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Demakis JG, Beauchamp C, Cull WL, et al. Improving Residents' Compliance With Standards of Ambulatory Care: Results From the VA Cooperative Study on Computerized Reminders. JAMA. 2000;284(11):1411–1416. doi:10.1001/jama.284.11.1411
Author Affiliations: VA Health Services Research and Development Service, Washington, DC (Dr Demakis); Department of Ambulatory Care, Durham VAMC, Durham, NC (Dr Beauchamp); Hines VA Cooperative Studies Program Coordinating Center, Hines, Ill (Drs Cull and Henderson and Ms Denwood); Department of Rheumatology, St Louis VAMC, St Louis, Mo (Dr Eisen); Department of General Internal Medicine, Medical College of Wisconsin, Milwaukee (Dr Lofgren); Department of Internal Medicine, Minneapolis VAMC, Minneapolis, Minn (Dr Nichol); and Department of General Medicine, University of Michigan, Ann Arbor (Dr Woolliscroft).
Context Computerized systems to remind physicians to provide appropriate care
have not been widely evaluated in large numbers of patients in multiple clinical
Objective To examine whether a computerized reminder system operating in multiple
Veterans Affairs (VA) ambulatory care clinics improves resident physician
compliance with standards of ambulatory care.
Design, Setting, and Participants A total of 275 resident physicians at 12 VA medical centers were randomly
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 standards of care (SOC) was applicable.
Main Outcome Measures Compliance with 13 SOC, tracked using hospital databases 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 standards 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 standards 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 standards combined
(17.9% vs 12.2%; OR, 1.57; 95% CI, 1.45-1.71; P<.001)
and for 9 of the 13 standards examined individually. The benefit of reminders,
however, declined throughout the course of the study, even though the reminders
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.
Randomized controlled trials of computerized reminders (CRs) to physicians
to improve their compliance with specific standards of care (SOC) were first
reported in 1976.1 During the next 17 years,
other randomized controlled trials2-21
were reported that compared the use of CRs with manual reminders or no reminders.
In some of the trials,11,16,17
CRs were given to patients as well as physicians, but generally, CRs were
given only to resident physicians.
Although the overall effects of the CRs were positive, there were serious
limitations to the published studies. All studies were single-site trials
and nearly all involved relatively few patients (eg, between 32 and 1460 patients,
with the exception of 2 studies of 70007 and
12,46717 patients). Since most of the computer
systems were developed to meet the needs of a particular institution, there
was little opportunity to extend the studies beyond the single sites. The
number of conditions for which CRs were generated varied from 1 to 11, with
the exception of 1 study of more than 100 conditions. Five studies involved
5 or fewer reminder conditions. All CRs were for preventive care such as influenza
and pneumococcal vaccines or mammography. Two sites accounted for 11 of the
previously published trials.1-3,7-9,11-15
The Department of Veterans Affairs centralized database and Cooperative
Studies Program provided a unique opportunity to assess the generalizability
and overall utility of using CRs to improve the quality of care involving
multiple sites and using a host of different SOC. Specifically, we examined
whether providing CRs of well-accepted SOC to resident physicians in ambulatory
care clinics can increase compliance with those standards. This study also
addressed (1) whether CRs can work in multiple sites around the country with
the same database and (2) whether CRs can work with multiple reminders that
include treatment as well as prevention interventions.
A total of 275 resident physicians from 12 Veterans Affairs (VA) medical
centers participated in the study. Resident physicians were chosen for participation
because they were the VA physicians who were most involved in patient primary
care at the time of the study. During the course of the study, the residents
cared for 18,700 unique patients, and 12,989 of these patients were eligible
for at least 1 of the investigated SOC.
The SOC were chosen on the basis of their importance to the Department
of Veterans Affairs ambulatory care patient population, a population composed
mainly of middle-aged and elderly males with chronic diseases; and feasibility
of identifying diagnoses, exclusionary factors, treatments, procedures, and
instructions via the hospital computer system. In the planning stages of the
study, a committee of Chiefs of Ambulatory Care Services in the VA generated
a preliminary list of SOC using existing published medical guidelines and
literature search strategies. More than 30 potential SOC were identified.
The capability of the computer system to monitor the standards was then assessed
to identify the 13 standards that were used in the trial (Table 1).
The study was a clinical trial comparing the performance of residents
receiving CRs with the performance of residents not receiving CRs. Data collection
for the study began January 31, 1995, and ended June 30, 1996. At each site,
resident physicians were assigned to either the reminder group or the control
group. For sites using a firm or team system, each firm was randomly assigned
to 1 of the 2 groups, and all residents in the firm were assigned to that
group. For sites not using a firm system, half-day blocks of residents were
randomly assigned to the reminder or control groups. Firms or half-day blocks
of residents, rather than individual residents, were randomized to reduce
communication between members of the intervention and control arms. Also,
a concerted effort was made at each site to have residents from the same firm
or block substitute for one another when necessary to prevent contamination.
A total of 153 residents were assigned to the control group, and 146 residents
were assigned to the reminder group. A total of 143 residents in the control
group and 132 residents in the reminder group completed the study. For the
24 residents who failed to complete the study, 12 had residencies that concluded
before the completion of the study, 4 left their residencies prematurely,
and 8 remained in their residencies but no longer wished to participate in
the study. There was no significant difference in the drop-out rates between
the treatment groups (P = .33). The 275 residents
completing the study exceeded the target sample size for the study of 260
At the beginning of the study, residents in both the reminder and the
control groups were asked to complete a questionnaire exploring their knowledge
of and attitudes toward the SOC being studied. Later, they attended a 1-hour
instruction session where the principal investigator at each site discussed
the rationale for and benefits of the SOC being studied. During the instruction
session, all residents received a booklet that listed the SOC and provided
the rationale and several references supporting each standard. Residents in
the reminder group were also provided with an introduction to the reminder
system. This consisted of an education session of 1 to 2 hours that explained
the general value of reminder systems and the presentation of a videotape,
designed specifically for this study, that demonstrated in detail how the
reminder system worked.
Data were collected for at least 2 weeks before reminders were activated
to provide a period for comparing baseline adherence rates between the reminder
and control groups for a sample of residents' patients. Once the intervention
period began, CRs were presented to residents in 2 ways to ensure that they
would see each reminder prior to evaluating each patient. First, each examination
room has a computer terminal that is connected to the hospital computer server.
When a resident in the intervention group entered a patient name into the
computer, all reminders pertaining to that patient were automatically presented
in bold letters. Each reminder consisted of a notification that the SOC applied
to the patient. Accompanying each notification was a brief rationale for the
standard. Second, a computer-generated summary (typically 6-8 pages) of a
patient's health, including a list of his or her medical conditions and a
list of his or her most recent clinic visits, is routinely placed at the beginning
of the medical chart on the day of the clinic visit. For the intervention
group, this health summary was modified to include all reminders that pertained
to the patient. This information appeared on page 2 of the health summary
after patient-identifying information. Control group residents continued to
receive standard health summaries without the reminders.
At no point in the study was any performance feedback given to the hospitals
or the residents concerning individual resident adherence levels or overall
hospital adherence levels. Accordingly, residents were never evaluated based
on their compliance with the SOC.
Adherence to the SOC was the primary dependent variable, and adherence
was measured for all patients visiting a study physician whom were eligible
for 1 or more of the SOC. Adherence was measured in 2 different ways: general
adherence or visit-specific adherence. General adherence used a patient's last visit as a reference point and measured the
proportion of patients with 1 of the SOC who were in compliance with that
SOC at a time point following the patient's last visit. This measure did not
determine the specific point in time during the study when the care was provided,
but only whether care had been provided by their last visit.
Visit-specific adherence, on the other hand,
measured whether residents delivered appropriate care at the time of a specific
patient visit by providing the care according to the SOC. This was accomplished
by tracking adherence both before and after each visit. Before each visit,
it was determined, based on review of prior care, whether a patient needed
to receive specific services. The adherence measurement after the visit then
identified whether residents provided care according to the SOC. This measure
allowed multiple observations in the database for the same patient and SOC
combination if a patient visited the clinic repeatedly and the suggested care
had not been provided at the time of each visit.
For both measures, adherence was treated dichotomously, with adherence
equal to 1 if proper care had been given to the patient and to 0 if proper
care had not been given. An adherence measurement was included in the database
for all SOC for which the patient was eligible.
Table 1 provides a list
of the 13 SOC that were studied. Eligibility and compliance with the various
SOC were determined using information from 2 sources: (1) an encounter form
completed at the time of each visit and (2) each hospital's computer system.
The encounter forms were optical scan forms that contained a list of 152 diagnoses,
20 procedures, and 17 patient instructions, such as a discussion of the benefits
of exercise or proper nutrition. The diagnoses, procedures, and instructions
listed on the encounter form were those that were most likely to be reported
in the VA ambulatory clinics. Residents were instructed to mark each diagnosis
that was treated, each procedure that was administered, and each instruction
that was given. There were also spaces on the encounter form to enter "other"
diagnoses, instructions, or procedures.
For this study, computer software was developed that downloaded the
information from the encounter forms and integrated this information with
hospital information about patients' demographics, prescriptions, treatments,
and laboratory test results. The program then identified all eligible patients
and determined whether proper care had been given to those patients. This
program was run weekly at each site.
Several actions were taken to ensure that adherence was being tracked
accurately. First, prior to data collection, each of the SOC was individually
checked at the 12 sites by a data evaluation committee who sampled cases and
checked the accuracy of the integration program with patient charts and hospital
files. Because of the considerable time it took the Data Evaluation Committee
to check the computer program for each SOC at each site, the exact timing
of data collections varied for the different SOC within and among sites.
Second, at each site, monthly completion rates were determined to guarantee
that residents were using the encounter forms. The average completion rate
across all sites was 96.9% (range, 92.2%-100%).
Finally, for roughly 5% of the encounter forms that were completed each
month, audits were conducted to check the accuracy of the marked information.
Specifically, these audits assessed the concordance between information marked
on the encounter form and information written in the medical chart. Most of
the diagnoses (76.9%) were present both in the medical chart and on the encounter
form. It was expected that some diagnoses would not be found on the encounter
forms because the residents were instructed to only mark diagnoses that they
treated at that visit.
Statistical analyses were based on the sample of 12,989 unique patients
who were eligible for 1 or more of the SOC studied. An α level of .05
or 95% confidence interval (CI) was used for all statistical analyses (exact P values are also reported).
The dependent measure of interest in the study was adherence to the
SOC. Because adherence is potentially influenced by both patient and physician
variables, multilevel logistic regression was used to analyze adherence as
a dichotomous variable at the patient level while accounting for the clustering
of patients within resident physicians. This was accomplished using generalized
estimating equations.22 For visit-specific
adherence, multilevel logistic regression analyses that accounted for the
clustering of visits within patients were used to test the statistical significance
of the differences between the groups.
The mean age of the resident physicians at the start of the study was
28.4 years (SD = 3.12 years). There were more male residents (70.9%) than
female residents (29.1%), and 17.5% of the residents graduated from foreign
medical schools. As part of the knowledge and attitudes survey that was given
prior to the study, residents used a 5-point scale (5 = highest) to rate for
each SOC their level of agreement with the standard, the level of research
evidence supporting the standard, and the feasibility of implementing the
standard at their hospital. The overall mean ratings for the standards were
4.3, 4.0, and 3.6 for agreement, research support, and feasibility, respectively.
The mean age of the patients was 65.9 years (SD = 10.9 years), and 98.4%
were male. There were no statistically significant differences in physician
or patient characteristics at baseline between the reminder and control groups.
There were also no significant differences in baseline general adherence between
the control group and the reminder group for all SOC combined (55.3% vs 53.0%)
and for 11 of the 13 SOC examined individually (Table 2). There was wide variation in the baseline adherence rates
for the different standards, ranging from 4.4% for pneumococcal vaccination
to 79.1% for atrial fibrillation-warfarin, aspirin, or ticlopidine.
Table 3 presents adherence
rates for the reminder and control groups during the intervention period.
The general adherence method was used. These rates represent the proportion
of patients seen by a study physician during the intervention period who were
in compliance with the SOC by their last visit. The results show that the
reminder group had a statistically significantly higher adherence rate (58.8%)
compared with the control group (53.5%) for all SOC combined (odds ratio [OR],
1.24; 95% CI, 1.08-1.42). Significantly higher adherence rates were also found
for 5 of the 13 SOC analyzed individually, and another 6 SOC showed nonsignificant
differences favoring the reminder group. The largest effect was for pneumococcal
vaccination (12.7% vs 4.3%; OR, 3.26; 95% CI, 2.09-5.09).
The change in adherence rates for all SOC combined from the baseline
to the intervention period favored the reminder group at 11 of the 12 participating
sites. The reminder group showed statistically significantly greater improvement
in adherence compared with controls (P≤.05) at
4 of the 12 sites.
Table 4 shows a comparison
of residents' visit-specific adherence in the control and reminder groups
for all SOC combined and for each SOC individually. As was previously shown
for general adherence, the reminder group had a significantly higher rate
of visit-specific adherence (17.9%) than the control group (12.2%) for all
SOC combined (OR, 1.57; 95% CI, 1.45-1.71) and for 9 of the SOC examined individually.
Large effects were found for pneumococcal vaccine (OR, 7.85; 95% CI, 3.83-16.08),
diabetes/peripheral vascular disease-foot examination (OR, 2.57; 95% CI, 2.02-3.26),
and for diabetes-eye examination (OR, 2.19; 95% CI, 1.63-2.94). The 9 SOC
that showed significant benefits of reminders were all activated in the early
phase of the study.
Figure 1 plots the rates of
visit-specific adherence across the course of the study for the 9 SOC that
were initiated early in the study. The results show that residents' responsiveness
to the reminders decreased throughout the study. This treatment by time interaction
was statistically significant (P < .001). Simple
effect analyses showed that adherence rates significantly declined across
time (P<.001) for the reminder group, but the
adherence rates for the control group were unaffected by time (P = .16).
The purpose of this VA cooperative study was to test the hypothesis
that CRs of well-accepted SOC can effect an increase in residents' compliance
with multiple standards of ambulatory care across multiple medical centers.
In addition to involving multiple centers and concurrently using 13 SOC, this
clinical trial was unique in involving both preventive measures as well as
treatment for specific diagnoses, having a large sample size, measuring adherence
using both general and visit-specific analyses, and in using a lengthy intervention
period that allowed the tracking of adherence rates over time.
The trial furthered previous research by demonstrating higher adherence
with the reminder system across 12 medical centers for the combined 13 SOC.
The general adherence rates increased from an already fairly high 53.0% at
baseline to 58.8% during the intervention period for the reminder group (a
10.9% relative increase or a 5.8 percentage point absolute increase), while
the control group showed a slight decrease from 55.3% adherence at baseline
to 53.5% adherence in follow-up (a 3.3% relative decrease or a 1.8 percentage
point absolute decrease). However, the increase in the general adherence rate
in the CR group was not as large as that reported by some other studies.23
Visit-specific adherence rates in both the reminder and control groups
were low. Residents' failure to deliver the suggested care more regularly
may be related to busy clinic schedules combined with a belief that the standards
may not have an immediate impact on patients' health. The standards with the
lowest adherence rates tended to be prevention rather than treatment oriented,
such as smoking cessation, counseling, and pnuemococcal vaccination. Still,
the fairly high number of patients in compliance with the standards by the
time of the patient's last visit, as indicated by the general adherence measure,
shows that patients' compliance with the standards is determined by more than
residents' actions at any single ambulatory care visit. Patients often attend
the ambulatory clinics multiple times in a year, giving physicians several
opportunities to provide the recommended care, and in many instances, patients
may receive the suggested care as an inpatient or as part of larger hospitalwide
patient education efforts.
This study demonstrated that improvements in adherence could be realized
for multiple standards concurrently across multiple sites. However, enthusiasm
for the reminder system was tempered by the finding that physicians became
less likely to respond to reminders across the time course of the study. Previous
studies have shown sizable decrements in SOC compliance during wash-out periods
that followed reminder deactivation. We showed a similar decrement, in spite
of maintaining the reminders.
We observed that the initial positive response to CRs systematically
declined across the course of the study even though the reminders remained
active. There are several potential reasons for this finding. One possibility
is that external changes in the practice of medicine lead to the residents
discounting the reminders. However, no similar decrement in performance was
observed for the control group, which would be expected if residents began
questioning the standards. Another more likely explanation is that in a busy
clinic the competing demands on residents' time lead to inattention to the
A lack of feedback concerning residents' performance may have contributed
to the observed decline. Perhaps providing performance feedback24-26
and/or educational reinforcement to residents would help sustain the positive
effects of reminders. Nonetheless, our data indicated that computer reminders
installed at multiple sites can improve compliance with multiple SOCs.
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