Susan Wells

Integrated electronic decision support increases cardiovascular disease risk assessment four fold in routine primary care practice

Background A decade of cardiovascular disease (CVD) risk-based guidelines, education programmes and widespread availability of paper-based risk prediction charts have not significantly influenced targeting of CVD risk management in New Zealand primary care practice. A web-based decision support system (PREDICT-CVD), integrated with primary care electronic medical record software was developed as one strategy to address this problem. Methods A before-after audit of 3564 electronic patient records assessed the impact of electronic decision support on documentation of CVD risk and CVD risk factors. Participants were patients meeting national guideline criteria for CVD risk assessment, registered with 84/107 (78.5%) general practitioners (GPs) in one large primary care organization who used electronic patient medical records, and had PREDICT-CVD installed. The GPs received group education sessions, practice IT support and a small risk assessment payment. Four weeks of practice visit records were audited from 1 month after installation of PREDICT-CVD, and during the same 4-week period 12 months earlier. Results Less than 3% of eligible patients had a documented CVD risk before PREDICT-CVD installation. This increased four-fold (RR = 4.0; 95% confidence interval 2.4–6.5) after installation and documentation of all relevant CVD risk factors also increased significantly. Conclusion Documentation of CVD risk in primary care patient records in New Zealand is negligible, despite being recommended as a prerequisite for targeted treatment for over 10 years, suggesting that previous strategies were ineffective. We demonstrate that integrated electronic decision support can quadruple CVD risk assessment in just one cycle of patient visits.

The GATE frame: critical appraisal with pictures

Epidemiological evidence about the accuracy of diagnostic tests, the power of prognostic markers, and the efficacy and safety of interventions is the cornerstone of evidence-based health care.1 Practitioners of evidence-based health care require critical appraisal skills to judge the validity of this evidence. The Evidence-Based Medicine (EBM) Working Group members are international leaders in teaching critical appraisal skills, and their users’ guides for appraising the validity of the healthcare literature2 have long been the basis of teaching programmes worldwide. However, we found that many of our students took a reductionist “paint by numbers” approach when using the Working Group’s guides. Students could answer individual appraisal questions correctly but would have difficulty assessing overall study quality. We believe this is due to a poor understanding of epidemiological study design. So over the past 15 years of teaching critical appraisal we have modified the EBM Working Group approach and developed the Graphic Appraisal Tool for Epidemiological studies (GATE) frame to help our students conceptualise the whole study as well as its component parts. GATE is a visual framework that illustrates the generic design of all epidemiological studies (figure 1). We now teach critical appraisal by “hanging” studies and the EBM Working Group’s appraisal questions on the GATE frame. Figure 1  The GATE frame. This editorial outlines the GATE approach to critical appraisal, illustrated throughout using the Heart and Estrogen/progestin Replacement Study (HERS), a randomised, double blind, placebo controlled trial of the effect of daily oestrogen plus progestin on coronary heart disease (CHD) death in postmenopausal women.3 A detailed critical appraisal of HERS using a GATE-based checklist is available online.4 The GATE frame incorporates a triangle, circle, square, and arrow (figure 1), labelled with the acronym PECOT (or PICOT). The triangle (figure 2) represents the population studied: “P” for population or …

Patients Prefer Pictures to Numbers to Express Cardiovascular Benefit From Treatment

PURPOSE This study aimed to determine which methods of expressing a preventive medication’s benefit encourage patients with known cardiovascular disease to decide to take the medication and which methods patients prefer. METHODS We identified patients in Auckland, New Zealand, family practices located in areas of differing socioeconomic status who had preexisting heart disease (myocardial infarction, angina, or both) and were taking statins. The patients were interviewed about their preference for methods of expressing the benefit of a hypothetical medication. Benefits were expressed numerically (relative risk, absolute risk, number needed to treat, odds ratio, natural frequency) and graphically. Statistical testing was adjusted for practice. RESULTS We interviewed 100 eligible patients, representing a 53% response rate. No matter how the risk was expressed, the majority of patients indicated they would be encouraged to take the medication. Two-thirds (68) of the patients preferred 1 method of expressing benefit over others. Of this group, 57% preferred the information presented graphically. This value was significantly greater (P <.001) than the 19% who chose the next most preferred option, relative risk. Few patients preferred absolute risk (13%) or natural frequencies (9%). Only a single patient (1%) preferred the odds ratio. None preferred number needed to treat. Ninety percent of patients responding to a question about framing preferred positive framing (description of the benefit of treatment) over negative framing (description of the harm of not being treated). CONCLUSIONS Although number needed to treat is a useful tool for communicating risk and benefit to clinicians, this format was the least likely to encourage patients to take medication. As graphical representation of benefit was the method patients preferred most, consideration should be given to developing visual aids to support shared clinical decision making.

Should the first priority in cardiovascular risk management be those with prior cardiovascular disease

Background: Cardiovascular disease (CVD) prevention guidelines typically dichotomise patients by history of CVD, as patients with prior CVD are assumed to be at high CVD risk, whatever their CVD risk profiles. Objective: To assess the appropriateness of this practice by comparing CVD event rates of patients with and without prior CVD, over and above risk predicted by standard CVD risk factors. Methods: Between 2002 and 2007 CVD risk assessments were generated using a web-based Framingham risk prediction algorithm in routine primary care. Individual risk profiles were subsequently linked to national hospitalisation and death records. Observed and predicted (Framingham) CVD risk were compared in patients with and without prior CVD. Results: 35 760 patients were assessed including 10.4% with prior CVD. Of 1216 first CVD events during an average follow-up of 2.05 years, 42% occurred in those with prior CVD. Among those without prior CVD, the predicted Framingham five-year CVD risk was similar to the observed risk extrapolated to five years; in the highest Framingham risk band (>20% five-year risk), observed risk was 25.3%. Among those with prior CVD the observed risk extrapolated to five years rose from 21.7% in the lowest Framingham risk band (<5%) to 49% in the highest (>20%). Conclusions: Patients with prior CVD have five-year CVD risks approximately 20% higher, in absolute terms than patients without prior CVD, after accounting for standard risk factors. Almost half the CVD events occurred in those with prior CVD. These patients should be the highest priority for intensive preventive management in primary care.

Personal Health Records and Health Care Utilization

ELECTRONIC PERSONAL HEALTH RECORDS (PHRS) ARE a new twist on an old concept. Traditionally, patients often collected their physicians’ contact details, health-related reports, well-baby books, and specialist letters at home in a file cabinet or shoebox. With the wide availability of personal computers, these collections could go digital, providing patients with a summary of their health records and including the care they received. The intended goal was that patients might more actively manage their health care needs. There are 2 main electronic architectures: one linked directly to the physician’s practice-based electronic health record, the other free-standing in cyberspace, without a linkage. The first architecture appears to be dominating the scene and offers many advantages because it can include specific information from the medical record that is difficult and timeconsuming for patients to access otherwise. Functions typically include a problem list, medication list, list of allergies, test results, and links to personalized health information. Additional services such as patient reminders for preventive health checks and the ability for patients to securely e-mail their physicians, make an appointment, ask for a new prescription, and sort out billing claims and payments are often included. Such “tethered” PHRs are called patient portals. Patient portals are increasingly popular, with estimates that more than 70 million individuals in the United States already have access to them, although it is unclear how many are actually using them. Some research suggests that patient portals improve patient satisfaction, enhance personal empowerment, and increase patient-physician communication. Patient portals also have potential to improve patient outcomes through enhanced safety—through medication checks; improved screening for and monitoring of chronic disease; and reduced costs, for example, by avoiding test duplication. However, the extent to which care is actually improved is uncertain, and the features necessary to achieve improved health outcomes are unclear. Despite this, many health care systems—especially integrated delivery systems—have already invested in PHRs because of the potential advantages. Patients and health care practitioners involved in longitudinal care—including physicians, nurses, pharmacists, and others—are interested in using PHRs to access and exchange medical information. Physicians in particular have had some reservations about moving forward in this area, partly because of concern that they will be bombarded with questions and that patients will have trouble interpreting their results. However, most of the empirical experiences to date suggest that these problems do not represent major issues when patients are provided and adopt PHRs. Still, with the exception of the integrated systems in the United States, health care organization adoption rates of patient portals are relatively low here and around the world. But this is likely to change. Consumers are becoming more and more comfortable with doing a host of things online, such as banking; checking the weather; and organizing their friends, family, and leisure time, often using mobile “apps.” There has been an element of physician inertia with sharing control of health information via patient portals; it seems almost an anachronism that most patients still cannot easily access their children’s immunization records or view their latest laboratory test results. However, in the United States, the implementation of meaningful use—a set of criteria that physicians have to meet to receive financial incentives for adopting and using electronic health records—has advanced this cause. Patient advocates have successfully argued that adoption of patient portals should be made part of meaningful use, and to qualify in stage 2 of meaningful use, physicians will need to offer patients the ability to view online, download, and transmit their health information and will even be held accountable that at least 5% of their patients have accessed their records electronically. The rationale is to incent physicians to encourage their patients to access their health information electronically. The incentives to physicians are sufficiently large that many more patients are likely to have access to portals soon.

Selection and validation of quality indicators for the Shorter Stays in Emergency Departments National Research Project

Objective: Despite the spread of time targets for ED lengths of stay around the world, there have been few studies exploring the effects of such policies on quality of ED care. The Shorter Stays in Emergency Departments (SSED) National Research Project seeks to address this. The purpose of this paper was to describe how the indicators for the SSED study in New Zealand were selected and validated.

Will screening individuals at high risk of cardiovascular events deliver large benefits? Yes

The Department of Health is planning to identify and treat all adults over 40 at high risk of a cardiovascular event. Rod Jackson and colleagues argue that a well targeted programme will save many lives, but Simon Capewell (doi: 10.1136/bmj.a1395) thinks whole population approaches would be more cost effective

Implementing performance improvement in New Zealand emergency departments: the six hour time target policy national research project protocol

BackgroundIn May 2009, the New Zealand government announced a new policy aimed at improving the quality of Emergency Department care and whole hospital performance. Governments have increasingly looked to time targets as a mechanism for improving hospital performance and from a whole system perspective, using the Emergency Department waiting time as a performance measure has the potential to see improvements in the wider health system. However, the imposition of targets may have significant adverse consequences. There is little empirical work examining how the performance of the wider hospital system is affected by such a target. This project aims to answer the following questions: How has the introduction of the target affected broader hospital performance over time, and what accounts for these changes? Which initiatives and strategies have been successful in moving hospitals towards the target without compromising the quality of other care processes and patient outcomes? Is there a difference in outcomes between different ethnic and age groups? Which initiatives and strategies have the greatest potential to be transferred across organisational contexts?Methods/designThe study design is mixed methods; combining qualitative research into the behaviour and practices of specific case study hospitals with quantitative data on clinical outcomes and process measures of performance over the period 2006-2012. All research activity is guided by a Kaupapa Māori Research methodological approach. A dynamic systems model of acute patient flows was created to frame the study. Consequences of the target (positive and negative) will be explored by integrating analyses and insights gained from the quantitative and qualitative streams of the study.DiscussionAt the time of submission of this protocol, the project has been underway for 12 months. This time was necessary to finalise both the case study sites and the secondary outcomes through key stakeholder consultation. We believe that this is an appropriate juncture to publish the protocol, now that the sites and final outcomes to be measured have been determined.

Cohort Profile: The PREDICT Cardiovascular Disease Cohort in New Zealand Primary Care (PREDICT-CVD 19)

Cohort Profile: The PREDICT Cardiovascular Disease Cohort in New Zealand Primary Care (PREDICT-CVD 19) Sue Wells,* Tania Riddell, Andrew Kerr, Romana Pylypchuk, Carol Chelimo, Roger Marshall, Daniel J. Exeter, Suneela Mehta, Jeff Harrison, Cam Kyle, Corina Grey, Patricia Metcalf, Jim Warren, Tim Kenealy, Paul L. Drury, Matire Harwood, Dale Bramley, Geeta Gala and Rod Jackson School of Population Health, University of Auckland, Auckland, New Zealand, Middlemore Hospital, Cardiology Department, Auckland, New Zealand, School of Pharmacy, University of Auckland, Auckland, New Zealand, Endocrinology Services, Auckland District Health Board, Auckland, New Zealand, Computer Sciences, University of Auckland, School of Medicine, University of Auckland, Auckland, New Zealand, Waitemata District Health Board, Auckland, New Zealand and Northern Regional Alliance, Auckland, New Zealand

Are quality improvement collaboratives effective? A systematic review

Background Quality improvement collaboratives (QIC) have proliferated internationally, but there is little empirical evidence for their effectiveness. Method We searched Medline, Embase, CINAHL, PsycINFO and the Cochrane Library databases from January 1995 to December 2014. Studies were included if they met the criteria for a QIC intervention and the Cochrane Effective Practice and Organisation of Care (EPOC) minimum study design characteristics for inclusion in a review. We assessed study bias using the EPOC checklist and the quality of the reported intervention using a subset of SQUIRE 1.0 standards. Results Of the 220 studies meeting QIC criteria, 64 met EPOC study design standards for inclusion. There were 10 cluster randomised controlled trials, 24 controlled before-after studies and 30 interrupted time series studies. QICs encompassed a broad range of clinical settings, topics and populations ranging from neonates to the elderly. Few reports fully described QIC implementation and methods, intensity of activities, degree of site engagement and important contextual factors. By care setting, an improvement was reported for one or more of the study’s primary effect measures in 83% of the studies (32/39 (82%) hospital based, 17/20 (85%) ambulatory care, 3/4 nursing home and a sole ambulance QIC). Eight studies described persistence of the intervention effect 6 months to 2 years after the end of the collaborative. Collaboratives reporting success generally addressed relatively straightforward aspects of care, had a strong evidence base and noted a clear evidence-practice gap in an accepted clinical pathway or guideline. Conclusions QICs have been adopted widely as an approach to shared learning and improvement in healthcare. Overall, the QICs included in this review reported significant improvements in targeted clinical processes and patient outcomes. These reports are encouraging, but most be interpreted cautiously since fewer than a third met established quality and reporting criteria, and publication bias is likely.