We enrolled 75 adults . Mean age was 53 . 59 % were female , 73 % white , and 23 % African-American . 66 % had some college education . 43 % had a 10-year CHD risk of 0–5 % , 25 % a risk of 6–10 % , 24 % a risk of 11–20 % , and 5 % a risk of > 20 % . 78 % had at least one option to reduce their CHD risk , but only 45 % accurately identified the strategies best supported by evidence . 41 patients received the decision aid  , 34 received  usual care . In unadjusted analysis , the decision aid increased the proportion of patients who discussed CHD risk reduction with their doctor from 24 % to 40 % ( absolute difference 16 % ; 95 % CI -4 % to + 37 % ) and increased the proportion who had a specific plan to reduce their risk from 24 % to 37 % ( absolute difference 13 % ; 95 % CI -7 % to + 34 % ) . In pre-post testing , the decision aid also appeared to increase the proportion of patients with plans to intervene on their CHD risk ( absolute increase ranging from 21 % to 47 % for planned medication use and 5 % to 16 % for planned behavioral interventions ) . Conclusion Our study confirms patients ' limited knowledge about their CHD risk and effective risk reduction options and provides preliminary evidence that an individually-tailored decision aid about CHD prevention might be expected to increase patients ' discussion s about CHD prevention with their doctor and their plans for CHD risk reduction . These findings should be replicated in studies with a larger sample size and patients at overall higher risk of CHD . Trial Registration : Clinical Trials.gov BACKGROUND Home telehealth programs often focus on a single disease , yet many patients who need monitoring have multiple conditions . This study evaluated secondary outcomes from a clinical trial evaluating the efficacy of home telehealth to improve outcomes of patients with co-morbid diabetes and hypertension . SUBJECTS AND METHODS A single-center r and omized controlled clinical trial compared two remote monitoring intensity levels ( low and high ) and usual care in patients with type 2 diabetes and hypertension being treated in primary care . Secondary outcomes assessed were knowledge ( diabetes , hypertension , medications ) , self-efficacy , adherence ( diabetes , medications ) , and patient perceptions of the intervention mode . RESULTS Knowledge scores improved in the high-intensity intervention group participants , but upon further analysis , we found the intervention effect was not mediated by gain in knowledge . No significant differences were found across the groups in self-efficacy , adherence , or patient perceptions of the intervention mode . CONCLUSIONS Home telehealth can enhance detection of key clinical symptoms that occur between regular physician visits . While our intervention improved glycemic and blood pressure control , the mechanism of the effect for this improvement was not clear BACKGROUND The Coronary Health Assessment Study ( CHAS ) was developed to determine the feasibility of using patient-specific , multifactorial computerized coronary risk profiles as a clinical decision aid to support primary prevention of CHD . METHODS Study participants included 253 community based physicians , r and omized into profile and control groups , and 958 of their patients . The profile group physicians received coronary risk profiles for their patients within 10 working days after the baseline patient assessment providing early feedback . The control group received their profiles only if the patient was clinical ly reevaluated during a 3-month follow-up visit . Patients ' coronary risk factors were evaluated at baseline and at follow-up . RESULTS The profile group had a significantly higher ( P < 0.05 ) ratio of high-risk/low-risk patients who returned for a follow-up visit compared to the control group ( 1.23 vs 0.77 ) . The patients in the profile group also had significantly ( P < 0.05 ) greater mean reductions in total cholesterol ( -0.5 vs -0.1 mmol/L ) , LDL cholesterol ( -0.4 vs 0.0 mmol/L ) , the total cholesterol/ HDL ratio ( -0.6 vs -0.2 ) , and the predicted 8-year coronary risk ( -1.8 vs -0.3 % ) . CONCLUSIONS Computer-generated coronary risk profiles can be effective in assisting physicians to identify high-risk patients . Their use is also associated with significantly greater improvements in the serum lipid profiles and the overall coronary risk of these patients BACKGROUND Computerized decision support systems ( CDSSs ) linked with electronic medical records ( EMRs ) are promoted as an effective means of improving patient care . However , very few high- quality studies are set in routine , community-based clinical care , and no consistent evidence of an effect on patient outcomes has been found . METHODS A r and omized controlled trial among EMR-using primary care practice s in Ontario , Canada . Patients 55 years or older with previous vascular events , diabetes mellitus , hypertension , or hypercholesterolemia were r and omized to the Computerization of Medical Practice s for the Enhancement of Therapeutic Effectiveness ( COMPETE III ) CDSS intervention or to usual care . The intervention included personally tailored electronic vascular risk monitoring and treatment advice shared between the physician and patient , risk calculation , and a clinical re source . The primary outcome was a composite score of 8 recommended process outcomes at 1 year . Data collectors were blinded to group allocation . Analysis used the intention-to-treat principle with multiple imputation for missing data . RESULTS We r and omized and included in the analysis 1102 patients in 49 community-based physician practice s ( 53.4 % female ; mean age , 69.1 years ; 28.0 % with a previous vascular event ) . The intervention group ( 545 [ 49.5 % ] ) had a significantly greater improvement in mean process composite , with a difference of 4.70 ( P < .001 ) on a 27-point scale . Intervention patients had significantly higher odds of rating their continuity of care ( 4.18 ; P < .001 ) and their ability to improve their vascular health ( 3.07 ; P < .001 ) as improved . Despite this improvement , the clinical outcomes -vascular events , clinical variables , and quality of life-were not improved . CONCLUSION Despite favorable review s and important improvements in the complex processes required to reduce vascular risk , clinical outcomes remain unchanged OBJECTIVE To conduct a 1-year r and omized clinical trial to evaluate a remote comprehensive diabetes self-management education ( DSME ) intervention , Diabetes TeleCare , administered by a dietitian and nurse/certified diabetes educator ( CDE ) in the setting of a federally qualified health center ( FQHC ) in rural South Carolina . RESEARCH DESIGN AND METHODS Participants were recruited from three member health centers of an FQHC and were r and omized to either Diabetes TeleCare , a 12-month , 13-session curriculum delivered using telehealth strategies , or usual care .  RESULTS Mixed linear regression model results for repeated measures showed a significant reduction in glycated hemoglobin ( GHb ) in the Diabetes TeleCare group from baseline to 6 and 12 months ( 9.4 ± 0.3 , 8.3 ± 0.3 , and 8.2 ± 0.4 , respectively ) compared with usual care ( 8.8 ± 0.3 , 8.6 ± 0.3 , and 8.6 ± 0.3 , respectively ) . LDL cholesterol was reduced at 12 months in the Diabetes TeleCare group compared with usual care . Although not part of the original study design , GHb was reduced from baseline to 12 and 24 months in the Diabetes TeleCare group ( 9.2 ± 0.4 , 7.4 ± 0.5 , and 7.6 ± 0.5 , respectively ) compared with usual care ( 8.7 ± 0.4 , 8.1 ± 0.4 , and 8.1 ± 0.5 , respectively ) in a post hoc analysis of a subset of the r and omized sample who completed a 24-month follow-up visit . CONCLUSIONS Telehealth effectively created access to successfully conduct a 1-year remote DSME by a nurse CDE and dietitian that improved metabolic control and reduced cardiovascular risk in an ethnically diverse and rural population To assess the effectiveness of a portable electronic diary as a data collection device for overactive bladder symptoms , and to evaluate its level of patient acceptability compared with a conventional paper‐based voiding diary OBJECTIVES . Parents and children often overreport adherence to treatment regimens , which in turn complicates interpretation and application of clinical trial findings . The objective of this investigation was to test the effect of reporting mode on accuracy of  inhaled corticosteroid-adherence reporting in children with asthma and their parents under conditions similar to those of an asthma clinical trial . PATIENTS AND METHODS . Participants included 104 children who were being treated with an inhaled corticosteroid delivered by a metered-dose inhaler for asthma diagnosed by their health care provider . Each parent and child dyad was r and omly assigned to 1 of 3 self-report adherence- assessment modes : ( 1 ) audio computer-assisted self-interviewing ; ( 2 ) face-to-face interview with study staff ; or ( 3 ) self-administered paper- and -pencil question naire . At the 4 monthly visits , the parent and child were interviewed separately and asked questions about adherence on the previous day and in the past week . Electronic devices were attached to the each participant 's metered-dose inhaler to provide an objective record of actual daily medication activations . RESULTS . Both children and parents greatly overreported their inhaled corticosteroid adherence when queried about either time frame ( 1 day or 1 week ) in any of the 3 interview modes . One of 3 responses reported full adherence when no medication had been taken . Inconsistent with the study hypothesis , discrepancy between self-report and objective ly measured adherence was greatest in the computer-interview condition . In the optimal circumstance where children were interviewed by study staff about their adherence within the previous 24 hours , reported adherence was within the ±25 % accuracy range for only half of the participants . Larger discrepancy scores were observed for both parents and children when reporting by computer or question naire . CONCLUSIONS . Under the best of conditions in this study , accuracy of self-report was insufficient to provide a st and -alone measure of adherence . Verification of treatment adherence by objective measures remains necessary Background Efficacious strategies for the primary prevention of coronary heart disease ( CHD ) are underused , and , when used , have low adherence . Existing efforts to improve use and adherence to these efficacious strategies have been so intensive that they are impractical for clinical practice . Methods We conducted a r and omized trial of a CHD prevention intervention ( including a computerized decision aid and automated tailored adherence messages ) at one university general internal medicine practice . After obtaining informed consent and collecting baseline data , we r and omized patients ( men and women age 40 - 79 with no prior history of cardiovascular disease ) to either the intervention or usual care . We then saw them for two additional study visits over 3 months . For intervention participants , we administered the decision aid at the primary study visit ( 1 week after baseline visit ) and then mailed 3 tailored adherence reminders at 2 , 4 , and 6 weeks . We assessed our outcomes ( including the predicted likelihood of angina , myocardial infa rct ion , and CHD death over 10 years ( CHD risk ) and self-reported adherence ) between groups at 3 month follow-up . Data collection occurred from June 2007 through December 2009 . All study procedures were IRB approved . Results We r and omized 160 eligible patients ( 81 intervention ; 79 control ) and followed 96 % to study conclusion . Mean predicted CHD risk at baseline was 11.3 % . The intervention increased self-reported adherence to chosen risk reducing strategies by 25 percentage points ( 95 % CI 8 % to 42 % ) , with the biggest effect for aspirin . It also changed predicted CHD risk by -1.1 % ( 95 % CI -0.16 % to -2 % ) , with a larger effect in a pre-specified subgroup of high risk patients . Conclusion A computerized intervention that involves patients in CHD decision making and supports adherence to effective prevention strategies can improve adherence and reduce predicted CHD risk . Clinical trials registration number Clinical Trials.gov : Surveys of risk behaviors have been hobbled by their reliance on respondents to report accurately about engaging in behaviors that are highly sensitive and may be illegal . An audio computer-assisted self-interviewing ( audio-CASI ) technology for measuring those behaviors was tested with 1690 respondents in the 1995 National Survey of Adolescent Males . The respondents were r and omly assigned to answer questions using either audio-CASI or a more traditional self-administered question naire . Estimates of the prevalence of male-male sex , injection drug use , and sexual contact with intravenous drug users were higher by factors of 3 or more when audio-CASI was used . Increased reporting was also found for several other risk behaviors OBJECTIVES We compared reports of sexual behaviors given in st and ard face-to-face interviews with reports given in audio computer-assisted self-interviews ( ACASIs ) and culturally specific interactive interviews  among adolescents in India . We sought to determine which of the interview methods leads to higher reporting of sexual behaviors among economically disadvantaged 15 - 19-year-olds in urban India . METHODS We conducted a r and omized trial in which each participant ( 583 boys and 475 girls ) was assigned to 2 interview methods : face-to-face interview and ACASI or interactive interview . We used matched case-control analyses to assess differences in the individual 's reporting on the 2 methods . RESULTS Female participants consistently reported fewer sexual behaviors in ACASIs than in face-to-face interviews , whereas male participants ' reports differed according to type of sexual behavior and interview mode . Both male and female participants reported more sexual behaviors during interactive interviews than during face-to-face interviews . Twenty-eight percent of male participants reported having engaged in heterosexual intercourse in interactive interviews , as compared with 20 % in face-to-face interviews ( P < .01 ) ; the corresponding percentages for female participants were 7 % and 2 % ( P<.01 ) . CONCLUSIONS Our results showed that young people were more likely to report sexual behaviors in culturally specific interactive interviews than in face-to-face interviews . By contrast , ACASIs did not uniformly lead to higher reporting levels than did face-to-face interviews OBJECTIVE Demographic , behavioral , and diagnostic information should routinely be collected from clients with severe mental illness , and data gathering should employ the most efficient techniques available . Surveys are increasingly conducted via Web-based computer-assisted interviewing ( CAI ) , but this technique is not well vali date d for patients with severe mental illness . A r and omized clinical trial of 245 clients was carried out to compare face-to face and computer-assisted interviewing ( 233 clients completed two surveys ) . METHODS Self-report data were collected on demographic characteristics , substance abuse , risk behaviors for blood-borne diseases , trauma history , and posttraumatic stress disorder . Each client was assessed twice and r and omly assigned to one of the four possible combinations of interviewer and computer ( computer and computer , N=53 ; computer and interviewer , N=56 ; interviewer and computer , N=59 ; and interviewer and interviewer , N=65 ) . The two formats were compared on feasibility , client preference , cost , reliability , convergent validity , and criterion validity . RESULTS This study demonstrated the feasibility of  CAI across a variety of inpatient and outpatient setting s. All participants who began the CAI process completed the interview and responded to over 95 % of the survey items . Participants liked using the computers as well as they liked face-to-face interviews , and they completed the  CAI  as quickly . CAI produced data as reliable and valid as face-to-face interviews produced and was less expensive , and results were available more quickly . The two formats were similar in criterion validity . CONCLUSIONS CAI appears to be a viable technology for gathering clinical data from the population with severe mental illness and for transforming such information into a useful , quickly accessible form to aid in clinical decision making BACKGROUND The primary care evaluation of chest pain represents a significant diagnostic challenge . OBJECTIVE To determine if electronic alerts to physicians can improve the quality and safety of chest pain evaluations . DESIGN AND PARTICIPANTS R and omized , controlled trial conducted between November 2008 and January 2010 among 292 primary care clinicians caring for 7,083 adult patients with chest pain and no history of cardiovascular disease . INTERVENTIONClinicians received alerts within the electronic health record during office visits for chest pain . One alert recommended performance of an electrocardiogram and administration of aspirin for high risk patients ( Framingham Risk Score ( FRS ) ≥ 10 % ) , and a second alert recommended against performance of cardiac stress testing for low risk patients ( FRS < 10%).MAIN MEASURES The primary outcomes included performance of an electrocardiogram and administration of aspirin therapy for high risk patients ; and avoidance of cardiac stress testing for low risk patients .KEY RESULTS The majority ( 81 % ) of patients with chest pain were classified as low risk . High risk patients were more likely than low risk patients to be evaluated in the emergency department ( 11 % versus 5 % , p < 0.01 ) and to be hospitalized ( 7 % versus 3 % , p < 0.01 ) . Acute myocardial infa rct ion occurred among 26 ( 0.4 % ) patients , more commonly among high risk compared to low risk patients ( 1.1 % versus 0.2 % , p < 0.01 ) . Among high risk patients , there was no difference between the intervention and control groups in rates of performing electrocardiograms ( 51 % versus 48 % , p = 0.33 ) or administering aspirin ( 20 % versus 18 % , p = 0.43 ) . Among low risk patients , there was no difference between intervention and control groups in rates of cardiac stress testing ( 10 % versus 9 % , p = 0.40 ) . CONCLUSIONS Primary care management of chest pain is suboptimal for both high and low risk patients . Electronic alerts do not increase risk-appropriate care for these patients Automated and on-dem and decision support systems integrated into an electronic medical record have proven to be an effective implementation strategy for guidelines . Cholgate is a r and omized controlled trial comparing the effect of automated and on-dem and decision support on the management of cardiovascular disease factors in primary care A total of 278 hypertensive patients in three clinics were r and omly allocated to have their medical records held in a computer system ( 136 ) or on st and ard hospital notes ( 142 ) . For the computer system the doctor completed a structured input form , and the information on symptoms , physical findings , and diagnoses was more complete than that in the st and ard notes . This result ed in certain symptoms and risk factors being recognised more often when the computer system was used . The hypertension clinics ' routines were not disrupted by the introduction of a computer-held system , and follow-up consultation times were not affected by the type of records kept , although the first consultation took eight minutes longer when computer documents were completed . The patients remained in the trial for one year and clinical management was assessed from blood pressure control , drop-out rates , and the frequency of performing investigations . These estimates of management showed no significant difference between the two groups , but the attempt to tailor the computer system to help management made the system acceptable to the doctors using it . The computer system continues to be used and is providing data for research into hypertension This study describes the influence of a computerized medical record summary system in three disease areas ( hypertension , obesity and renal disease ) observed in the course of a controlled , r and omized and prospect i ve study of 479 Northwestern University Clinic patients . Experimental patients , who had available automated record summaries , and control patients , who had available only the manual record  , were compared on several medical tests and procedures whose yearly occurrence was considered good medical practice for this patient population , and were compared as well on several measures of outcome of medical care . Evidence suggesting better care and outcome of care among patients with computerized record summaries available is presented PURPOSE We wanted to determine the impact of automated family history assessment and tailored messages for coronary heart disease , stroke , diabetes , colorectal , breast , and ovarian cancer on preventive behaviors compared with a st and ard preventive message . METHODS The study was a cluster-r and omized clinical trial that included 41 primary care practice s , the majority in the Midwest , using Family Healthware  , a self-administered , Web-based tool that assesses familial risk for the diseases and provides personalized risk-tailored messages . Patients in the control group received an age- and sex-specific health message related to lifestyle and screening . Smoking cessation , fruit and vegetable intake , physical activity , aspirin use , blood pressure , and cholesterol and blood glucose screening  were assessed at baseline and 6 months after the intervention . RESULTS Of 4,248 participants , 3,344 ( 78 % ) completed the study . Participants were white ( 91 % ) , female ( 70 % ) , and insured ( 97 % ) , and had a mean age of 50.6 years ( range 35–65 years ) . Intervention participants were more likely to increase daily fruit and vegetable consumption  from 5 or fewer servings a day to 5 or more servings a day ( OR = 1.29 ; 95 % confidence interval [ CI ] , 1.05–1.58 ) and to  increase physical activity ( OR = 1.47 ; 95 % CI , 1.08–1.98 ) to 5 to 6 times a week for 30 minutes or more a week . The absolute differences in proportion were 3 % and 4 % , respectively . Intervention participants were less likely to move from not having cholesterol screening in the last 5 years to having their cholesterol measured within 5 years ( OR = 0.34 ; 95 % CI , 0.17–0.67 ) , with an absolute difference of 15 % . CONCLUSIONS Messages tailored to an individual ’s familial risk for 6 common diseases modestly increased self-reported physical activity and fruit and vegetable intake but reduced the likelihood of receiving cholesterol screening Electronic decision-support tools may help to improve management of hyperlipidemia and other chronic diseases . This study examined the impact of lipid management tools integrated into an electronic medical record ( EMR ) in primary care practice s. This r and omized controlled trial was conducted in a national network of physicians who use an outpatient EMR . Adult primary care physicians were r and omized by office to receive an electronic form that was embedded in the EMR . The form contained prompts regarding suboptimal care based on Adult Treatment Panel-III ( ATP-III ) guidelines , as well as reporting tools to identify patients outside of office visits whose lipid management was suboptimal . All active patients , ages 20 - 79 years , whose physicians participated in the study , were categorized as high , moderate , or low cardiovascular risk , and the proportion who were tested for hyperlipidemia , at lipid goal , and on lipid-lowering medications if not at goal were measured according to ATP-III guidelines . A total of 105 physicians from 25 offices and 64,150 patients were included in the study . Outcomes improved for most measures from before to 1 year after the intervention ( November 1 , 2005 to October 31 , 2006 ) . However , after controlling for confounding variables and for clustering in multilevel modeling , only up-to- date lipid testing for high-risk patients was statistically better in the intervention group as compared to the control group ( adjusted odds ratio 15.0 , P < 0.05 ) . This study showed few differences in quality of lipid management after implementing an EMR-based disease management intervention in primary care setting s. Future studies may need to examine more comprehensive interventions that include office staff in a team approach to care PURPOSE We compared the completeness of data collection using paper forms and using electronic forms loaded on h and held computers in an office-based patient interview survey conducted within the American Academy of Family Physicians National Research Network . METHODS We asked 19 medical assistants and nurses in family practice s to administer a survey about pneumococcal immunizations to 60 older adults each , 30 using paper forms and 30 using electronic forms on h and held computers .  By r and om assignment , the interviewers used either the paper or electronic form first . Using multilevel analyses adjusted for patient characteristics and clustering of forms by practice , we analyzed the completeness of the data . RESULTS A total of 1,003 of the expected 1,140 forms were returned to the data center . The overall return rate was better for paper forms ( 537 of 570 , 94 % ) than for electronic forms ( 466 of 570 , 82 % ) because of technical difficulties experienced with electronic data collection and stolen or lost h and held computers . Errors of omission on the returned forms , however , were more common using paper forms . Of the returned forms , only 3 % of those gathered electronically had errors of omission , compared with 35 % of those gathered on paper . Similarly , only 0.04 % of total survey items were missing on the electronic forms , compared with 3.5 % of the survey items using paper forms . CONCLUSIONS Although h and held computers produced more complete data than the paper method for the returned forms , they were not superior because of the large amount of missing data due to technical difficulties with the h and -held computers or loss or theft . Other hardware solutions , such as tablet computers or cell phones linked via a wireless network directly to a Web site , may be better electronic solutions for the future
target: The study showed that the computerized decision aid appears to increase the proportion of patients who responded to invitations to discuss CVD prevention with their doctor .
  We tentatively conclude that CAHTS can provide individually-tailored information about CVD prevention .
background: BACKGROUND AND OBJECTIVES CVD is an important global healthcare issue ; it is the leading cause of global mortality , with an increasing incidence identified in both developed and developing countries .
  It is also an extremely costly disease for healthcare systems unless managed effectively .
  In this review we aim ed to : - Assess the effect of computer-assisted versus oral- and -written history taking on the quality of collected information for the prevention and management of CVD . -
  Assess the effect of computer-assisted versus oral- and -written history taking on the prevention and management of CVD .