title: Rational Prescribing in Primary Care (RaPP): Economic Evaluation of an Intervention to Improve Professional Practice An electronic prompt in dispensing software to promote clinical interventions by community pharmacists: a randomized controlled trial. Clinical effect of computer generated physician reminders in health screening in primary health care - a controlled clinical trial of preventive services among the elderly Electronic Alerts Versus On-Demand Decision Support to Improve Dyslipidemia Treatment: A Cluster Randomized Controlled Trial Improving Diabetes Care in Practice Protocol for the 'e-Nudge trial': a randomised controlled trial of electronic feedback to reduce the cardiovascular risk of individuals in general practice [ISRCTN64828380] The Vermont Diabetes Information System: A Cluster Randomized Trial of a Population Based Decision Support System Evaluation of computer based clinical decision support system and risk chart for management of hypertension in primary care: randomised controlled trial Shared electronic vascular risk decision support in primary care: Computerization of Medical Practices for the Enhancement of Therapeutic Effectiveness (COMPETE III) randomized trial. Combined Task Delegation, Computerized Decision Support, and Feedback Improve Cardiovascular Risk for Type 2 Diabetic Patients A randomized outpatient trial of a decision-support information technology tool. Development and evaluation of a Computer-Assisted Management Protocol (CAMP): improved compliance with care guidelines for diabetes mellitus. Effects of an automated electronic reminder in changing the antiplatelet drug-prescribing behavior among Italian general practitioners in diabetic patients: an intervention trial. An endocrinologist-supported intervention aimed at providers improves diabetes management in a primary care site: improving primary care of African Americans with diabetes (IPCAAD) 7. Improving residents' compliance with standards of ambulatory care: results from the VA Cooperative Study on Computerized Reminders. Implementing clinical guidelines in the treatment of hypertension in general practice. Evaluation of patient outcome related to implementation of a computer-based clinical decision support system. A controlled time-series trial of clinical reminders: using computerized firm systems to make quality improvement research a routine part of mainstream practice. A prospective controlled trial of computerized decision support for lipid management in primary care. Impact of a multifaceted intervention on cholesterol management in primary care practices: guideline adherence for heart health randomized trial. Research Paper: A Randomized Trial of "Corollary Orders" to Prevent Errors of Omission Actionable reminders did not improve performance over passive reminders for overdue tests in the primary care setting Use of an Automated Decision Support Tool Optimizes Clinicians’ Ability to Interpret and Appropriately Respond to Structured Self-Monitoring of Blood Glucose Data Rational Prescribing in Primary Care (RaPP): A Cluster Randomized Trial of a Tailored Intervention Pharmacologic Therapy for Type 2 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes Chronic care model and shared care in diabetes: randomized trial of an electronic decision support system. Translating Cholesterol Guidelines Into Primary Care Practice: A Multimodal Cluster Randomized Trial Can hand-held computers improve adherence to guidelines? A (Palm) Pilot study of family doctors in British Columbia. Use of a computer to detect and respond to clinical events: its effect on clinician behavior. The veterans' study to improve the control of hypertension (V-STITCH): design and methodology. Automated electronic reminders to facilitate primary cardiovascular disease prevention: randomised controlled trial. Implementing clinical guidelines in the treatment of diabetes mellitus in general practice. Evaluation of effort, process, and patient outcome related to implementation of a computer-based decision support system. Patient education and provider decision support to control blood pressure in primary care: a cluster randomized trial. Individualized electronic decision support and reminders to improve diabetes care in the community: COMPETE II randomized trial The effect of computer reminders on GPs' prescribing behaviour: A cluster-randomised trial Use of reminders for preventive procedures in family medicine. Patients and computers as reminders to screen for diabetes in family practice Effects of documentation-based decision support on chronic disease management. An intervention to overcome clinical inertia and improve diabetes mellitus control in a primary care setting: Improving Primary Care of African Americans with Diabetes (IPCAAD) 8. Computer-generated physician and patient reminders. Tools to improve population adherence to selected preventive services. Impact of Computerized Decision Support on Blood Pressure Management and Control: A Randomized Controlled Trial The effect of the Vermont Diabetes Information System on inpatient and emergency room use: results from a randomized trial. Computer reminders to implement preventive care guidelines for hospitalized patients. Evaluation of laboratory monitoring alerts within a computerized physician order entry system for medication orders. Computer-based vs manual health maintenance tracking. A controlled trial. Opportunistic electronic reminders. Improving performance of preventive care in general practice. Failure of computerized treatment suggestions to improve health outcomes of outpatients with uncomplicated hypertension: results of a randomized controlled trial. Implementing clinical guidelines in the treatment of hypertension in general practice. Increasing the Detection and Response to Adherence Problems with Cardiovascular Medication in Primary Care through Computerized Drug Management Systems: A Randomized Controlled Trial A Randomized Trial of Computerized Reminders for Blood Pressure Screening in Primary Care Impact of decision support in electronic medical records on lipid management in primary care. Impact of Electronic Health Record Clinical Decision Support on Diabetes Care: A Randomized Trial
abstract: Background Interventions design ed to narrow the gap between research findings and clinical practice may be effective , but also costly . Economic evaluations are necessary to judge whether such interventions are worth the effort . We have evaluated the economic effects of a tailored intervention to support the implementation of guidelines for the use of antihypertensive and cholesterol-lowering drugs . The tailored intervention was evaluated in a r and omized trial , and was shown to significantly increase the use of thiazides for patients started on antihypertensive medication , but had little or no impact on other outcomes . The increased use of thiazides was not expected to have an impact on health outcomes . Methods and Findings We performed cost-minimization and cost-effectiveness analyses on data from a r and omized trial involving 146 general practice s from two geographical areas in Norway . Each practice was r and omized to either the tailored intervention ( 70 practice s ; 257 physicians ) or control group ( 69 practice s ; 244 physicians ) . Only patients that were being started on antihypertensive medication were included in the analyses . A multifaceted intervention was tailored to address identified barriers to change . Key components were an educational outreach visit with audit and feedback , and computerized reminders . Pharmacists conducted the visits . A cost-minimization framework was adopted , where the costs of intervention were set against the reduced treatment costs ( principally due to increased use of thiazides rather than more expensive medication ) . The cost-effectiveness of the intervention was estimated as the cost per additional patient being started on thiazides . The net annual cost ( cost minimization ) in our study population was US$ 53,395 , corresponding to US$ 763 per practice . The cost per additional patient started on thiazides ( cost-effectiveness ) was US$ 454 . The net annual savings in a national program was modeled to be US$ 761,998 , or US$ 540 per practice after 2 y. In this scenario the savings exceeded the costs in all but two of the sensitivity analyses we conducted , and the cost-effectiveness was estimated to be US$ 183 . Conclusions We found a significant shift in prescribing of antihypertensive drugs towards the use of thiazides in our trial . A major reason to promote the use of thiazides is their lower price compared to other drugs . The cost of the intervention was more than twice the savings within the time frame of our study . However , we predict modest savings over a 2-y period UNLABELLED What is already known about this subject . Computerized prompts and reminders have been shown to be effective in changing the behaviour of health professionals in a variety of setting s. There is little literature describing or evaluating electronic decision-support for pharmacists . What this study adds . An electronic prompt in dispensing software for a targeted clinical intervention has a significant effect on  pharmacists  ' behaviour . A markedly increased rate of recording and performing the targeted clinical intervention was found . The effect of the prompt reduces markedly once the prompt is deactivated . AIM To evaluate the effect of an electronic prompt in dispensing software on the frequency of clinical interventions recorded by community pharmacists . METHOD An electronic decision-support prompt identifying patients for a targeted proactive clinical intervention was developed and implemented . Each time an oral antidiabetic agent was dispensed , a prompt was displayed reminding pharmacists to discuss the suitability of aspirin therapy in eligible patients with diabetes . The prompt was r and omly assigned to 31 of 52 metropolitan pharmacies in Melbourne ( Australia ) for 6 weeks , with the remaining pharmacies as controls . RESULTS One hundred and fifty pharmacists in 52 pharmacies recorded a total of 2396 clinical interventions at an intervention rate of 0.92 interventions per 100 patients [ 95 % confidence interval ( CI ) 0.58 , 1.23 ] . Pharmacists recorded a total of 201 target interventions related to aspirin therapy in diabetes at an intervention rate of 2.55 interventions per 100 diabetic patients ( 95 % CI 0.85 , 4.24 ) . All of the targeted clinical interventions were recorded in the prompt arm ; no targeted interventions were recorded in the control group . The effect of the prompt decreased over the study period and was not maintained after prompt deactivation . CONCLUSION An electronic prompt significantly increased pharmacists ' recording of the targeted clinical intervention in diabetic patients . An electronic decision-support prompt has significant potential to promote community pharmacists ' contribution to the quality use of medicines OBJECTIVES To apply and evaluate the effects of a program for computer generated physician reminders , integrated with an electronic patient record ( EPR ) system , for opportunistic health screening in elderly patients . DESIGN A pilot study design ed as a 20-month clinical trial with a control group and a 20-month non-intervention follow-up using a computer reminder program that selects patients for screening in five intervention areas ( diabetes , hypertension , cobalamin deficiency , hypothyroidism and anaemia ) . SETTING Four primary health care ( PHC ) centres in suburban Stockholm . SUBJECTS The intervention was design ed for patients 70 years or older from one health care centre who visited a general practitioner ( GP ) during the first 20-month period . Patients from the three remaining centres served as controls . MAIN OUTCOME MEASURES The number of patients who underwent the tests , who had pathological test results , new diagnoses and new pharmacological treatments in both patient groups . RESULTS In total , 602 patients underwent screening and 1989 were controls . There was a statistically significant , moderate or marked increase ( 13 - 75 % ) in the number of patients who were tested in all five intervention areas . An increase in pathological test results ( 1 - 8 % ) was found in two areas : hypertension and cobalamin deficiency . There was an increase in the number of patients with the diagnosis of cobalamin deficiency during the study . At follow-up a decrease in new diagnoses for anaemia was found . CONCLUSION The system seems to be associated with a moderate to large increase in laboratory and manual screening tests for both established and new screening areas . The effect on clinical outcomes was found mainly in a not-yet-established screening area ( cobalamin deficiency ) , indicating that the system may be clinical ly useful when introducing new screening services Background — Indirect evidence shows that alerting users with clinical decision support systems seems to change behavior more than requiring users to actively initiate the system . However , r and omized trials comparing these methods in a clinical setting are lacking . We studied the effect of both alerting and on-dem and decision support with respect to screening and treatment of dyslipidemia based on the guidelines of the Dutch College of General Practitioners . Methods and Results — In a clustered r and omized trial design , 38 Dutch general practice s ( 77 physicians ) and 87 886 of their patients ( 39 433 men 18 to 70 years of age and 48 453 women 18 to 75 years of age ) who used the ELIAS electronic health record participated . Each practice was assigned to receive alerts , on-dem and support , or no intervention . We measured the percentage of patients screened and treated after 12 months of follow-up . In the alerting group , 65 % of the patients requiring screening were screened ( relative risk versus control=1.76 ; 95 % confidence interval , 1.41 to 2.20 ) compared with 35 % of patients in the on-dem and group ( relative risk versus control=1.28 ; 95 % confidence interval , 0.98 to 1.68 ) and 25 % of patients in the control group . In the alerting group , 66 % of patients requiring treatment were treated ( relative risk versus control=1.40 ; 95 % confidence interval , 1.15 to 1.70 ) compared with 40 % of patients ( relative risk versus control=1.19 ; 95 % confidence interval , 0.94 to 1.50 ) in the on-dem and group and 36 % of patients in the control group . Conclusion — The alerting version of the clinical decision support systems significantly improved screening and treatment performance for dyslipidemia by general practitioners OBJECTIVE —The purpose of this study was to determine whether implementation of a multicomponent organizational intervention can produce significant change in diabetes care and outcomes in community primary care practice s. RESEARCH DESIGN AND METHODS —This was a group-r and omized , controlled clinical trial evaluating the practical effectiveness of a multicomponent intervention ( TRANSLATE )  in 24 practice s. The intervention included implementation of an electronic diabetes registry , visit reminders , and patient-specific physician alerts . A site coordinator facilitated previsit planning and a monthly review of performance with a local physician champion . The principle outcomes were the percentage of patients achieving target values for the composite of systolic blood pressure ( SBP ) < 130 mmHg , LDL cholesterol < 100 mg/dl , and A1C < 7.0 % at baseline and 12 months . Six process measures were also followed . RESULTS —Over 24 months , 69,965 visits from 8,405 adult patients with type 2 diabetes were recorded from 238 health care providers in 24 practice s from 17 health systems .  Diabetes process measures increased significantly more in intervention than in control practice s , giving net increases as follows : foot examinations 35.0 % ( P < 0.0.001 ) ; annual eye examinations 25.9 % ( P < 0.001 ) ; renal testing 28.5 % ( P < 0.001 ) ; A1C testing 8.1%(P < 0.001 ) ; blood pressure monitoring 3.5 % ( P = 0.05 ) ; and LDL testing 8.6 % ( P < 0.001 ) . Mean A1C adjusted for age , sex , and comorbidity decreased significantly in intervention practice s ( P < 0.02 ) . At 12 months , intervention practice s had significantly greater improvement in achieving recommended clinical values for SBP , A1C , and LDL than control clinics ( P = 0.002 ) . CONCLUSIONS — Introduction of a multicomponent organizational intervention in the primary care setting significantly increases the percentage of type 2 diabetic patients achieving recommended clinical outcomes Background Cardiovascular disease ( including coronary heart disease and stroke ) is a major cause of death and disability in the United Kingdom , and is to a large extent preventable , by lifestyle modification and drug therapy . The recent st and ardisation of electronic codes for cardiovascular risk variables through the United Kingdom 's new General Practice contract provides an opportunity for the application of risk algorithms to identify high risk individuals . This r and omised controlled trial will test the benefits of an automated system of alert messages and practice search es to identify those at highest risk of cardiovascular disease in primary care data bases . Design Patients over 50 years old in practice data bases will be r and omised to the intervention group that will receive the alert messages and search es , and a control group who will continue to receive usual care . In addition to those at high estimated risk , potentially high risk patients will be identified who have insufficient data to allow a risk estimate to be made . Further groups identified will be those with possible undiagnosed diabetes , based either on elevated past recorded blood glucose measurements , or an absence of recent blood glucose measurement in those with established cardiovascular disease . Outcome measures The intervention will be applied for two years , and outcome data will be collected for a further year . The primary outcome measure will be the annual rate of cardiovascular events in the intervention and control arms of the study . Secondary measures include the proportion of patients at high estimated cardiovascular risk , the proportion of patients with missing data for a risk estimate , and the proportion with undefined diabetes status at the end of the trial BACKGROUND Optimal care for patients with diabetes is difficult to achieve in clinical practice . OBJECTIVE To evaluate the impact of a registry and decision support system on processes of care , and physiologic control . PARTICIPANTS R and omized trial with clustering at the practice level , involving 7,412 adults with diabetes in 64 primary care practice s in the Northeast . INTERVENTIONS Provider decision support ( reminders for overdue diabetes tests , alerts regarding abnormal results , and quarterly population reports with peer comparisons ) and patient decision support ( reminders and alerts ) . MEASUREMENTS AND MAIN RESULTS Process and physiologic outcomes were evaluated in all subjects . Functional status was evaluated in a r and om patient sample via question naire . We used multiple logistic regression to quantify the effect , adjusting for clustering and potential confounders . Intervention subjects were significantly more likely to receive guideline -appropriate testing for cholesterol ( OR = 1.39 ; [ 95%CI 1.07 , 1.80 ] P = 0.012 ) , creatinine ( OR = 1.40 ; [ 95%CI 1.06 , 1.84 ] P = 0.018 ) , and proteinuria ( OR = 1.74 ; [ 95%CI 1.13 , 1.69 ] P = 0.012 ) , but not A1C ( OR = 1.17 ; [ 95 % CI 0.80 , 1.72 ] P = 0.43 ) . Rates of control of A1C and LDL cholesterol were similar in the two groups . There were no differences in blood pressure , body mass index , or functional status . CONCLUSIONS A chronic disease registry and decision support system based on easily obtainable laboratory data was feasible and acceptable to patients and providers . This system improved the process of laboratory monitoring in primary care , but not physiologic control Abstract Objectives : To investigate the effect of a computer based clinical decision support system and a risk chart on absolute cardiovascular risk , blood pressure , and prescribing of cardiovascular drugs in hypertensive patients . Design : Cluster r and omised controlled trial . Setting : 27 general practice s in Avon . Participants : 614 patients aged between 60 and 79 years with high blood pressure . Interventions : Patients were r and omised to computer based clinical decision support system plus cardiovascular risk chart ; cardiovascular risk chart alone ; or usual care . Main outcome measures : Percentage of patients in each group with a five year cardiovascular risk≥10 % , systolic blood pressure , diastolic blood pressure , prescribing of cardiovascular drugs . Results : Patients in the computer based clinical decision support system and chart only groups were no more likely to have cardiovascular risk reduced to below 10 % than patients receiving usual care . Patients in the computer based clinical decision support group were more likely to have a cardiovascular risk≥10 % than chart only patients , odds ratio 2.3 ( 95 % confidence interval 1.1 to 4.8 ) . The chart only group had significantly lower systolic blood pressure compared with the usual care group ( difference in means−4.6 mm Hg ( 95 % confidence interval−8.4 to−0.8 ) . Reduction of diastolic blood pressure did not differ between the three groups . The chart only group were twice as likely to be prescribed two classes of cardiovascular drugs and over three times as likely to be prescribed three or more classes of drugs compared with the other groups . Conclusions : The computer based clinical decision support system did not confer any benefit in absolute risk reduction or blood pressure control and requires further development and evaluation before use in clinical care can be recommended . Use of chart guidelines are associated with a potentially important reduction in systolic blood pressure 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 —The Diabetes Care Protocol combines task delegation ( a practice nurse ) , computerized decision support , and feedback every 3 months . We studied the effect of the Diabetes Care Protocol on A1C and cardiovascular risk factors in type 2 diabetic patients in primary care . RESEARCH DESIGN AND METHODS —In a cluster r and omized trial , mean changes in cardiovascular risk factors between the intervention and control groups after 1 year were calculated by generalized linear models . RESULTS —Throughout the Netherl and s , 26 intervention practice s included 1,699 patients and 29 control practice s 1,692 patients . The difference in A1C change was not significant , whereas total cholesterol , LDL cholesterol , and blood pressure improved significantly more in the intervention group . The 10-year coronary heart disease risk estimate of the UK Prospect i ve Diabetes Study improved 1.4 % more in the intervention group . CONCLUSIONS —Delegation of routine diabetes care to a practice nurse combined with computerized decision support and feedback did not improve A1C but reduced cardiovascular risk in type 2 diabetes patients BACKGROUND Decision-support information technology is often adopted to improve clinical decision making , but it is rarely rigorously evaluated . Congress m and ated the evaluation of Problem-Knowledge Couplers ( PKC Corp , Burlington , Vt ) , a decision-support tool proposed for the Department of Defense 's new health information network . METHODS This was a patient-level r and omized trial conducted at 2 military practice s. A total of 936 patients were allocated to the intervention group  and 966 to usual care .  Couplers were applied before routine ambulatory clinic visits . The primary outcome was quality of care , which was assessed based on the total percentage of any of 24 health care quality process measures ( opportunities to provide evidence -based care ) that were fulfilled . Secondary outcomes included medical re sources consumed within 60 days of enrollment and patient and provider satisfaction . RESULTS There were 4639 health care opportunities ( 2374 in the Coupler group and 2265 in the usual-care group ) , with no difference in the proportion of opportunities fulfilled ( 33.9 % vs 30.7 % ; P = .12 ) . Although there was a modest improvement in performance on screening/preventive measures , it was offset by poorer performance on some measures of acute care . Coupler patients used more laboratory and pharmacy re sources than usual-care patients ( logarithmic mean difference , 71 dollars ) . No difference in patient satisfaction was observed between groups , and provider satisfaction was mixed . CONCLUSION This study provides no strong evidence to support the utility of this decision-support tool , but it demonstrates the value of rigorous evaluation of decision-support information technology Disease-specific st and ards for directing patient management are becoming increasingly important . These st and ards , however , are often not followed because they are not sufficiently integrated into the clinical care setting . In this study we describe the development and evaluation of a Computer-Assisted Management Protocol ( CAMP ) of care guidelines for diabetes mellitus . While other studies have shown improved compliance with rule-based reminders , the CAMP customizes disease-specific care guidelines to individual patients over time . We evaluated the effect of the CAMP on compliance with guidelines in a prospect i ve , r and omized controlled study . The study was performed at a family practice clinic where much of the patient record is maintained electronically on The Medical Record ( TMR ) . The management protocol was developed from st and ards published by the American Diabetes Association . Fifty-eight providers were r and omized to either receive or not receive the CAMP for diabetes . Compliance with st and ards  was assessed by chart audits of all encounters with diabetic patients during the study interval . The following conclusion was made : the Computer-Assisted Management Protocol result ed in a statistically significant improvement in compliance with diabetes care st and ards OBJECTIVE To evaluate whether an electronic reminder integrated into a routine computer system increases the use of antiplatelet drugs  for diabetic patients among Italian general practitioners ( GPs ) . RESEARCH DESIGN AND METHODS A r and omized controlled trial was carried out among 300 GPs and their patients selected from the Health Search Data base . Among these , 150 GPs ( intervention group ) received instructions to activate an electronic reminder plus a letter summarizing the beneficial effects of antiplatelet drugs in diabetic patients with at least one additional cardiovascular risk factor ( " high risk " ) , whereas the other 150 GPs ( control group ) received only the letter . The electronic reminder , integrated into a st and ard software system for the management of the daily clinical practice , was displayed when every participating GP opened the medical record of diabetic patients aged > or = 30 years . Only high-risk diabetic patients were included in the analysis . Patients were considered under antiplatelet treatment if they received two or more prescriptions at baseline and during the follow-up . RESULTS We selected 15,343 high-risk diabetic patients , 7,313 belonging to GPs of the control group and 8,030 belonging to GPs of the intervention group . Overall , 1,672 patients ( 22.9 % ) of the control group and 1,886 ( 23.5 % ) patients of the intervention group received  antiplatelet drugs  at baseline ( P = N.S. ) . At the end of the follow-up , the number of treated patients was significantly increased in the intervention group ( odds ratio 1.99 , 95 % CI 1.79 - 2.22 ) versus the control group . The effect of the electronic reminder was more relevant among those patients with one or more cardiovascular risk factors but without previous cardiovascular diseases ( CVDs ) , compared with those with CVDs . CONCLUSIONS These findings provide evidence for the effect of an electronic reminder in affecting the prescriptive behavior of GPs OBJECTIVE Management of diabetes is frequently suboptimal in primary care setting s , where providers often fail to intensify therapy when glucose levels are high , a problem known as clinical inertia . We asked whether interventions targeting clinical inertia can improve outcomes . RESEARCH DESIGN AND METHODS A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center . We studied all patients ( 4,138 ) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were r and omized to be control subjects or to receive one of three interventions . Instead of consultative advice , the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient 's visit , individual face-to-face feedback on performance for 5 min every 2 weeks , or both . RESULTS Over an average patient follow-up of 15 months within the intervention site , improvements in and final HbA1c ( A1C ) with feedback + reminders ( deltaA1C 0.6 % , final A1C 7.46 % ) were significantly better than control ( deltaA1C 0.2 % , final A1C 7.84 % , P < 0.02 ) ; changes were smaller with feedback only and reminders only ( P = NS vs. control ) . Trends were similar but not significant with systolic blood pressure ( sBP ) and LDL cholesterol . Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabetes Association goals for both A1C and sBP . Over a 2-year period , overall glycemic control improved in the intervention site but did not change in other primary care sites ( final A1C 7.5 vs. 8.2 % , P < 0.001 ) . CONCLUSIONS Feedback on performance aim ed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control . Partnering generalists with diabetes specialists may be important to enhance diabetes management in other primary care setting CONTEXT Computerized systems to remind physicians to provide appropriate care have not been widely evaluated in large numbers of patients in multiple clinical setting s. OBJECTIVE To examine whether a computerized reminder system operating in multiple Veterans Affairs ( VA ) ambulatory care clinics improves  resident physician compliance  with st and ards of ambulatory care . DESIGN , SETTING , AND PARTICIPANTS A total of 275 resident physicians at 12 VA medical centers were r and omly assigned in firms or half-day clinic blocks to either a reminder group ( n = 132 ) or a control group ( n = 143 ) . During a 17-month study period ( January 31 , 1995-June 30 , 1996 ) , the residents cared for 12,989 unique patients for whom at least 1 of the studied st and ards of care ( SOC ) was applicable . MAIN OUTCOME MEASURES Compliance with 13 SOC  , tracked using hospital data bases and encounter forms completed by residents , compared between residents in the reminder group vs those in the control group . RESULTS Measuring compliance as the proportion of patients in compliance with all applicable SOC by their last visit during the study period , the reminder group had statistically significantly higher rates of compliance than the control group for all st and ards combined ( 58.8 % vs 53.5 % ; odds ratio [ OR ] , 1.24 ; 95 % confidence interval [ CI ] , 1.08 - 1.42 ; P = .002 ) and for 5 of the 13 st and ards examined individually . Measuring compliance as the proportion of all visits for which care was indicated in which residents provided proper care , the reminder group also had statistically significantly higher rates of compliance than the control group for all st and ards combined ( 17.9 % vs 12.2 % ; OR , 1.57 ; 95 % CI , 1.45 - 1.71 ; P<.001 ) and for 9 of the 13 st and ards examined individually . The benefit of reminders , however , declined throughout the course of the study , even though the reminders remained active . CONCLUSIONS Our data indicate that reminder systems installed at multiple sites can improve  residents ' compliance to multiple SOC . The benefits of such systems , however , appear to deteriorate over time . Future research needs to explore methods to better sustain the benefits of reminders . JAMA . 2000;284:1411 - 1416 OBJECTIVE To evaluate the implementation of clinical guidelines for hypertension in general practice by use of a computer-based clinical decision support system ( CDSS ) and a specific implementation strategy . Evaluation of patient outcome . DESIGN R and omised study with health centres as units . The intervention group had the CDSS installed and made ready for use , doctors and assistants were trained and received a user-manual , the doctors were offered telephone repetitions , a seminar in risk intervention and , at the same seminar , further demonstration of the CDSS . The doctors received baseline registration s with information of how they treated their own hypertensive patients , and use of the CDSS was checked repeatedly . SETTING General practice in Sør- and Nord-Trøndelag counties in Norway , 380,000 inhabitants . PARTICIPANTS Seventeen health centres with 24 doctors and 984 patients in the intervention group . Data from 879 patients used in the final analyses . Twelve health centres with 29 doctors and 1255 patients in the control group . Data from 1119 patients used in the final analyses . MAIN OUTCOME MEASURES After an intervention period of 18 months , group differences in level of systolic and diastolic blood pressure , serum cholesterol , body mass index , and risk score for myocardial infa rct ion were calculated , as well as group differences in fractions of smokers . RESULTS Significant group difference in favour of intervention group : diastolic blood pressure 1 mmHg ( 95 % CI -1.89 , -0.17 ) . However , a significant baseline difference in systolic blood pressure in favour of control group of 2.7 mmHg ( 95 % CI 1.0 , 4.5 ) had been reduced to 1.2 mmHg ( 95 % CI -0.6 , 3.0 ) after intervention . CONCLUSION Implementation of clinical guidelines in the treatment of hypertensive patients in general practice by means of a CDSS and several other procedures for implementation did not affect patient outcome in any clinical ly significant way OBJECTIVE To explore the feasibility of conducting unobtrusive interventional research in community practice setting s by integrating firm-system techniques with time-series analysis of relational-repository data . STUDY SETTING A satellite teaching clinic divided into two similar , but geographically separated , primary care group practice s called firms . One firm was selected by chance to receive the study intervention . Forty-two providers and 2,655 patients participated . STUDY DESIGN A nonr and omized controlled trial of computer-generated preventive reminders . Net effects were determined by quantitatively combining population -level data from parallel experimental and control interrupted time series extending over two-month baseline and intervention periods . DATA COLLECTION Mean rates at which mammography , colorectal cancer screening , and cholesterol testing were performed on patients due to receive each maneuver at clinic visits were the trial 's outcome measures . PRINCIPAL FINDINGS Mammography performance increased on the experimental firm by 154 percent ( 0.24 versus 0.61 , p = .03 ) . No effect on fecal occult blood testing was observed . Cholesterol ordering decreased on both the experimental ( 0.18 versus 0.1 1 , p = .02 ) and control firms ( 0.13 versus 0.07 , p = .03 ) coincident with national guidelines retreating from recommending screening for young adults . A traditional uncontrolled interrupted time-series design would have incorrectly attributed the experimental-firm decrease to the introduction of reminders . The combined analysis properly indicated that no net prompting effect had occurred , as the difference between firms in cholesterol testing remained stochastically stable over time ( 0.05 versus 0.04 , p = .75 ) . A logistic-regression analysis applied to individual-level data produced equivalent findings . The trial incurred no supplementary data collection costs . CONCLUSIONS The apparent validity and practicability of our reminder implementation study should encourage others to develop computerized firm systems capable of conducting controlled time-series trials 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 Physician adherence to National Cholesterol Education Program clinical practice guidelines has been poor . METHODS We recruited 68 primary care family and internal medicine practice s ; 66 were r and omly allocated to a study arm ; 5 practice s withdrew , result ing in 29 receiving the Third Adult Treatment Panel ( ATP III ) intervention and 32 receiving an alternative intervention focused on the Seventh Report of the Joint National Committee on the Prevention , Detection , Evaluation , and Treatment of High Blood Pressure ( JNC-7 ) . The ATP III providers received a personal digital assistant providing the Framingham risk scores and ATP III-recommended treatment . All practice s received copies of each clinical practice guideline , an introductory lecture , 1 performance feedback report , and 4 visits for intervention-specific academic detailing . Data were abstract ed at 61 practice s from r and om sample s of medical records of patients treated from June 1 , 2001 , through May 31 , 2003 ( baseline ) , and from May 1 , 2004 , through April 30 , 2006 ( follow-up ) . The proportion screened with subsequent appropriate decision making ( primary outcome ) was calculated . Generalized estimating equations were used to compare results by arm , accounting for clustering of patients within practice s. RESULTS We examined 5057 baseline and 3821 follow-up medical records . The screening rate for lipid levels increased from 43.6 % to 49.0 % ( ATP III practice s ) and from 40.1 % to 50.8 % ( control practice s ) ( net difference , -5.3 % [ P = .22 ] ) . Appropriate management of lipid levels decreased slightly ( 73.4 % to 72.3 % ) in ATP III practice s and more markedly ( 79.7 % to 68.9 % ) in control practice s. The net change in appropriate management favored the intervention ( + 9.7 % ; 95 % confidence interval [ CI ] , 2.8%-16.6 % [ P < .01 ] ) . Appropriate drug prescription within 4 months decreased in both arms ( 38.8 % to 24.8 % in ATP III practice s and 45.3 % to 24.1 % in control practice s ; net change , + 7.2 % [ P = .37 ] ) Overtreatment declined from 6.6 % to 3.9 % in ATP III and rose from 4.2 % to 6.4 % in control practice s ( net change , -4.9 % [ P = .01 ] ) . CONCLUSIONS A multifactor intervention including personal digital assistant-based decision support may improve primary care physician adherence to the ATP III guidelines . Trial Registration clinical trials.gov Identifier : NCT00224848 OBJECTIVE Errors of omission are a common cause of systems failures . Physicians often fail to order tests or treatments needed to monitor/ameliorate the effects of other tests or treatments . The authors hypothesized that automated , guideline -based reminders to physicians , provided as they wrote orders , could reduce these omissions . DESIGN The study was performed on the inpatient general medicine ward of a public teaching hospital . Faculty and housestaff from the Indiana University School of Medicine , who used  computer workstations  to write orders , were r and omized to intervention and control groups . As intervention physicians wrote orders for 1 of 87 selected tests or treatments , the computer suggested corollary orders needed to detect or ameliorate adverse reactions to the trigger orders . The physicians could accept or reject these suggestions . RESULTS During the 6-month trial , reminders about corollary orders were presented to 48 intervention physicians and withheld from 41 control physicians . Intervention physicians ordered the suggested corollary orders in 46.3 % of instances when they received a reminder , compared with 21.9 % compliance by control physicians ( p < 0.0001 ) . Physicians discriminated in their acceptance of suggested orders , readily accepting some while rejecting others . There were one third fewer interventions initiated by pharmacists with physicians in the intervention than control groups . CONCLUSION This study demonstrates that physician workstations , linked to a comprehensive electronic medical record , can be an efficient means for decreasing errors of omissions and improving adherence to practice guidelines Actionable reminders ( electronic reminders linked to computerized order entry ) might improve care by facilitating direct ordering of recommended tests . The authors implemented four enhanced actionable reminders targeting performance of annual mammography , one-time bone-density screening , and diabetic testing . There was no difference in rates of appropriate testing between the four intervention and four matched , control primary care clinics for screening mammography ( OR 0.81 , 95 % CI 0.64 to 1.02 ) , bone-density exams ( OR 1.29 , 95 % CI 0.82 to 2.02 ) , HbA1c monitoring ( OR 0.91 , 95 % CI 0.58 to 1.42 ) and LDL cholesterol monitoring ( OR 1.40 , 95 % CI 0.76 to 2.59 ) . Of the survey respondents , 79 % almost never used the system or were unaware of the functionality . In the 9/228 ( 3.9 % ) cases with indirect evidence of mammography reminder use , there was a significantly lower proportion with test performance . Our actionable reminders did not improve receipt of overdue testing , potentially due to limitations of workflow integration OBJECTIVE We evaluated the impact of an automated decision support tool ( DST ) on clinicians ’ ability to identify glycemic abnormalities in structured self-monitoring of blood glucose ( SMBG ) data and then make appropriate therapeutic changes based on the glycemic patterns observed . RESEARCH DESIGN AND METHODS In this prospect i ve , r and omized , controlled , multicenter study , 288 clinicians ( 39.6 % family practice physicians , 37.9 % general internal medicine physicians , and 22.6 % nurse practitioners ) were r and omized to structured SMBG alone ( STG ; n = 72 ) ; structured SMBG with DST ( DST ; n = 72 ) ; structured SMBG with an educational DVD ( DVD ; n = 72 ) ; and structured SMBG with DST and the educational DVD ( DST+DVD ; n = 72 ) . Clinicians analyzed 30 patient cases ( type 2 diabetes ) , identified the primary abnormality , and selected the most appropriate therapy . RESULTS A total of 222 clinicians completed all 30 patient cases with no major protocol deviations . Significantly more DST , DVD , and DST+DVD clinicians correctly identified the glycemic abnormality and selected the most appropriate therapeutic option compared with STG clinicians : 49 , 51 , and 55 % , respectively , vs. 33 % ( all P < 0.0001 ) with no significant differences among DST , DVD , and DST+DVD clinicians . CONCLUSIONS Use of structured SMBG , combined with the DST , the educational DVD , or both , enhances clinicians ’ ability to correctly identify significant glycemic patterns and make appropriate therapeutic decisions to address those patterns . Structured testing interventions using either the educational DVD or the DST are equally effective in improving data interpretation and utilization . The DST provides a viable alternative when comprehensive education is not feasible , and it may be integrated into medical practice s with minimal training Background A gap exists between evidence and practice regarding the management of cardiovascular risk factors . This gap could be narrowed if systematic ally developed clinical practice guidelines were effectively implemented in clinical practice . We evaluated the effects of a tailored intervention to support the implementation of systematic ally developed guidelines for the use of antihypertensive and cholesterol-lowering drugs for the primary prevention of cardiovascular disease . Methods and Findings We conducted a cluster-r and omized trial comparing a tailored intervention to passive dissemination of guidelines in 146 general practice s in two geographical areas in Norway . Each practice was r and omized to either the tailored intervention ( 70 practice s ; 257 physicians ) or control group ( 69 practice s ; 244 physicians ) . Patients started on medication for hypertension or hypercholesterolemia during the study period and all patients already on treatment that consulted their physician during the trial were included . A multifaceted intervention was tailored to address identified barriers to change . Key components were an educational outreach visit with audit and feedback , and computerized reminders linked to the medical record system . Pharmacists conducted the visits . Outcomes were measured for all eligible patients seen in the participating practice s during 1 y before and after the intervention . The main outcomes were the proportions of ( 1 ) first-time prescriptions for hypertension where thiazides were prescribed , ( 2 ) patients assessed for cardiovascular risk before prescribing antihypertensive or cholesterol-lowering drugs , and ( 3 ) patients treated for hypertension or hypercholesterolemia for 3 mo or more who had achieved recommended treatment goals . The intervention led to an increase in adherence to guideline recommendations on choice of antihypertensive drug . Thiazides were prescribed to 17 % of patients in the intervention group versus 11 % in the control group ( relative risk 1.94 ; 95 % confidence interval 1.49–2.49 , adjusted for baseline differences and clustering effect ) . Little or no differences were found for risk assessment prior to prescribing and for achievement of treatment goals . Conclusions Our tailored intervention had a significant impact on prescribing of antihypertensive drugs , but was ineffective in improving the quality of other aspects of managing hypertension and hypercholesterolemia in primary care The American Diabetes Association ( ADA ) first released its St and ards of Medical Care in Diabetes for health professionals in 1989 . These practice guidelines provide an extensive set of evidence -based recommendations that are up date d annually for the diagnosis and management of patients with diabetes . The 2017 St and ards cover all aspects of patient care ( 1 ) ; this guideline synopsis focuses on pharmacologic approaches for patients with type 2 diabetes . Guideline Development and Evidence Grading To develop the 2017 St and ards , the ADA Professional Practice Committee , which comprises physicians , adult and pediatric endocrinologists , diabetes educators , registered dietitians , epidemiologists , and public health experts , systematic ally search ed MEDLINE from 1 January 2016 ( date of last previous search ) to November 2016 . The committee revised recommendations based on the new evidence or , in some cases , to clarify prior ones or match the strength of the wording to the strength of the evidence . It also solicited feedback from the larger clinical community . The recommendations are rated as A , B , C , or E. Those with an A rating are based on large , well- design ed , multicenter clinical trials or high- quality meta-analyses . Recommendations with lower- quality evidence may be equally important and are based on well-conducted cohort studies ( B rating ) or uncontrolled studies ( C rating ) . Those assigned an E rating are consensus recommendations for which there is no evidence from clinical trials , in which clinical trials may be impractical , or in which there is conflicting evidence . The ADA funds development of the St and ards from its general revenues with no industry support or involvement . Details on the methodology , information about the committee members and their conflict-of-interest disclosures , and the complete St and ards can be downloaded at professional.diabetes.org/annals . Pharmacologic Therapy for Type 2 Diabetes : Recommendations Metformin , if not contraindicated and if tolerated , is the preferred initial pharmacologic agent for the treatment of type 2 diabetes ( A rating ) . Long-term use of metformin may be associated with biochemical vitamin B12 deficiency , and periodic measurement of vitamin B12 levels should be considered in patients treated with metformin , especially those with anemia or peripheral neuropathy ( B rating ) . Providers should consider initiating insulin therapy ( with or without additional agents ) in patients with newly diagnosed type 2 diabetes who are symptomatic , have a hemoglobin A1c ( HbA1c ) level of 10 % or greater , or have a blood glucose level of 16.7 mmol/L ( 300 mg/dL ) or greater ( E rating ) . If noninsulin monotherapy at the maximum tolerated dose does not achieve or maintain the HbA1c target after 3 months , adding a second oral agent , a glucagon-like peptide-1 (GLP-1)receptor agonist , or basal insulin should be considered ( A rating ) . For patients with type 2 diabetes who are not achieving glycemic goals , insulin therapy should be instituted without delay ( B rating ) . A patient-centered approach should be used to guide the choice of pharmacologic agents ( E rating ) . Initial Treatment Approach : Metformin Metformin monotherapy should be initiated at the time of diagnosis of type 2 diabetes for most patients unless there are contraindications . It is effective , safe , and inexpensive and may reduce the risk for cardiovascular events and death ( 2 ) . A large meta- analysis ( 3 ) supports the use of metformin monotherapy as first-line therapy . It may be safely used in patients with an estimated glomerular filtration rate as low as 30 mL/min/1.73 m2 ( 4 ) ; the U.S. label of metformin was recently revised to reflect its safety in patients with an estimated glomerular filtration rate of 30 mL/min/1.73 m2 or greater ( 5 ) . Gastrointestinal side effects are common in patients receiving metformin . In the authors ' experience , these side effects can be reduced if metformin monotherapy is started at a dose of 500 mg once or twice daily with food and titrated gradually to the maximum effective dose ( 2 g/d ) . Patients should be advised to stop taking their medication if they experience nausea , vomiting , or dehydration . The Diabetes Prevention Program Outcomes Study found that long-term users of metformin may develop vitamin B12 deficiency . Periodic testing of vitamin B12 levels should be considered in metformin users , especially those with anemia or peripheral neuropathy ( 6 ) . Using Pharmacotherapies Other Than or in Addition to Metformin If the patient does not tolerate or has a contraindication to metformin , another option should be considered . The ADA/European Association for the Study of Diabetes position statement ( 7 ) recommends a patient-centered approach , including assessment of efficacy , hypoglycemia risk , effect on weight , side effects , cost , and patient preferences . A table detailing characteristics of all available glucose-lowering agents in the United States that may guide individualized treatment choices is available in section 8 of the St and ards ( 8) . Tables 1 and 2 depict the costs of antihyperglycemic agents that were extracted from the Red Book ( 9 ) . With so many choices , patients and providers should be able to find a mutually agreeable treatment option . Table 1 . Median Monthly Cost of Maximum Approved Daily Dose of Noninsulin Glucose-Lowering Agents in the United States * Table 2 . Median Cost of Insulins  in the United States , Calculated as the AWP per 1000 Units of Specified Dosage Form/Product * For patients with an HbA1c level of 9 % or greater who are not acutely symptomatic , initiation of dual combination therapy ( Figure 1 ) should be considered to more quickly achieve the target HbA1c level . If the patient has a r and om glucose level of 16.7 mmol/L ( 300 mg/dL ) or greater or an HbA1c level of 10 % or greater and has acute symptoms of polyuria , polydipsia , or weight loss , combination therapy that includes insulin should be considered ( Figure 2 ) . Figure 1 . Antihyperglycemic therapy for type 2 diabetes : general recommendations . The order in the chart was determined by historical availability and the route of administration , with injectables to the right ; it is not meant to denote any specific preference . Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed , with the usual transition moving vertically from top to bottom ( although horizontal movement within therapy stages is also possible , depending on the circumstances ) . Adapted with permission from Inzucchi and colleagues ( 7 ) . DPP-4-i= dipeptidyl peptidase-4 inhibitor ; GI= gastrointestinal ; GLP-1-RA= glucagon-like peptide-1receptor agonist ; GU= genitourinary ; HbA1c= hemoglobin A1c ; HF= heart failure ; SGLT-2-i= sodiumglucose contransporter-2 inhibitor . * See Dieuzeide and colleagues ( 21 ) for description of efficacy and cost categorizations . Usually a basal insulin ( such as neutral protamine Hagedorn , glargine , detemir , or degludec ) . Figure 2 . Combination injectable therapy for type 2 diabetes . Adapted with permission from Inzucchi and colleagues ( 7 ) . GLP-1-RA= glucagon-like peptide-1receptor agonist ; HbA1c= hemoglobin A1c ; SMBG= self-monitored blood glucose . Assessing Response and Deciding to Intensify Therapy Providers should assess whether the HbA1c target has been achieved within approximately 3 months of therapy initiation ( Figure 1 ) ; if it has not , therapy should be intensified ( Figure 2 ) . They should use shared decision making and a patient-centered approach when selecting a second agent . Potential combination therapies include a sulfonylurea , thiazolidinedione , dipeptidyl peptidase-4 ( DPP-4 ) inhibitor , sodiumglucose contransporter-2 ( SGLT-2 ) inhibitor , GLP-1receptor agonist , or basal insulin . Insulin should also be considered as part of any combination regimen for patients with severe hyperglycemia , especially if symptoms or catabolic features ( such as weight loss or ketosis ) are present . Patients should be reassessed within 3 months for achievement of the HbA1c target . Recent Evidence From Cardiovascular Outcomes Trials Major cardiovascular outcomes trials have studied patients with type 2 diabetes and established cardiovascular disease , including EMPA-REG ( Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients ) ( 10 ) and the LEADER ( Liraglutide Effect and Action in Diabetes : Evaluation of Cardiovascular Outcome Results ) trial ( 11 ) . These 2 studies found that , compared with placebo and st and ard treatment , empagliflozin and liraglutide reduced composite outcomes for myocardial infa rct ion , stroke , and cardiovascular death in population s in which most , if not all , patients had established atherosclerotic cardiovascular disease . Whether other agents in the same class as empagliflozin and liraglutide have similar benefits , and whether the treatments benefit patients at lower risk for cardiovascular disease , is unknown . Cardiovascular outcomes trial data for the DPP-4 inhibitors sitagliptin ( 12 ) , saxagliptin ( 13 ) , and alogliptin ( 14 ) showed no statistically significant differences in rates of major cardiovascular events between treatment and placebo groups . Recent Warnings About Pharmacotherapies In May 2015 , the U.S. Food and Drug Administration ( FDA ) issued a warning that SGLT-2 inhibitors may lead to ketoacidosis in the absence of significant hyperglycemia ( termed euglycemic diabetic ketoacidosis ) . Patients who develop symptoms of ketoacidosis  , which may include dyspnea , nausea , vomiting , and abdominal pain  , should stop taking SGLT-2 inhibitors and immediately seek medical attention ( 15 ) . In April 2016 , the FDA also warned that the DPP-4 inhibitors saxagliptin and alogliptin may increase the risk for heart failure , especially in patients with preexisting heart failure or renal impairment ( 16 ) . Insulin Therapy Diabetes is a progressive condition , and many patients with type 2 diabetes eventually require and benefit from insulin therapy . Early patient education about expected disease progression OBJECTIVE To assess the effect of a specialist telemedicine intervention for improving diabetes care using the chronic care model ( CCM ) . PARTICIPANTS AND METHODS As part of the CCM , 97 primary care physicians at 6 primary care practice s in Rochester , MN , referred 639 patients to an on-site diabetes educator between July 1 , 2001 , and December 31 , 2003 . On first referral , physicians were central ly r and omized to receive a telemedicine intervention ( specialty advice and evidence -based messages regarding medication management for cardiovascular risk ) or no intervention , keeping outcome assessors and data analysts blinded to group assignment . After each subsequent clinical encounter , endocrinologists review ed an abstract from the patient 's electronic medical record and provided management recommendations and supporting evidence to intervention physicians via e-mail . Control physicians received e-mail with periodic generic information about cardiovascular risk reduction in diabetes . Outcome measures included diabetes care processes ( diabetes test completion ) , outcomes ( metabolic and cardiovascular risk factors , estimated coronary artery disease risk ) , and patient costs ( payer perspective ) . RESULTS During the intervention , 951 ( 70 % ) of the 1361 endocrinology review s detected performance gaps and result ed in a message ; primary care physicians reported using 49 % of messages in patient care . With a mean of 21 months ' follow-up , the intervention , compared with control , did not significantly enhance metabolic outcomes or reduce estimated risk of coronary artery disease ( adjusted mean difference , -1 % ; 95 % confidence interval , -19 % to 17 % ) . The intervention group incurred lower costs ( P=.02 ) but not in diabetes-related costs . CONCLUSION Specialty telemedicine did not significantly enhance the value of CCM in primary care PURPOSE We wanted to determine whether an intervention based on patient activation and a physician decision support tool was more effective than usual care for improving adherence to National Cholesterol Education Program guidelines . METHODS A 1-year cluster r and omized controlled trial was performed using 30 primary care practice s ( 4,105 patients ) in southeastern New Engl and . The main outcome was the percentage of patients screened for hyperlipidemia and treated to their low-density lipoprotein ( LDL ) and non – high-density lipoprotein ( HDL ) cholesterol goals . RESULTS After 1 year of intervention , both r and omized practice groups improved screening ( 89 % screened ) , and 74 % of patients in both groups were at their LDL and non-HDL cholesterol goals ( P < .001 ) . Using intent-to-treat analysis , we found no statistically significant differences between practice groups in screening or percentage of patients who achieved LDL and non-HDL cholesterol goals . Post hoc analysis showed practice s who made high use of the patient activation kiosk were more likely to have patients screened ( odds ratio [ OR ] = 2.54 ; 95 % confidence interval [ CI ] , 1.97–3.27 ) compared with those who made infrequent or no use . Additionally , physicians who made high use of decision support tools were more likely to have their patients at their LDL cholesterol goals ( OR = 1.27 ; 95 % CI , 1.07–1.50 ) and non-HDL goals ( OR = 1.23 ; 95 % CI , 1.04–1.46 ) than low-use or no-use physicians . CONCLUSION This study showed null results with the intent-to-treat analysis regarding the benefits of a patient activation and a decision support tool in improving cholesterol management in primary care practice s. Post hoc analysis showed a potential benefit in practice s that used the e-health tools more frequently in screening and management of dyslipidemia . Further research on how to incorporate and increase adoption of user-friendly , patient-centered e-health tools to improve screening and management of chronic diseases and their risk factors is warranted OBJECTIVE To examine whether Palm Prevention , a free software tool for Palm OS personal digital assistants ( PDAs ) that provides quick access to preventive guidelines in a patient-specific manner at the point of care , improved adherence to five preventive measures in primary care . DESIGN Prospect i ve intervention pilot study . SETTING Vancouver , BC , and surrounding area . PARTICIPANTS Eight general practitioners . INTERVENTIONS Each physician used Palm Prevention for five preventive measures during routine preventive health visits with 10 patients ( n = 80 ) . Charts of consenting patients were review ed for documentation of recommended maneuvers . MAIN OUTCOME MEASURES Rates of adherence to five evidence -based guidelines selected from the Canadian and American task forces on preventive care and incorporated into Palm Prevention . RESULTS Intervention and control physicians were similar in their familiarity with and use of PDAs , and they recruited similar patients for the study . Intervention and control groups had similar rates of screening for hypertension . Intervention improved adherence to the remaining four guidelines : cervical cancer screening increased 22 % ( only absolute increases are reported ) ; hyperlipidemia screening increased 30 % ; colorectal cancer screening increased 27 % ; and  prophylaxis with acetylsalicylic acid in high-risk patients increased 38 % . Participants were surveyed after the study ; all reported that they found the software helpful and would continue using Palm Prevention . Usage statistics showed that study participants used the tool outside the trial : users entered between 28 and 68 unique patients into the program during the 2-month intervention . CONCLUSION This pilot study suggests PDAs are useful in improving preventive care and facilitating translation of knowledge into practice . This was particularly apparent with newer guidelines A computer was used to prospect ively detect and suggest responses to simple , medication-related events as reflected in a computerized record in a prospect i ve , r and omized 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 implication s 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 clinical ly 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 BACKGROUND Among the 60 million Americans with hypertension , only approximately 31 % have their blood pressure ( BP ) under control ( < 140/90 mm Hg ) . Despite the damaging impact of hypertension and the availability of evidence -based target values for BP , interventions to improve BP control have had limited success . OBJECTIVES A r and omized controlled health services intervention trial with a split-plot design is being conducted to improve BP control . This 4-year trial evaluates both a patient and a provider intervention in a primary care setting among diagnosed hypertensive veterans . METHODS In a cluster-r and omization , 30 primary care providers in the Durham VAMC Primary Care Clinic were r and omly assigned to receive the provider intervention or control . The provider intervention is a patient-specific electronically generated hypertension decision support system ( DSS ) delivering guideline -based recommendations to the provider at each patient 's visit , design ed to improve guideline -concordant therapy . For these providers , a sample of their hypertensive patients ( n=588 ) was r and omly assigned to receive a telephone-administered patient intervention or usual care . The patient intervention incorporates patients ' need assessment s and involves tailored behavioral and education modules to promote medication adherence and improve specific health behaviors .  All modules are delivered over the telephone bi-monthly for 24 months . In this trial , the primary outcome is the proportion of patients who achieve a BP < or = 140/90 mm Hg at each outpatient clinic visit over 24 months . CONCLUSION Despite the known risk of poor BP control , a majority of adults still do not have their BP controlled . This study is an important step in testing the effectiveness of a patient and provider intervention to improve BP control among veterans in the primary care setting BACKGROUND Primary care data bases contain cardiovascular disease risk factor data , but practical tools are required to improve identification of at-risk patients . AIM To test the effects of a system of electronic reminders ( the ' e-Nudge ' ) on cardiovascular events and the adequacy of data for cardiovascular risk estimation . DESIGN OF STUDY R and omised controlled trial . SETTING Nineteen general practice s in the West Midl and s , UK . METHOD The e-Nudge identifies four groups of patients aged over 50 years on the basis of estimated cardiovascular risk and adequacy of risk factor data in general practice computers . Screen messages highlight individuals at raised risk and prompt users to complete risk profiles where necessary . The proportion of the study population in the four groups was measured , as well as the rate of cardiovascular events in each arm after 2 years . RESULTS Over 38 000 patients ' electronic records were r and omised . The intervention led to an increase in the proportion of patients with sufficient data who were identifiably at risk , with a difference of 1.94 % compared to the control group ( 95 % confidence interval [ CI ] = 1.38 to 2.50 , P<0.001 ) . A corresponding reduction occurred in the proportion potentially at risk but requiring further data for a risk estimation ( difference = -3.68 % , 95 % CI = -4.53 to -2.84 , P<0.001 ) . No significant difference was observed in the incidence of cardiovascular events ( rate ratio = 0.96 , 95 % CI = 0.85 to 1.10 , P = 0.59 ) . CONCLUSION Automated electronic reminders using routinely collected primary care data can improve the adequacy of cardiovascular risk factor information during everyday practice and increase the visibility of the at-risk population OBJECTIVES To evaluate the implementation of clinical guidelines for diabetes mellitus in general practice with a specific computer-based clinical decision support system ( CDSS ) as part of the intervention . METHODS R and omized study with health center as unit . General practice in Sør- and Nord-Trøndelag counties in Norway , 380,000 inhabitants . Seventeen health centers with 24 doctors and 499 patients with diabetes mellitus were in the intervention group and 12 health centers with 29 doctors and 535 patients were in the control group . Main outcome measures were group differences in fractions of patients without registration s ( process evaluation ) and mean group differences for the same variables ( patient outcome evaluation ) . RESULTS Statistically significant group differences were experienced for fractions of patients without registration of cigarette smoking ( intervention group , 82.6 % ; control group 94.5 % ) , body mass index ( 78.2 % vs. 93.0 % ) , and sufficient registration s for calculation of risk score for myocardial infa rct ion ( 91.1 % vs. 98.3 % ) ; all during 18 months . Large center variations were shown for all variables . The only statistically significant group difference was -2.3 mm Hg ( 95 % CI , -3.8 , -0.8 ) in diastolic blood pressure in favor of the intervention group . Statistically insignificant differences in favor of the intervention group were HbA1c , -0.1 % ( 95 % CI , -0.4 , 0.1 ) , systolic blood pressure , -1.2 mm Hg ( 95 % CI , -4.4 , 2.0 ) . Statistically insignificant differences in favor of the control group were fractions of smokers , + 3.0 % ( 95 % CI , -4.0 , 10.0 ) , body mass index , + 0.3 kg/m2 ( 95 % CI , -0.8 , 1.4 ) , risk score in female + 0.1 ( 95 % CI , -5.1 , 5.2 ) , and risk score in male + 2.6 ( 95 % CI , -14.2 , 19.5 ) . CONCLUSIONS Implementation of clinical guidelines for diabetes mellitus in general practice , by means of a CDSS and several procedures for implementation , did not result in a clinical ly significant change in doctors ' behavior or in patient outcome BACKGROUND Less than one third of the 65 million Americans with hypertension have adequate blood pressure ( BP ) control . This study examined the effectiveness of 2 interventions for improving patient BP control . METHODS This was a 2-level ( primary care provider and patient ) cluster r and omized trial with 2-year follow-up occurring among patients with hypertension enrolled from a Veterans Affairs Medical Center primary care clinic . Primary care providers ( n = 17 ) in the intervention received computer-generated decision support design ed to improve guideline concordant medical therapy at each visit ; control providers ( n = 15 ) received a reminder at each visit . Patients received usual care or a bimonthly tailored nurse-delivered behavioral telephone intervention to improve hypertension treatment . The primary outcome was proportion of patients who achieved a BP < 140/90 mm Hg ( < 130/85 for diabetic patients ) over the 24-month intervention . RESULTS Of the 816 eligible patients contacted , 190 refused and 38 were excluded . The 588 enrolled patients had a mean age of 63 years , 43 % had adequate baseline BP control , and 482 ( 82 % ) completed the 24-month follow-up . There were no significant differences in amount of change in BP control in the 3 intervention groups as compared to the hypertension reminder control group . In secondary analyses , rates of BP control for all patients receiving the patient behavioral intervention ( n = 294 ) improved from 40.1 % to 54.4 % at 24 months ( P = .03 ) ; patients in the nonbehavioral intervention group improved from 38.2 % to 43.9 % ( P = .38 ) , but there was no between-group differences at the end of the study . CONCLUSION The brief behavioral intervention showed improved outcomes over time , but there were not significant between group differences Background : Diabetes mellitus is a complex disease with serious complications . Electronic decision support , providing information that is shared and discussed by both patient and physician , encourages timely interventions and may improve the management of this chronic disease . However , it has rarely been tested in community-based primary care . Methods : In this pragmatic r and omized trial , we r and omly assigned adult primary care patients with type 2 diabetes to receive the intervention or usual care .  The intervention involved shared access by the primary care provider and the patient to a Web-based , colour-coded diabetes tracker , which provided sequential monitoring values for 13 diabetes risk factors , their respective targets and brief , prioritized messages of advice . The primary outcome measure was a process composite score . Secondary outcomes included clinical composite scores , quality of life , continuity of care and usability . The outcome assessors were blinded to each patient ’s intervention status . Results : We recruited sequentially 46 primary care providers and then 511 of their patients ( mean age 60.7 [ st and ard deviation 12.5 ] years ) . Mean follow-up was 5.9 months . The process composite score was significantly better for patients in the intervention group than for control patients ( difference 1.27 , 95 % confidence interval [ CI ] 0.79–1.75 , p < 0.001 ) ; 61.7 % ( 156/253 ) of patients in the intervention group , compared with 42.6 % ( 110/258 ) of control patients , showed improvement ( difference 19.1 % , p < 0.001 ) . The clinical composite score also had significantly more variables with improvement for the intervention group ( 0.59 , 95 % CI 0.09–1.10 , p = 0.02 ) , including significantly greater declines in blood pressure ( −3.95 mm Hg systolic and −2.38 mm Hg diastolic ) and glycated hemoglobin ( −0.2 % ) . Patients in the intervention group reported greater satisfaction with their diabetes care . Interpretation : A shared electronic decision-support system to support the primary care of diabetes improved the process of care and some clinical markers of the quality of diabetes care . ( Clinical Trials.gov trial register no. NCT00813085 . OBJECTIVE It is difficult to control drug-prescribing behaviour in general practice , despite the development and distribution of guidelines . The purpose of this study was to assess the effect on drug-prescribing behaviour of implementing prescribing guidelines by means of a reactive computer reminder system ( CRS ) . DESIGN Cluster-r and omised controlled trial with an incomplete block design in the south of the Netherl and s : 25 GPs ( 7 GP practice s ) received reminders about antibiotics and asthma/ COPD prescriptions , 28 GPs ( 7 GP practice s ) received reminders about cholesterol prescriptions . Prescription guidelines were integrated into the computerised GP information system . MEASUREMENTS Both performance indicators and prescription volumes were calculated as the main outcome measures . Next to individual volume measure , sum scores were constructed on the volume measures per drug group ( antibiotics , asthma/ COPD and cholesterol ) . RESULTS Variation between GPs turned out to be larger and more skewed than expected . No differences between groups were found for indicators and volumes related to recommendations advocating certain drugs . Although there was a tendency towards clinical ly relevant results for prescription volumes that were supposed to drop , the difference in sum score between the groups was not significant . For antibiotic prescriptions that were supposed to drop , the sum score for the intervention group was 28.2 ( 95 % CI : 20.8 - 44.5 ) prescriptions per 1000 patients per GP , while this was 39.7 ( 95 % CI : 29.7 - 64.1 ) for the control group ( p 0.2 ) . For prescriptions asthma/ COPD that were supposed to drop , the sum score for the intervention group was 1.1 ( 95 % CI : 0.6 - 2.6 ) prescriptions per 1000 patients per GP , while this was 2.2 ( 95 % CI : 1.4 - 4.3 ) for the control group ( p 0.1 ) . On three specific recommendations ( on quinolones for cystitis , corticosteroids for CPOD , and antibiotics for acute sore throat ) significant differences were found . CONCLUSIONS This study turned out to be underpowered due to high inter doctor variation in prescribing behaviour . Nevertheless , computerised reminders sometimes have a favourable effect on restricting certain drugs that are not or no longer indicated in general practice OBJECTIVE To compare the effectiveness of three computerized reminder systems in the delivery of five preventive procedures in family practice . DESIGN Prospect i ve , r and omized , controlled study . SETTING Ottawa Civic Hospital Family Medicine Centre . PARTICIPANTS Of 8502 patients 15 years of age or more who were not in a hospital or institution 5883 were r and omly 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 r and omized portion of the study but were monitored . INTERVENTION 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 . OUTCOME MEASURE Rates of completion of the preventive procedures required . MAIN RESULTS 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 r and omized 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 . CONCLUSION Computerized reminder systems do improve the delivery of preventive services in family practice Abstract BACKGROUND : In New Zeal and , 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 . OBJECTIVES : To test the effectiveness of patients or computers as reminders to screen for diabetes in patients attending FPs . DESIGN : A r and omized-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 . PARTICIPANTS : One hundred and seven FPs . MEASUREMENTS : 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 . RESULTS : 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 . CONCLUSIONS : Patient and computer reminders were effective methods to increase screening for diabetes . However , the effects were not additive OBJECTIVE To evaluate whether a new documentation-based clinical decision support system ( CDSS ) is effective in addressing deficiencies in the care of patients with coronary artery disease ( CAD ) and diabetes mellitus ( DM ) . STUDY DESIGN Controlled trial r and omized by physician . METHODS We assigned primary care physicians ( PCPs ) in 10 ambulatory practice s to usual care or the CAD/DM Smart Form for 9 months . The primary outcome was the proportion of deficiencies in care that were addressed within 30 days after a patient visit . RESULTS The Smart Form was used for 5.6 % of eligible patients . In the intention-to-treat analysis , patients of intervention PCPs had a greater proportion of deficiencies addressed within 30 days of a visit compared with controls ( 11.4 % vs 10.1 % , adjusted and clustered odds ratio = 1.14 ; 95 % confidence interval , 1.02 - 1.28 ; P = .02 ) . Differences were more pronounced in the " on-treatment " analysis : 17.0 % of deficiencies were addressed after visits in which the Smart Form was used compared with 10.6 % of deficiencies after visits in which it was not used ( P < .001 ) . Measures that improved included documentation of smoking status and prescription of antiplatelet agents when appropriate . CONCLUSIONS Overall use of the CAD/DM Smart Form was low , and improvements in management were modest . When used , documentation-based decision support shows promise , and future studies should focus on refining such tools , integrating them into current electronic health record platforms , and promoting their use , perhaps through organizational changes to primary care practice BACKGROUND Although clinical trials have shown that proper management of diabetes can improve outcomes , and treatment guidelines are widespread , glycated hemoglobin ( HbA1c ) levels in the United States are rising . Since process measures are improving , poor glycemic control may reflect the failure of health care providers to intensify diabetes therapy when indicated-- clinical inertia . We asked whether interventions aim ed at health care provider behavior could overcome this barrier and improve glycemic control . METHODS In a 3-year trial , 345 internal medicine residents were r and omized to be controls or to receive computerized reminders providing patient-specific recommendations at each visit and /or feedback on performance every 2 weeks . When glucose levels exceeded 150 mg/dL ( 8.33 mmol/L ) during visits of 4038 patients , health care provider behavior was characterized as did nothing , did anything ( any intensification of therapy ) , or did enough ( if intensification met recommendations ) . RESULTS At baseline , residents did anything for 35 % of visits and did enough for 21 % of visits when changes in therapy were indicated , and there were no differences among intervention groups . During the trial , intensification increased most during the first year and then declined . However , intensification increased more in the feedback alone and feedback plus reminders groups than for reminders alone and control groups ( P<.001 ) . After 3 years , health care provider behavior in the reminders alone and control groups returned to baseline , whereas improvement with feedback alone and feedback plus reminders groups was sustained : 52 % did anything , and 30 % did enough ( P<.001 for both vs the reminders alone and control groups ) . Multivariable analysis showed that feedback on performance contributed independently to intensification and that intensification contributed independently to fall in HbA1c ( P<.001 for both ) . CONCLUSIONS Feedback on performance given to medical resident primary care providers improved provider behavior and lowered HbA1c levels . Similar approaches may aid health care provider behavior and improve diabetes outcomes in other primary care setting 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 r and omized 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 setting BACKGROUND We conducted a cluster r and omized controlled trial to examine the effectiveness of computerized decision support ( CDS ) design ed to improve hypertension care and outcomes in a racially diverse sample of primary care patients . METHODS We r and omized 2,027 adult patients receiving hypertension care in 14 primary care practice s to either 18 months of their physicians receiving CDS for each hypertensive patient or to usual care without computerized support for the control group .  We assessed prescribing of guideline -recommended drug therapy and levels of blood pressure control for patients in each group and examined if the effects of the intervention differed by patients ’ race/ethnicity using interaction terms . MEASUREMENTS AND MAIN RESULTS Rates of blood pressure control were 42 % at baseline and 46 % at the outcome visit with no significant differences between groups . After adjustment for patients ’ demographic and clinical characteristics , number of prior visits , and levels of baseline blood pressure control , there were no differences between intervention groups in the odds of outcome blood pressure control . The use of CDS to providers significantly improved Joint National Committee ( JNC ) guideline adherent medication prescribing compared to usual care ( 7 % versus 5 % , P < 0.001 ) ; the effects of the intervention remained after multivariable adjustment ( odds ratio [ OR ] 1.39 [ CI , 1.13–1.72 ] ) and the effects of the intervention did not differ by patients ’ race and ethnicity . CONCLUSIONS CDS improved appropriate medication prescribing with no improvement in disparities in care and overall blood pressure control . Future work focusing on improvement of these interventions and the study of other practical interventions to reduce disparities in hypertension-related outcomes is needed OBJECTIVE : To describe the effect of the Vermont Diabetes Information System ( VDIS ) on hospital and emergency room use DATA SOURCE : Statewide discharge data base STUDY DESIGN : R and omized controlled trial of a decision support system for 7,412 adults with diabetes and their 64 primary care providers . DATA COLLECTION / DATA EXTRACTION : Charges and date s for hospital admissions and emergency room care in Vermont during an average of 32 months of observation . Data from New York hospitals were not available . PRINCIPAL FINDINGS : Patients r and omized to VDIS were admitted to the hospital less often than control subjects ( 0.17 admissions vs. 0.20 ; P=0.01 ) and generated lower hospital charges ( $ 3,113 vs. $ 3,480 ; P=0.019 ) . VDIS patients also had lower emergency room utilization ( 0.27 visits vs. 0.36 ; P<0.0001 ) and charges ( $ 304 vs. $ 414 ; P<0.0001 ) . The intervention was particularly effective in men and in older subjects . CONCLUSIONS : In spite of data limitations that tended to reduce the apparent effect of the system ; this r and omized , controlled trial showed that VDIS reduces hospitalization and emergency room utilization and expenses BACKGROUND Hospitalizations are an opportunity to provide preventive care . OBJECTIVE To determine if computer reminders , which we have shown to be effective in our ambulatory care setting , increasing the provision of inpatient preventive care . METHODS R and omized , controlled trial on the general medicine inpatient service of an urban , university-affiliated public hospital . Study subjects were 78 house staff rotating on the 6 general medicine services . The intervention was reminders to physicians printed on daily rounds reports about preventive care for which their patients were eligible , and suggested orders for preventive care provided through the physicians ' workstations . The preventive care guidelines were derived from the US Preventive Care Task Force recommendations . Compliance with preventive care guidelines and house staff attitudes toward providing preventive care to hospitalized patients were the main outcome measures . RESULTS No significant differences were seen between intervention and control physicians in compliance with preventive care guidelines in the aggregate or when individual preventive care actions individual preventive care actions were analyzed . This was true even though most physicians endorsed providing most kinds of preventive care for hospitalized patients . CONCLUSIONS Despite past success in increasing preventive care in the outpatient setting , we were unable , using a moderately intensive intervention , to increase the provision of preventive care during hospitalizations . The physicians providing care during the hospitalization were not the patients ' primary care physicians , which proved to be an important barrier . More intensive interventions , or more direct linkages between inpatient and outpatient care providers , may be required to overcome this resistance BACKGROUND Errors involving medication use are common . Computerized physician order entry ( CPOE ) can improve prescribing practice s. Few studies have examined the effect of CPOE in combination with decision support tools on prescribing practice s in the outpatient setting . Less is known about prescribers ' adherence to laboratory monitoring recommendations . OBJECTIVE To evaluate if reminders presented during CPOE for medications would increase physicians ' compliance with guidelines for laboratory monitoring at initiation of therapy . STUDY DESIGN R and omized prospect i ve intervention study . METHODS Two hundred seven primary care physicians in a group-model managed care organization were r and omized to receive or not receive drug laboratory monitoring alerts within the CPOE system .  Adherence to laboratory monitoring recommendations for patients prescribed selected medications was compared between physician groups . RESULTS There was no significant difference between the control and intervention group physicians in the overall rate of compliance with ordering the recommended laboratory monitoring for patients prescribed study medications . Laboratory monitoring was performed as recommended 56.6 % of the time in the intervention group compared with 57.1 % of the time in the control group ( P = .31 ) . In cases in which a statistically significant difference was demonstrated , improved compliance favored the intervention group ( eg , 71.2 % vs 62.3 % [ P = .003 ] for gemfibrozil and 75.7 % vs 73.9 % [ P = .05 ] for statins ) . CONCLUSIONS As CPOE becomes more prevalent , additional research is needed to determine effective decision support tools . These findings then should be communicated to the developers and users of computerized medical record systems OBJECTIVE To compare computer-based with manual health maintenance tracking systems to determine whether ( 1 ) a computer-based system will result in better provider compliance with the practice health maintenance protocol , ( 2 ) the incremental cost of operating a computer-based vs a manual health maintenance tracking system differs , and ( 3 ) inactive patients will respond to health maintenance reminders . DESIGN Two-year prospect i ve , r and omized , controlled trial . SETTING Rural , multiple-office , nonprofit , fee-for-service family practice . PATIENTS Adult members of families in which at least one member had been seen by the practice within the past 2 years . INTERVENTION A computer-based health maintenance tracking system that generated annual provider and patient reminders for all patients regardless of appointment status compared with a manual flowchart-based tracking system in which patient reminders were triggered by provider request . OUTCOME MEASURES Provider compliance with the health maintenance protocol determined by preintervention and postintervention chart audits , costs of computer-based tracking , and response of inactive patients to health maintenance reminders . RESULTS Overall provider compliance with the health maintenance protocol increased 15 percentage points in the computer-based tracking group and four percentage points in the manual group . The computer-based tracking group had significantly higher provider compliance than the manual group for eight of 11 procedures . The computer-based tracking system cost 78 cents per patient per year to operate . It was not associated with increased office visits or patient billings . CONCLUSIONS Computer-based health maintenance tracking improved provider health maintenance compliance compared with a manual system . The finding that health maintenance compliance improved without a significant increase in patient visits or billings requires confirmation in other setting s but suggests that considerable health maintenance can be incorporated into ongoing patient care BACKGROUND Preventive care is an important role for general practitioners , yet opportunities for prevention are often missed . METHOD We provided an automatic electronic record preventive care reminder system for  12 preventive care activities for one 10 doctor practice . All patients who attended were r and omised by the terminal digit of their record number . RESULTS The control uptake of opportunistic prevention was low ; ranging from 1.5 % ( tetanus immunisation ) to 27 % ( influenza immunisation ) . The reminders increased this by significant but small amounts for four out of 12 activities ( immunisation for tetanus and pneumococcus and recording of allergies and weight ) , insignificant increases for four ( mumps , measles and rubella immunisation , recording of smoking , and taking of cervical smears and of blood pressure ) , and insignificantly decreased influenza immunisation , and screening for diabetes and hyperlipidaemia . DISCUSSION Opportunistic electronic reminders have the potential to increase preventive care in general practice STUDY OBJECTIVE To assess the effects of evidence -based treatment suggestions for hypertension made to physicians and pharmacists using a comprehensive electronic medical record system . DESIGN R and omized controlled trial with a 2 x 2 factorial design of physician and pharmacist interventions , which result ed in four groups of patients :  physician intervention only , pharmacist intervention only , intervention by physician and pharmacist , and intervention by neither physician nor pharmacist ( control ) . SETTING Academic primary care internal medicine practice . SUBJECTS Seven hundred twelve patients with uncomplicated hypertension . MEASUREMENTS AND MAIN RESULTS Suggestions were displayed to physicians on computer workstations used to write outpatient orders and to pharmacists when filling prescriptions . The primary end point was generic health-related quality of life . Secondary end points were symptom profile and side effects from antihypertensive drugs , number of emergency department visits and hospitalizations , blood pressure measurements , patient satisfaction with physicians and pharmacists , drug therapy compliance , and health care charges . In the control group , implementation of care changes in accordance with treatment suggestions was observed in 26 % of patients . In the intervention groups , compliance with suggestions was poor , with treatment suggestions implemented in 25 % of patients for whom suggestions were displayed only to pharmacists , 29 % of those for whom suggestions were displayed only to physicians , and 35 % of the group for whom both physicians and pharmacists received suggestions ( p=0.13 ) . Intergroup differences were neither statistically significant nor clinical ly relevant for generic health-related quality of life , symptom and side-effect profiles , number of emergency department visits and hospitalizations , blood pressure measurements , charges , or drug therapy compliance . CONCLUSION Computer-based intervention using a sophisticated electronic physician order-entry system failed to improve compliance with treatment suggestions or outcomes of patients with uncomplicated hypertension Discrepancies between clinical guidelines and clinical practice call for practical implementation strategies . This study evaluates the implementation of clinical guidelines for hypertension in general practice with a specific computer-based clinical decision support system ( CDSS ) as part of the intervention . We carried out a r and omized study of general practice health centres in Sør- and Nord-Trøndelag counties in Norway ( population 380000 ) . A total of 17 health centres were included , with 24 doctors and 984 patients in the intervention group . Data from 887 patients was used in the analyses . There were 12 health centres with 29 doctors and 1255 patients in the control group . Data from 1127 control patients was used in the analyses . The main outcome measures were doctor 's behaviour , measured by adherence to registration of recommended variables in the Norwegian clinical guidelines for hypertension . The aim of the intervention was to lower the fractions of patients without registration s. However , there were no clinical ly significant differences between the intervention group and the control group for fractions of patients without registration of blood pressure ( intervention group 14.3 % , control group 14.2 % ) or serum cholesterol ( 62.3 % vs. 56.8 % ) during 12 months , nor , during 18 months , for fractions of patients without a registration of cigarette smoking ( 82.9 % vs. 87.1 % ) , cardiovascular inheritance ( 79.5 % vs. 73.4 % ) and body mass index ( 81.5 % vs. 89.2 % ) . One or several variables necessary for calculation of risk score for myocardial infa rct ion were missing in 91.7 % of patients in the intervention group and 91.9 % of patients in the control group . Large centre variations were shown for all variables . Implementation of clinical guidelines in the treatment of hypertensive patients in general practice , by means of a CDSS and several procedures for implementation did not result in clinical ly significant changes in the doctors ' behaviour . Of importance are both the lack of user-friendliness of the specific CDSS and problems in performing time-consuming multidimensional procedures Background . Adherence with antihypertensive and lipid-lowering therapy is poor , result ing in an almost 2-fold increase in hospitalization . Treatment side effects , cost , and complexity are common reasons for nonadherence , and physicians are often unaware of these potentially modifiable problems . Objective . To determine if a cardiovascular medication tracking and nonadherence alert system , incorporated into a computerized health record system , would increase drug profile review by primary care physicians , increase the likelihood of therapy change , and improve adherence with antihypertensive and lipid-lowering drugs . Methods . There were 2293 primary care patients prescribed lipid-lowering or antihypertensive drugs who were r and omized to the adherence tracking and alert system or active medication list alone  to determine if the intervention increased drug profile review , changes in cardiovascular drug treatment , and refill adherence in the first 6 months . An intention to treat analysis was conducted using generalized estimating equations to account for clustering within physician . Results . Overall , medication adherence was below 80 % for 36.3 % of patients using lipid-lowering drugs and 40.8 % of patients using antihypertensives at the start of the trial . There was a significant increase in drug profile review in the intervention compared to the control group ( 44.5 % v. 35.5 % ; P < 0.001 ) , a nonsignificant increase in drug discontinuations due to side effects ( 2.3 % v. 2.0 % ; P = 0.61 ) , and a reduction in therapy increases ( 28.5 % v. 29.1 % ; P = 0.86 ) . There was no significant change in refill adherence after 6 months of follow-up . Conclusion . An adherence tracking and alert system increases drug review but not therapy changes or adherence in prevalent users of cardiovascular drug treatment . Targeting incident users where adverse treatment effects are more common and combining adherence tracking and alert tools with motivational interventions provided by multidisciplinary primary care teams may improve the effectiveness of the intervention 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 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 wanted to assess the impact of an electronic health record – based diabetes clinical decision support system on control of hemoglobin A1c ( glycated hemoglobin ) , blood pressure , and low-density lipoprotein ( LDL ) cholesterol levels in adults with diabetes . METHODS We conducted a clinic-r and omized trial conducted from October 2006 to May 2007 in Minnesota . Included were 11 clinics with 41 consenting primary care physicians and the physicians ’ 2,556 patients with diabetes . Patients were r and omized either to receive or not to receive an electronic health record (EHR)–based clinical decision support system design ed to improve care for those patients whose hemoglobin A1c , blood pressure , or LDL cholesterol levels were higher than goal at any office visit . Analysis used general and generalized linear mixed models with repeated time measurements to accommo date the nested data structure . RESULTS The intervention group physicians used the EHR-based decision support system at 62.6 % of all office visits made by adults with diabetes . The intervention group diabetes patients had significantly better hemoglobin A1c ( intervention effect −0.26 % ; 95 % confidence interval , −0.06 % to −0.47 % ; P=.01 ) , and better maintenance of systolic blood pressure control ( 80.2 % vs 75.1 % , P=.03 ) and borderline better maintenance of diastolic blood pressure control ( 85.6 % vs 81.7 % , P = .07 ) , but not improved low-density lipoprotein cholesterol levels ( P = .62 ) than patients of physicians r and omized to the control arm of the study . Among intervention group physicians , 94 % were satisfied or very satisfied with the intervention , and moderate use of the support system persisted for more than 1 year after feedback and incentives to encourage its use were discontinued . CONCLUSIONS EHR-based diabetes clinical decision support  significantly improved glucose control and some aspects of blood pressure control in adults with type 2 diabetes
target: Results were inconsistent for changes in CVD risk factors such as systolic and diastolic blood pressure , total and low-density lipoprotein cholesterol , and hemoglobin A1C levels .
  CONCLUSIONS CDSSs are effective in improving clinician practice s related to screening and other preventive care services , clinical tests , and treatments .
background: CONTEXT Clinical decision support systems ( CDSSs ) can help clinicians assess cardiovascular disease ( CVD ) risk and manage CVD risk factors by providing tailored assessment s and treatment recommendations based on individual patient data .
  The goal of this systematic review was to examine the effectiveness of CDSSs in improving screening for CVD risk factors , practice s for CVD-related preventive care services such as clinical tests and prescribed treatments , and management of CVD risk factors .