Sue Troyan

Individualized electronic decision support and reminders to improve diabetes care in the community: COMPETE II randomized trial

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 randomized trial, we randomly 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 [standard 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. (ClinicalTrials.gov trial register no. NCT00813085.)

The effectiveness of integrated health information technologies across the phases of medication management: a systematic review of randomized controlled trials.

OBJECTIVE The US Agency for Healthcare Research and Quality funded an evidence report to address seven questions on multiple aspects of the effectiveness of medication management information technology (MMIT) and its components (prescribing, order communication, dispensing, administering, and monitoring). MATERIALS AND METHODS Medline and 11 other databases without language or date limitations to mid-2010. Randomized controlled trials (RCTs) assessing integrated MMIT were selected by two independent reviewers. Reviewers assessed study quality and extracted data. Senior staff checked accuracy. RESULTS Most of the 87 RCTs focused on clinical decision support and computerized provider order entry systems, were performed in hospitals and clinics, included primarily physicians and sometimes nurses but not other health professionals, and studied process changes related to prescribing and monitoring medication. Processes of care improved for prescribing and monitoring mostly in hospital settings, but the few studies measuring clinical outcomes showed small or no improvements. Studies were performed most frequently in the USA (n=63), Europe (n=16), and Canada (n=6). DISCUSSION Many studies had limited description of systems, installations, institutions, and targets of the intervention. Problems with methods and analyses were also found. Few studies addressed order communication, dispensing, or administering, non-physician prescribers or pharmacists and their MMIT tools, or patients and caregivers. Other study methods are also needed to completely understand the effects of MMIT. CONCLUSIONS Almost half of MMIT interventions improved the process of care, but few studies measured clinical outcomes. This large body of literature, although instructive, is not uniformly distributed across settings, people, medication phases, or outcomes.

Shared electronic vascular risk decision support in primary care: Computerization of Medical Practices for the Enhancement of Therapeutic Effectiveness (COMPETE III) randomized trial.

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 randomized controlled trial among EMR-using primary care practices in Ontario, Canada. Patients 55 years or older with previous vascular events, diabetes mellitus, hypertension, or hypercholesterolemia were randomized to the Computerization of Medical Practices 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 resource. 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 randomized and included in the analysis 1102 patients in 49 community-based physician practices (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 reviews and important improvements in the complex processes required to reduce vascular risk, clinical outcomes remain unchanged.

Cost-effectiveness of a shared computerized decision support system for diabetes linked to electronic medical records

BACKGROUND Computerized decision support systems (CDSSs) are believed to enhance patient care and reduce healthcare costs; however the current evidence is limited and the cost-effectiveness remains unknown. OBJECTIVE To estimate the long-term cost-effectiveness of a CDSS linked to evidence-based treatment recommendations for type 2 diabetes. METHODS Using the Ontario Diabetes Economic Model, changes in factors (eg, HbA1c) from a randomized controlled trial were used to estimate cost-effectiveness. The cost of implementation, development, and maintenance of the core dataset, and projected diabetes-related complications were included. The base case assumed a 1-year treatment effect, 5% discount rate, and 40-year time horizon. Univariate, one-way sensitivity analyses were carried out by altering different parameter values. The perspective was the Ontario Ministry of Health and costs were in 2010 Canadian dollars. RESULTS The cost of implementing the intervention was

Automated telephone reminder messages can assist electronic diabetes care

483,699. The one-year intervention reduced HbA1c by 0.2 and systolic blood pressure by 3.95 mm Hg, but increased body mass index by 0.02 kg/m², resulting in a relative risk reduction of 14% in the occurrence of amputation. The model estimated that the intervention resulted in an additional 0.0117 quality-adjusted life year; the incremental cost-effectiveness ratio was

What do Canadians think about physician-pharmaceutical industry interactions?

160,845 per quality-adjusted life-year. CONCLUSION The web-based prototype decision support system slightly improved short-term risk factors. The model predicted moderate improvements in long-term health outcomes. This disease management program will need to develop considerable efficiencies in terms of costs and processes or improved effectiveness to be considered a cost-effective intervention for treating patients with type 2 diabetes.

Development and validation of a decision aid for choosing among antithrombotic agents for atrial fibrillation

Summary Telephone reminder systems have been used to assist in the treatment of many chronic diseases. However, it is unclear if these systems can increase medication and appointment adherence in patients with diabetes without direct patient–provider telephone contact. We tested the feasibility of using an automated telephone reminder system (ATRS) to deliver reminder messages to 253 adults with diabetes enrolled in a randomized controlled trial. Eighty-four percent of the patients were able to register using voice recognition and at least one reminder was delivered to 95% of registered patients over a period of 7.5 months. None of the demographic features studied predicted a patients ability to enrol or to receive reminder calls. At the end of the study, 63% of patients indicated that they wished to continue to receive ATRS calls. The level of system use as determined by the number of received reminder calls was not associated with a change in the number of physician visits or diabetes-related laboratory tests during follow-up. The clinical benefits and sustainability of ATRS remain unproven, but our results indicate that an automated reminder system can be effective for providing messages to a large group of older patients with diabetes.

Physician and patient willingness to pay for electronic cardiovascular disease management

BACKGROUND Many health professional and regulatory groups have guidelines for identifying, disclosing and managing potential conflicts of interest (COI). The opinions of the Canadian public regarding what constitutes COI are unknown. METHODS Bilingual telephone survey in all provinces using a validated questionnaire on public opinions on physician-pharmaceutical industry interactions (POPPII). Adults 18 years or older were contacted using random digit dialing (RDD) with representative national sampling of households. Results were analyzed for predictors of opinions and were compared with the reference COI guideline. Two follow-up focus groups were held. RESULTS 1041 participants (56.8% female, mean age 52.6 years (SD 16.5), 18.2% francophone, 57.7% with post-secondary education) completed the survey. 34.0% reported a prior concern about physician-pharmaceutical industry relationships. Acceptability of interactions varied from high for requesting information about a particular drug or small gifts of obvious educational value to the patient, to mixed for free meals to listen to pharmaceutical industry personnel or payment to attend a conference, to low for research recruitment fees, personal use of medication samples or for using information not yet public about a new drug to make investment decisions. Age of the participant influenced ratings of acceptability. There was reasonable agreement (>60% participants) with only half of the related reference COI guideline statements. CONCLUSIONS Public opinions on physician-pharmaceutical industry interactions differ depending on the scenario but suggest a significant level of concern regarding interactions involving direct financial benefit to physicians.

Process mapping evaluation of medication reconciliation in academic teaching hospitals: a critical step in quality improvement

BACKGROUND Multiple antithrombotic agents are available for stroke prevention in atrial fibrillation (AF). A decision aid can assist patients in making informed decisions that best serves their needs. OBJECTIVE To validate a decision aid to assist patients in choosing between antithrombotic agents (antiplatelets, warfarin, direct-acting oral anticoagulants (DOACs)) for AF. METHODS Patients (60years or older) were recruited for this prospective study. The decision aid presented descriptions related to AF, then charts portraying important outcomes for comparisons between 1) no treatment, aspirin and anticoagulants, 2) warfarin versus DOACs, and 3) DOAC versus DOAC. The primary outcome was confidence in making treatment decisions. The secondary outcomes included change in knowledge scores, ratings of clarity, helpfulness and comprehensiveness. RESULTS Eighty-one patients (mean age 75.2 [SD 7.5], 77% taking an anticoagulant) participated. After using the decision aid, mean decisional conflict score was low at 7.2 [SD 10.8] on a scale from 1 to 100. Mean knowledge score (total possible 10) improved from 7.4 [SD 1.7] to 9.3 [SD 1.0] (p<0.001). The mean helpfulness score in making a treatment choice was high at 6.2 [SD 0.9] on a scale from 1 to 7. No participant found the decision aid difficult to understand. Information in the decision aid was rated as good or excellent in terms of clarity and comprehensiveness. CONCLUSIONS Our decision aid addresses a key medication safety gap - assisting patients to participate in shared decisions about anticoagulation. Future research is required to evaluate how decision aids influence actual choices and clinical outcomes.

Comparative effectiveness and safety of oral anticoagulants for atrial fibrillation in real-world practice: a population-based cohort study protocol

OBJECTIVES Cardiovascular disease (CVD) is an important target for electronic decision support. We examined the potential sustainability of an electronic CVD management program using a discrete choice experiment (DCE). Our objective was to estimate physician and patient willingness-to-pay (WTP) for the current and enhanced programs. METHODS Focus groups, expert input and literature searches decided the attributes to be evaluated for the physician and patient DCEs, which were carried out using a Web-based program. Hierarchical Bayes analysis estimated preference coefficients for each respondent and latent class analysis segmented each sample. Simulations were used to estimate WTP for each of the attributes individually and for an enhanced vascular management system. RESULTS 144 participants (70 physicians, 74 patients) completed the DCE. Overall, access speed to updated records and monthly payments for a nurse coordinator were the main determinants of physician choices. Two distinctly different segments of physicians were identified - one very sensitive to monthly subscription fee and speed of updating the tracker with new patient data and the other very sensitive to the monthly cost of the nurse coordinator and government billing incentives. Patient choices were most significantly influenced by the yearly subscription cost. The estimated physician WTP was slightly above the estimated threshold for sustainability while the patient WTP was below. CONCLUSION Current willingness to pay for electronic cardiovascular disease management should encourage innovation to provide economies of scale in program development, delivery and maintenance to meet sustainability thresholds.