View Count: 144 |  Publish Date: December 04, 2012
E-Reminders to Providers Boost HIV Care (CME/CE)
E-Reminders to Providers Boost HIV CareByMichael Smith, North American Correspondent, MedPage TodayPublished: December 04, 2012ReviewedbyRobert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San FranciscoAction PointsInteractive computer alerts for healthcare providers improved HIV patient outcomes.Note that the study used a large, outpatient clinic system in which computer alerts were generated for virologic failure, evidence of suboptimal follow-up, and 11 abnormal laboratory results, with alerts generated after an automated check of hospital databases.
Interactive computer alerts for healthcare providers improved HIV patient outcomes, researchers reported.
In a single-institution randomized trial, the interactive alerts led to better immune reconstitution than static alerts, according to Gregory Robbins, MD, and colleagues at Massachusetts General Hospital in Boston. The average monthly CD4 cell count increase was 5.3 cells per cubic millimeter of blood among patients in the intervention group, compared with 3.2 for patients in the control group, a significant difference (P<0.040).
The alerts also decreased the rate of suboptimal clinical follow-up, Robbins and colleagues reported online in Annals of Internal Medicine.
Despite increasing interest in so-called clinical decision-support systems, there is scant evidence that they improve outcomes for HIV patients, or indeed for other chronic disease patients, the researchers noted.
To help fill the gap, they developed a system, used in a large outpatient clinic, in which computer alerts were generated for virologic failure, evidence of suboptimal follow-up, and 11 abnormal laboratory results. Alerts were generated after an automated nightly check of hospital databases.
For half of their patients -- assigned randomly -- healthcare providers saw the alerts only on the patients electronic medical records page and without additional information.
For the remaining patients, the alerts also appeared on the providers home page, were included in biweekly emails, and included hyperlinks to previous laboratory results, appointment histories, and previous alerts.
The 33 participating providers, caring for a total of 1,011 patients, were not aware of patient status.
The primary endpoint of the study was change in the count of CD4-positive T cells over the year-long study, while secondary endpoints included time to clinical events, 6-month suboptimal follow-up, and severe laboratory toxicity.
Suboptimal follow-up alerts were based on three rules: a missed appointment without a kept appointment within a week; no kept appointment in the previous 4 months, and no scheduled appointment in the next 2 months; and high-risk patients, defined as those with a missed appointment in the previous year, no kept appointment in the previous month, and no scheduled appointment in the next 2 months.
Robbins and colleagues found that the rate of 6-month suboptimal follow-up was significantly lower for those in the intervention group (20.6 events per 100 patient-years) than in the control group (30.1 events per 100 patient-years, P<0.022).
After a suboptimal follow-up alert, the median time to next scheduled appointment in the intervention group was 1.71 months, compared with 3.48 months for control patients (P<0.001).
There were no differences in the rate of virologic failure.
At the end of the study, the authors reported that more than 90% of participating providers supported adopting the system as part of standard care.
They cautioned that the study took place in a single institution that has a strong informatics environment.
They also noted the provider-based randomization might have introduced bias, because participants, despite not knowing which patients were in which group, might have been more closely monitoring all alerts.
The study had support from the National Institute of Allergy and Infectious Diseases. Robbins did not report any conflicts of interest.
Primary source: Annals of Internal Medicine Source reference: Robbins GK, et al Efficacy of a clinical decision-support system in an HIV practice: A randomized trial Ann Intern Med 2012; 157(11): 757-766).
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