title: Computer-administered cognitive-behavioral therapy for depression. A prospective controlled trial of computerized decision support for lipid management in primary care. Evaluation of computerized decision support for oral anticoagulation management based in primary care. Randomised controlled trial of computer assisted management of hypertension in primary care. Blood pressure, stroke, and coronary heart disease: Part 1, prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias Randomised controlled trial of computer-held medical records in hypertensive patients. Delivery of care for hypertension. Improving Hypertension Control: Impact of Computer Feedback and Physician Education A Randomized Trial of Computerized Reminders for Blood Pressure Screening in Primary Care Treatment of hypertension by computer and physician-a prospective controlled study.
abstract: The authors evaluated a six-session interactive computer cognitive-behavioral treatment program given to volunteer patients who met Research Diagnostic Criteria ( RDC ) for major or minor depressive disorder . Patients were r and omly assigned to computer-administered cognitive-behavioral treatment , to therapist-administered cognitive-behavioral treatment , or to a waiting-list control condition . After treatment and at 2-month follow-up , both treatment groups had improved significantly more than control subjects in their scores on the Beck Depression Inventory , SCL-90-R depression and global scales , Hamilton Rating Scale for Depression , and Automatic Thoughts Question naire . The treatment groups did not differ from each other at either time OBJECTIVES This study aim ed to assess the uptake and effect in primary care of a computerized decision support system ( DSS ) for the management of  hyperlipidaemia .  METHOD A prospect i ve controlled trial was conducted in 25 practice s covering a population of 150,000 in the city of Birmingham . The Primed system , a specialist developed , rule based DSS for general practice , was introduced prospect ively after a 3-month baseline data collection . The main outcome measures were nine months ' data on prescribing of lipid lowering agents ; use of laboratory tests ; and referrals to secondary care for the investigation of hyperlipidaemia . RESULTS System use was lower than expected . A shift was observed towards requests for appropriate follow-up of previously abnormal lipid results and a greater emphasis on full lipid profiles , in line with the DSS guidelines . Referrals showed a 55 % decrease on those expected ( NS ) . The prescribing evaluation revealed a large variation between practice s , but no significant alteration following system use . Views of users favoured decision support as a concept , but criticised technical problems with the system . CONCLUSIONS Greater integration of DSS software and practice based data h and ling systems is needed . The mode of data capture , and hence both the content and form of knowledge representation , in DSS must take greater account of the primary care consultation process if such systems are to be of use to practitioners BACKGROUND Increasing indications for oral anticoagulation has led to pressure on general practice s to undertake therapeutic monitoring . Computerized decision support ( DSS ) has been shown to be effective in hospitals for improving clinical management . Its usefulness in primary care has previously not been investigated . AIM To test the effectiveness of using DSS for oral anticoagulation monitoring in primary care by measuring the proportions of patients adequately controlled , defined as within the appropriate therapeutic range of International Normalised Ratio ( INR ) . METHOD All patients receiving warfarin from two Birmingham inner city general practice s were invited to attend a practice -based anticoagulation clinic . In practice A all patients were managed using DSS . In practice B patients were r and omized to receive dosing advice either through DSS or through the local hospital laboratory . Clinical outcomes , adverse events and patient acceptability were recorded . RESULTS Forty-nine patients were seen in total . There were significant improvements in INR control from 23 % to 86 % ( P > 0.001 ) in the practice where all patients received dosing through DSS . In the practice where patients were r and omized to either DSS or hospital dosing , logistic regression showed a significant trend for improvement in intervention patients which was not apparent in the hospital-dosed patients ( P < 0.001 ) . Mean recall times were significantly extended in patients who were dosed by the practice DSS through the full 12 months ( 24 days to 36 days ) ( P = 0.033 ) . Adverse events were comparable between hospital and practice -dosed patients , although a number of esoteric events occurred . Patient satisfaction with the practice clinics was high . CONCLUSION Computerized DSS enables the safe and effective transfer of anticoagulation management from hospital to primary care and may result in improved patient outcome in terms of the level of control , frequency of review and general acceptability The hypothesis that general practitioners would obtain better outcomes for patients with hypertension using a computer  than doctors not using a computer  was tested . Sixty family physicians were r and omised to two treatment strategies . " Test " physicians completed a data collection form after each visit from a patient with hypertension and mailed the forms to the test centre for processing . Computer feedback on management was mailed to the doctors . This encouraged doctors to apply the " stepped care " protocol , supplied charts of diastolic blood pressure v time , and ranked patients ' diastolic blood pressures by percentile . Letters were mailed to patients to remind them of appointments . " Control " doctors filled out the same data collection forms as test physicians , but neither doctors nor patients received computer feedback . Physicians who used the computer saw more patients per practice than control doctors ( test 50 patients , control 40 ) . For all patients the length of follow up was significantly longer in test practice s ( test 199 days , control 167 ) , and a smaller percentage dropped out of active treatment in test practice s ( test 37.5 % , control 42.1 % ) . For patients with " moderate " hypertension of a baseline diastolic pressure of greater than 104 mm Hg the mean score of the last recorded pressure was below the goal of 90 mm Hg in test practice s ( 88.5 mm Hg ) , but it failed to reach this goal in control practice s ( 93.3 mm Hg ) . A greater average reduction of diastolic pressure was achieved in test practice s ( test 21.7 mm Hg , control 16.7 mm Hg ) . Though patients with " moderate " hypertension were better controlled in test practice s than in control practice s , the patients in test practice s visited their doctors less often ( test 13.3 visits per patient-year , control 17.4 visits ) . Among patients with newly detected hypertension test practice s achieved a greater reduction in diastolic pressure than control practice s ( test 15.1 mm Hg v control 11.3 mm Hg ) and more sustained control of hypertension ( test 323 days per patient-year with a diastolic pressure of 90 mm Hg or less v control 259 days ) The associations of  diastolic blood pressure ( DBP )  with  stroke  and with coronary heart disease ( CHD ) were investigated in nine major prospect i ve observational studies : total 420,000 individuals , 843 strokes , and 4856 CHD events , 6 - 25 ( mean 10 ) years of follow-up . The combined results demonstrate positive , continuous , and apparently independent associations , with no significant heterogeneity of effect among different studies . Within the range of DBP studied ( about 70 - 110 mm Hg ) , there was no evidence of any " threshold " below which lower levels of DBP were not associated with lower risks of stroke and of CHD . Previous analyses have described the uncorrected associations of DBP measured just at " baseline " with subsequent disease rates . But , because of the diluting effects of r and om fluctuations in DBP , these substantially underestimate the true associations of the usual DBP ( ie , an individual 's long-term average DBP ) with disease . After correction for this " regression dilution " bias , prolonged differences in usual DBP of 5 , 7.5 , and 10 mm Hg were respectively associated with at least 34 % , 46 % , and 56 % less stroke and at least 21 % , 29 % , and 37 % less CHD . These associations are about 60 % greater than in previous uncorrected analyses . ( This regression dilution bias is quite general , so analogous corrections to the relations of cholesterol to CHD or of various other risk factors to CHD or to other diseases would likewise increase their estimated strengths . ) The DBP results suggest that for the large majority of individuals , whether conventionally " hypertensive " or " normotensive " , a lower blood pressure should eventually confer a lower risk of vascular disease 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 To overcome shortcomings in the delivery of care for hypertension various approaches have been developed including a system whereby care of hypertension is shared in a formal manner between general practitioners and hospital specialists . The feasibility , acceptability and cost-effectiveness of a computerised model of shared care were investigated in three matched groups of patients attending hypertension clinics in Glasgow . Glasgow Blood Pressure Clinic attenders considered suitable for shared care by their consultants were r and omised to shared care ( n = 277 ) or continued clinic follow-up ; a further control group ( n = 277 ) was identified from an independent nurse-practitioner clinic . After 2 years of follow-up , feasibility was estimated by the proportion of patients who had undergone an adequate review ( blood pressure , serum creatinine and electrocardiograph ) ; acceptability to general practitioners and patients was assessed by question naires ; cost-effectiveness was calculated as the cost ( to National Health Service and patient ) per adequate review . The drop-out rate for shared care over 2 years was 3 % compared with 14 % for the outpatient clinic and 9 % for the nurse-practitioner clinic . In year 2 , rates of adequate review s were 82 % , 52 % and 75 % , respectively . Blood pressure control was similar in the groups . Of 297 general practitioners invited to participate , 85 % agreed and 68 % wished to continue participation after 2 years . About 50 % of shared care patients preferred this method of follow-up compared with their earlier experience of clinic attendance . Shared care was more cost-effective than either conventional or nurse-practitioner clinic follow-up , especially with respect to cost to the patient ; costs per adequate review ( pound sterling ) were 28.96 , 50.55 and 30.95 , respectively . ( ABSTRACT TRUNCATED AT 250 WORDS Two interventions design ed to help physicians manage hypertensive patients were evaluated in a controlled trial : 1 ) computer-generated feedback to facilitate identification of poorly controlled patients ; and 2 ) a physician education program on clinical management strategies , emphasizing patient compliance . Four physician practice teams received either computer feedback , the education program , both , or neither . Feedback team physicians received seven monthly listings of the latest visits and blood pressures of their hypertensive patients . The self-administered learning program included written clinical simulations and associated didactic material .  Experimental and control physicians were similar in baseline knowledge , patient mix and level of training . All feedback team physicians requested appointments for listed patients , and their patients made twice as many visits as control patients during the intervention period ( p < 0.05 ) . Education team physicians showed significant gains on a content-specific post-intervention test : mean score 84 per cent compared with 74 per cent for the control group ( p < 0.005 ) . All patient groups showed improvement in blood pressure over the study period . However , no differences between intervention teams could be detected ( p > 0.20 ) . The probability of missing a 10 mm interteam difference in outcome diastolic pressure was 1 per cent ( power of 0.99 ) . Strategies for further improvement in outpatient hypertension management may need to come from outside the traditional medical model In a r and omized , controlled trial ( N = 8,298 ) the authors compared three ways of encouraging patients in a large family practice to obtain a blood pressure check . Working from computerized medical records at a teaching familymedicine center , the study included patients aged 18 years and over who had not had a blood pressure measurement during the previous year . In a normalcare control group , 21.1 % of those due for a blood pressure reading obtained one during the trial year . In one intervention group , a computer-generated message reminded the doctor to check the  blood pressure of patients who happened to visit the center for an appointment ; 30.7 % of patients allocated to this group were checked . In the second group , the nurse contacted patients by telephone and encouraged 24.1 % of those who were due for a check to obtain one . Sending a letter to patients in the third group yielded a 35.7 % compliance rate . Considering the costs of the three interventions , the physician reminder was the most cost effective , followed by the letter reminder . Although statistically significant , the impact of the reminders was modest . A better approach might involve a combination of routine reminders to the physician , followed by letters to noncompliant patients Abstract One hundred and sixteen patients with hypertension were allocated r and omly to treatment by a computer program or by physicians . All were under the care of physicians in one of two hypertension clinics , but for computer treated patients ( C ) the program provided physicians with treatment recommendations which they were free to follow or reject whereas no recommendations were made for physician treated patients ( P ) . The computer program could use thiazide , alphamethyldopa , hydralazine or quanethidine ; physicians used whatever drugs they wished . Blood pressure ( BP ) response was similar for both groups , as were drug side effects and overt non-compliance with treatment . A computer program such as this one could guide allied health workers in setting s where expert physicians are scarce , improving large scale treatment of hypertension
target: : It seems that computers have a favourable effect on the uptake and follow up of patients in hypertension management .
background: STUDY OBJECTIVE : To assess the effect of computers and computer-based clinical decision support systems on the  management of hypertension .