Effects of computerized guidelines for managing heart disease in primary care
A randomized, controlled trial
Cite this article as: Tierney, W.M., Overhage, J.M., Murray, M.D. et al. J GEN INTERN MED (2003) 18: 967. doi:10.1111/j.1525-1497.2003.30635.x
BACKGROUND: Electronic information systems have been proposed as one means to reduce medical errors of commission (doing the wrong thing) and omission (not providing indicated care).
OBJECTIVE: To assess the effects of computer-based cardiac care suggestions.
DESIGN: A randomized, controlled trial targeting primary care physicians and pharmacists.
SUBJECTS: A total of 706 outpatients with heart failure and/or ischemic heart disease.
INTERVENTIONS: Evidence-based cardiac care suggestions, approved by a panel of local cardiologists and general internists, were displayed to physicians and pharmacists as they cared for enrolled patients.
MEASUREMENTS: Adherence with the care suggestions, generic and condition-specific quality of life, acute exacerbations of their cardiac disease, medication compliance, health care costs, satisfaction with care, and physicians’ attitudes toward guidelines.
RESULTS: Subjects were followed for 1 year during which they made 3,419 primary care visits and were eligible for 2,609 separate cardiac care suggestions. The intervention had no effect on physicians’ adherence to the care suggestions (23% for intervention patients vs 22% for controls). There were no intervention-control differences in quality of life, medication compliance, health care utilization, costs, or satisfaction with care. Physicians viewed guidelines as providing helpful information but constraining their practice and not helpful in making decisions for individual patients.
CONCLUSIONS: Care suggestions generated by a sophisticated electronic medical record system failed to improve adherence to accepted practice guidelines or outcomes for patients with heart disease. Future studies must weigh the benefits and costs of different (and perhaps more Draconian) methods of affecting clinician behavior.
ambulatory information systems
clinical practice guidelines
coronary artery disease
decision support systems
drug utilization review
The opinions expressed herein do not necessarily reflect those of the funding agency or the authors’ institutions.
Grant Support: 1R01-HS07763 from the Agency for Healthcare Research and Quality.
Institute of Medicine. Crossing the Quality Chasm: A New System for the 21st Century. Washington, DC: National Academy Press; 2001.
Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370–6.
Brand DA, Newcomer LN, Freiburger A, Tian H. Cardiologists’ practices compared with practice guidelines: use of beta-blockade after acute myocardial infarction. J Am Coll Cardiol. 1995;26:1432–6.
Peterson LA, Norman ST, Leape LL, McNeil BJ. Comparison of use of medications after acute myocardial infarction in the Veterans Health Administration and Medicare. Circulation. 2001;104:2898–904.
Kennedy HL. Current utilization trends of beta-blockers in cardiovascular disease. Am J Med. 2001;110(suppl 5A):2S-6S.
Spencer F, Scleparis G, Goldberg RJ, Yarzebski J, Lessard D, Gore JM. Decade-long trends (1986–1997) in the medical treatment of patients with acute myocardial infarction: a community-wide perspective. Am Heart J. 2001;142:594–603.
The SOLVD Investigators. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med. 1992;327:685–91.
Konstam MA, Rousseau MF, Kronenberg MW, et al. Effect of the angiotensin converting enzyme inhibitor enalapril on the long-term progression of left ventricular dysfunction in patients with heart failure. SOLVD Investigators. Circulation. 1992;86:431–8.
Frye RL, Gibbons RJ, Schaff HV, et al. Treatment of coronary artery disease. J Am Coll Cardiol. 1989;13:957–68.
Parker JD, Parker JO. Nitrate therapy for stable angina pectoris. N Engl J Med. 1998;338:520–31.
Ridker PM, Manson JE, Gaziano M, et al. Low dose aspirin therapy for chronic stable angina: a randomized, placebo-controlled clinical trial. Ann Intern Med. 1991;114:835–9.
McDonald CJ. Protocol-based computer reminders, the quality of care and the non-perfectability of man. N Engl J Med. 1976;295:1351–5.
Williamson JW, Goldschmidt PG, Jillson IA (Office of the Assistant Secretary of Health, Department of Health, Education, and Welfare, contract 28277-0068GS). Medical Practice Information Demonstration Project: Final Report, Baltimore, MD: Policy Research Inc; 1979.
Institute of Medicine. Assessing Medical Technologies. Washington, DC: National Academy Press; 1985;5.
James BC, Hammond ME. The challenge of variation in medical practice. Arch Pathol Lab Med. 2000;124:1001–3.
Mulley AG, Eagle KA. What is inappropriate care? JAMA. 1988;260:540–1.
Park RE, Fink A, Brook RH, et al. Physician Ratings of Appropriate Indications for Six Medical and Surgical Procedures. Santa Monica, CA: RAND Corp; 1986.
McDonald CJ. Medical heuristics: the silent adjudicators of clinical practice. Ann Intern Med. 1996;124(1 Part 1):56–62.
Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
Institute of Medicine, Committee on Improving the Medical Record. The Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC: National Academy Press; 1991.
McDonald CJ, Hui SL, Smith DM, et al. Reminders to physicians from an introspective computer medical record. A two-year randomized trial. Ann Intern Med. 1984;100:130–8.
Ferguson JA, Weinberger M. Case management programs in primary care. J Gen Intern Med. 1998;13:123–6.
Harris LE, Luft FC, Rudy DW, Kesterson JG, Tierney WM. Effects of multidisciplinary case management of patients with chronic renal insufficiency. Am J Med. 1998;105:464–71.
McDonald CJ, Overhage JM, Tierney WM, et al. The Regenstrief Medical Record System: a quarter century experience. Int J Med Inf. 1999;54:225–53.
Tierney WM, Miller ME, Hui SL, McDonald CJ. Practice randomization and clinical research: the Indiana experience. Med Care. 1999;29:JS57-JS64.
Tierney WM, Miller ME, McDonald CJ. The effect on test ordering of informing physicians of the charges for outpatient diagnostic tests. N Engl J Med. 1990;233:1499–504.
Agency for Health Care Policy and Research. Heart Failure: Evaluation and Care of Patients with Left-Ventricular Systolic Dysfunction. Washington, DC: US Department of Health and Human Services (AHCPR Publication no. 94-0612); 1994.
Tierney WM. Computerizing guidelines: factors for success. J Am Med Inform Assoc. 1996;3(suppl 1):459–62.
Woolf SH. Practice guidelines: a new reality in medicine. Arch Intern Med. 1990;150:1811–8.
Tierney WM, Overhage JM, Takesue BY, et al. Computerizing guidelines to improve care and patient outcomes: the example of heart failure. J Am Med Inform Assoc. 1995;2:316–22.
Overhage JM, Mamlin B, Warvel J, Warvel J, Tierney W, McDonald CJ. A tool for provider interaction during patient care: G-CARE. Proc Annu Symp Comput Appl Med Care. 1995;178–82.
Tierney WM, Miller ME, Overhage JM, McDonald CJ. Physician inpatient order-writing on microcomputer workstations: effects on resource utilization. JAMA. 1993;269:379–83.
McDonald CJ, Tierney WM. The Medical Gopher—a microcomputer system to help find, organize and decide about patient data. West J Med. 1986;145:823–9.
The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels, 8th edn. New York: New York Heart Association; 1979.
Tierney WM. Improving clinical decisions and outcomes with information: a review. Int J Med Informat. 2001;62:1–9.
Overhage JM, Lukes A. Practical, reliable, comprehensive method for characterizing pharmacists’ clinical activities. Am J Health Syst Pharm. 1999;56:2444–50.
McHorney CA, Ware JE Jr. Construction and validation of an alternate form general mental health scale for the Medical Outcomes Study Short-Form 36-Item Health Survey. Med Care. 1995;33:15–28.
Wolinsky FD, Stump TE. A measurement model of the Medical Outcomes Study 36-Item Short-Form health survey in a clinical sample of disadvantaged, older, black, and white men and women. Med Care. 1996;34:537–48.
Dexter PR, Stump TE, Tierney WM, Wolinsky FD. The psychometric properties of the SF-36 health survey among older adults in the clinical setting. J Clin Geropsy. 1996;2:225–37.
Guyatt GH. Measurement of health-related quality of life in heart failure. J Am Coll Crdiol. 1993;22(suppl A):185A-191A.
Wolinsky FD, Wyrwich KW, Nienaber NA, Tierney WM. Generic versus disease-specific health status measures: an example using coronary artery disease and congestive heart failure patients. Eval Health Prof. 1998;21:216–43.
Webster GD. Final Report of the ABIM Patient Satisfaction Project. Philadelphia: American Board of Internal Medicine; 1988.
Stump TE, Dexter PR, Tierney WM, Wolinsky FD. Measuring patient satisfaction with physicians among older and diseased adults in the outpatient setting: a comparison of three instruments. Med Care. 1995;33:958–72.
Weinberger M, Murray MD, Marrero DG, et al. A pharmaceutical care program for patients with reactive airways disease. Am J Health Syst Pharm. 2001;58:791–6.
Inui TS, Carter WB, Pecoraro RE. Screening for noncompliance among patients with hypertension: is self-report the best available measure? Med Care. 1981;19:1061–4.
Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care. 1986;24:67–74.
Steiner JF, Koepsell TD, Fihn SD, Inui TS. A general method of compliance assessment using centralized pharmacy records. Description and validation. Med Care. 1988;26:814–23.
Murray MD, Harris LE, Overhage JM, Zhou XH, Smith F, Tierney WM. Association between medication possession ratio and reported compliance. J Gen Intern Med. 1997;12(suppl 1):77.
Tunis SR, Hayward RSA, Wilson MC, et al. Internists’ attitudes about clinical practice guidelines. Ann Intern Med. 1994;120:956–63.
Dudek FJ. The continuing misinterpretation of the standard error of measurement. Psychol Bull. 1979;86:335–7.
Wyrwich KW, Tierney WM, Wolinsky FD. Further evidence supporting a SEM-based criterion for identifying meaningful intra-individual changes in health-related quality of life. J Clin Epidemiol. 1999;52:861–73.
Shwartz M, Yound DW, Siegrist R. The ratio of costs to charges: how good a basis for estimating costs? Inquiry. 1995;32:476–81.
Schimmel VE, Alley C, Heath AM. Measuring costs: product line accounting versus ratio of cost to charges. Top Health Care Financ. 1987;13:76–86.
Zhou XH, Tu W. Comparisons of several independent population means when their samples contain non-zero log-normal and possibly zero observations. Biometrics. 1999;55:645–51.
Tierney WM, Hui SL, McDonald CJ. Delayed feedback of physician performance versus immediate reminders to perform preventive care: effects on physician compliance. Med Care. 1986;24:659–66.
Litzelman DK, Dittus RS, Miller ME, Tierney WM. Requiring physicians to respond to computerized reminders improves their compliance with preventive care protocols. J Gen Intern Med. 1993;8:311–7.
Dexter PR, Perkins S, Overhage JM, Maharry K, Kohler RB, McDonald CJ. A computerized reminder system to increase the use of preventive care for hospitalized patients. N Engl J Med. 2001;345:965–70.
Overhage JM, Tierney WM, Zhou XH, McDonald CJ. A randomized trial of “corollary orders” to prevent errors of omission. J Am Med Inform Assoc. 1997;4:364–75.
Eccles M, McColl E, Steen N, Rousseau N, Grimshaw J, Parkin D. Effect of computerised evidence based guidelines on management of asthma and angina in adults in primary care: cluster randomised controlled trial. BMJ. 2002;325:491–7.
Overhage JM, Tierney WM, McDonald CJ. Computer reminders to implement preventive care guidelines for hospitalized patients. Arch Intern Med. 1996;156:1551–6.
Martin AR, Wolf MA, Thibodeau LA, Dzau V, Braunwald E. A trial of two strategies to modify the test-ordering behavior of medical residents. N Engl J Med. 1980;303:1330–6.
Hillman AL, Ripley K, Goldfarb N, Nuamah I, Weiner J, Lusk E. Physician financial incentives and feedback: failure to increase cancer screening in Medicaid managed care. Am J Public Health. 1998;88:1699–701.
Kouides RW, Bennett NM, Lewis B, Cappuccio JD, Barker WH, LaForce FM. Performance-based physician reimbursement and influenza immunization rates in the elderly. Am J Prev Med. 1998;14:89–95.
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