Wijk, M.A.M. van

The impact of electronic memory in the treatment of dyslipidemia (Article)

2009-09-01T00:00:00Z

Electronic alerts versus on-demand decision support to improve dyslipidemia treatment: A cluster randomized controlled trial (Article)

2008-01-01T00:00:00Z

BACKGROUND - Indirect evidence shows that alerting users with clinical decision support systems seems to change behavior more than requiring users to actively initiate the system. However, randomized trials comparing these methods in a clinical setting are lacking. We studied the effect of both alerting and on-demand decision support with respect to screening and treatment of dyslipidemia based on the guidelines of the Dutch College of General Practitioners. METHODS AND RESULTS - In a clustered randomized trial design, 38 Dutch general practices (77 physicians) and 87 886 of their patients (39 433 men 18 to 70 years of age and 48 453 women 18 to 75 years of age) who used the ELIAS electronic health record participated. Each practice was assigned to receive alerts, on-demand support, or no intervention. We measured the percentage of patients screened and treated after 12 months of follow-up. In the alerting group, 65% of the patients requiring screening were screened (relative risk versus control=1.76; 95% confidence interval, 1.41 to 2.20) compared with 35% of patients in the on-demand group (relative risk versus control=1.28; 95% confidence interval, 0.98 to 1.68) and 25% of patients in the control group. In the alerting group, 66% of patients requiring treatment were treated (relative risk versus control=1.40; 95% confidence interval, 1.15 to 1.70) compared with 40% of patients (relative risk versus control=1.19; 95% confidence interval, 0.94 to 1.50) in the on-demand group and 36% of patients in the control group. CONCLUSION - The alerting version of the clinical decision support systems significantly improved screening and treatment performance for dyslipidemia by general practitioners.

Cost consequences of implementing an electronic decision support system for ordering laboratory tests in primary care: Evidence from a controlled prospective study in the Netherlands (Article)

2007-02-01T00:00:00Z

Background: The economic consequences of interventions to promote rational, evidence-based use of laboratory tests by physicians are not yet fully understood. We evaluated the cost consequences of a computer-based, guideline-driven decision-support system (CDSS) for ordering blood tests in primary care. Methods: We installed the CDSS in 118 practices [159 general practitioners (GPs)] throughout The Netherlands and calculated the costs of the intervention in this group. During a period of 6 months before and 6 months after installation of the CDSS, the test-ordering behavior of 87 (109 GPs) of these 118 study practices was studied and the results were compared with those of a nonhistorical control group that did not receive the CDSS. In addition the costs of laboratory requests were calculated for both groups. Results: Total intervention costs, comprising development costs and installation costs, amounted to €79 000 (€670 per practice). Whereas the introduction of the CDSS did not affect the number of order forms submitted to the laboratories, it did reduce the number of blood tests per order form. As a result, the CDSS yielded mean savings on the costs of laboratory requests of €847 per practice per 6 months. Conclusions: This study demonstrates that providing electronic decision support for ordering blood tests in primary care represents an economically promising concept. Savings on laboratory costs are achievable and not offset by disproportionally high intervention costs.

Identification of the four conventional cardiovascular disease risk factors by Dutch general practitioners. (Article)

2005-10-01T00:00:00Z

BACKGROUND: Detecting and managing the four major conventional risk factors, smoking, hypertension, diabetes mellitus, and hypercholesterolemia, is pivotal in the primary and secondary prevention of cardiovascular disease (CVD). OBJECTIVE: To assess the preventive activities of general practitioners (GPs) regarding the four conventional risk factors and the associated measurements for cardiovascular risk factors by GPs in relation to the time of the first clinical presence of CVD. SETTING: Large longitudinal general practice research database (the Integrated Primary Care Information database) in the Netherlands from September 1999 to August 2003. PARTICIPANTS AND METHODS: Patients > 18 year of age with newly diagnosed CVD with a valid history of at least 1 year before and after the first clinical diagnosis of CVD. Details on conventional risk factors and associated measurements for the four cardiovascular risk factors were assessed in relation to the first clinical diagnosis of CVD. RESULTS: In total, 157,716 patients met the study inclusion criteria. Of the 2,594 patients with newly diagnosed CVD, at least one of the four investigated risk factors was observed in 76% of women and 73% of men. In 40% of cases, no risk factor was recorded before the date of the first CVD diagnosis. In 16% of cases, no associated measurements were present before the first CVD diagnosis. CONCLUSION: In daily practice, GPs seem to focus on the secondary prevention of CVD. Intervention strategies that aim to influence GPs' case finding behavior should focus on increasing the awareness of physicians in performing risk factor-associated measurements in patients who are eligible for the primary prevention of CVD. Further research will have to show the feasibility and effectiveness of such intervention strategies.

AsthmaCritic: issues in designing a noninquisitive critiquing system for daily practice. (Article)

2003-09-01T00:00:00Z

The noninquisitive critiquing system, AsthmaCritic, uses routinely recorded electronic patient data to select and analyze records of patients with asthma or chronic obstructive pulmonary disease (COPD). The system generates critiquing comments and adds these comments to the patient record. The system was developed by using and expanding an existing generic critiquing system. After a brief overview of the system, this report focuses on the authors' design choices in light of existing literature and the issues that underlie these design choices. Currently, AsthmaCritic is used by primary care physicians and is undergoing clinical evaluation.

Cholgate - a randomized controlled trial comparing the effect of automated and on-demand decision support on the management of cardiovascular disease factors in primary care (Article)

2003-01-01T00:00:00Z

Automated and on-demand decision support systems integrated into an electronic medical record have proven to be an effective implementation strategy for guidelines. Cholgate is a randomized controlled trial comparing the effect of automated and on-demand decision support on the management of cardiovascular disease factors in primary care.

Compliance of general practitioners with a guideline-based decision support system for ordering blood tests (Article)

2002-01-01T00:00:00Z

BACKGROUND: Guidelines are viewed as a mechanism for disseminating a rapidly increasing body of knowledge. We determined the compliance of Dutch general practitioners with the recommendations for blood test ordering as defined in the guidelines of the Dutch College of General Practitioners. METHODS: We performed an audit of guideline compliance over a 12-month period (March 1996 through February 1997). In an observational study, a guideline-based decision support system for blood test ordering, BloodLink, was integrated with the electronic patient records of 31 general practitioners practicing in 23 practices (16 solo). BloodLink followed the guidelines of the Dutch College of General Practitioners. We determined compliance by comparing the recommendations for test ordering with the test(s) actually ordered. Compliance was expressed as the percentage of order forms that followed the recommendations for test ordering. RESULTS: Of 12 668 orders generated, 9091 (71%) used the decision-support software rather than the paper order forms. Twelve indications accounted for >80% of the 7346 order forms that selected a testing indication in BloodLink. The most frequently used indication for test ordering was "vague complaints" (2209 order forms; 30.1%). Of the 7346 order forms, 39% were compliant. The most frequent type of noncompliance was the addition of tests. Six of the 12 tests most frequently added to the order forms were supported by revisions of guidelines that occurred within 3 years after the intervention period. CONCLUSIONS: In general practice, noncompliance with guidelines is predominantly caused by adding tests. We conclude that noncompliance with a guideline seems to be partly caused by practitioners applying new medical insight before it is incorporated in a revision of that guideline.

Feasibility of AsthmaCritic, a decision-support system for asthma and COPD which generates patient-specific feedback on routinely recorded data in general practice (Article)

2002-01-01T00:00:00Z

BACKGROUND: Introducing decision-support systems as a tool to stimulate the dissemination of clinical guidelines in daily practice has been disappointing. Researchers have argued that integration of such systems with clinical practice is a prerequisite for acceptance. The big question concerns the feasibility of a true integration--if only routinely recorded data are used for such a system, can patient-specific feedback be produced? OBJECTIVE: The aim of this study was to assess the feasibility of generating patient-specific feedback based on routinely recorded data in general practice by AsthmaCritic, a decision-support system for asthma and chronic obstructive pulmonary disease (COPD). METHODS: We built the decision-support system AsthmaCritic and assessed its ability to detect asthma and COPD patient records and generate patient-specific feedback by retrospective analysis of routinely recorded data in 103 713 electronic patient records from primary care practices. We grouped feedback into categories of comments by age group (<12 years and > or =12 years). The main outcome measures were the number and percentage of "triggered" (selected) asthma and COPD patient records, and the number and percentage of records on which AsthmaCritic produced at least one feedback comment during the 1-year study period, by category of comments. RESULTS: AsthmaCritic detected 8784 (8.5%) asthma and COPD patient records. During the study period, AsthmaCritic generated 255 664 feedback comments (mean 3.4 per patient visit). The most frequently generated category of comments in the case of patients aged > or =12 years was "non-compliant prescription" (23.7%), whereas the most frequent category in the case of patients <12 years was "non-compliant route" (31.1%). CONCLUSIONS: This study shows that, using routinely recorded data only, AsthmaCritic is able to detect asthma and COPD patient records for further analysis and to produce patient-specific feedback.

BloodLink: Computer-based Decision Support for Blood Test Ordering; Assessment of the effect on physicians' test-ordering behavior (Doctoral Thesis)

2000-10-25T00:00:00Z

Requesting blood tests is an important aspect of the health care delivered by the general practitioner in The Netherlands. About three to four percent of the patients encounters with Dutch general practitioners result in the physician requesting blood tests, which is lower than in many other European countries. Although test ordering is limited to three to four percent of patients encounters with the general practitioner, the use of diagnostic tests in general practice, has known an overwhelming growth in the years behind. Physicians' use of blood tests, however, is not always appropriate. General practitioners are taught test ordering when training in hospitals before settling down in general practice. Hospital morbidity, however, is different from morbidity patterns in general practice. Appropriate test ordering panels in hospital settings, therefore, are not always appropriate for primary care. Nevertheless, general practitioners use these test panels, once taught, automatically in the primary care setting. Uncertainty and the desire not to miss a diagnosis stimulate the use of blood tests. Excessive and inappropriate test ordering is not only expensive but also may even add to the uncertainty by generating unexpected abnormal or false positive values. The use of blood tests may thus even increase uncertainty and stimu late further unnecessary diagnostic investigations. It is important, therefore, that once the decision to obtain blood tests has been made, appropriate test ordering is adhered to. Influencing this heuristic test-ordering behavior has proven to be difficult.

Analysis of the practice guidelines of the Dutch College of General Practitioners with respect to the use of blood tests (Article)

1999-01-01T00:00:00Z

OBJECTIVE: To determine the consistency among the practice guidelines of the Dutch College of General Practitioners with respect to the use of blood tests. METHODS: The authors evaluated 64 practice guidelines of the Dutch College of General Practitioners. For each guideline, they analyzed each sentence that contained a reference to a blood test to determine the clinical situation in which the test should be performed (the indication) and to determine the tests that should be performed in that situation (the recommended test). An incomplete recommendation refers to a guideline that mentioned a blood test but did not identify the indication for that test. An inconsistency refers to the situation in which one guideline recommended a certain test for a given indication whereas another guideline mentioned the same indication but did not recommend the same test. RESULTS: Twenty-seven practice guidelines mentioned blood tests. Of these, three explicitly recommended not to request blood tests. Five guidelines contained incomplete recommendations, and the authors encountered two inconsistencies among the guidelines. Twenty-three guidelines mentioned blood tests and allowed the authors to identify indications and recommended tests. CONCLUSION: The identification of indications and recommended tests allows evaluation of consistency among practice guidelines. Although some incomplete recommendations and inconsistencies were discovered, the majority of the guidelines provide clear and unambiguous recommendations for blood-test ordering in primary care.