Computed Critiquing Integrated into Daily Clinical Practice Affects Physicians’ Behavior

Summary

Objective: We developed AsthmaCritic, a non-inquisitive critiquing system integrated with the general practitioners’ electronic medical records. The system is based on the guidelines for asthma and chronic obstructive pulmonary disease (COPD) as issued by the Dutch College of General Practitioners. This paper assesses the effect of AsthmaCritic on monitoring and treatment of asthma and COPD by Dutch general practitioners in daily practice.

Methods: A randomized clinical trial in 32 practices (40 Dutch general practitioners) using electronic patient records. An intervention group was given the use of AsthmaCritic, a control group continued working in the usual manner. Both groups had the disposal of the asthma and COPD guidelines routinely distributed by the Dutch College of General Practitioners. We measured the average number of contacts, FEV₁ (forced ex-piratory volume), and peak-flow measurements per asthma/COPD patient per practice; and, the average number of antihistamine, cromoglycate, deptropine, and oral bronchodilator prescriptions per asthma/COPD patient per practice.

Results: The number of contacts increased in the age group of 12-39 years. The number of FEV₁, peak-flow measurements, and the ratio of coded measurements increased, whereas the number of cromoglycate prescriptions decreased in the age group of 12-39 years.

Conclusions: Our study shows that the guideline-based critiquing system AsthmaCritic changed the manner in which the physicians monitored their patients and, to a lesser extent, their treatment behavior. In addition, the physicians changed their data-recording habits.

Keywords

Clinical decision support systems - computerized medical record - medical informatics - practice guidelines - feedback - asthma - COPD

• References

• 1 Taylor DM, Auble TE, Calhoun WJ, Mosesso , Jr VN. Current outpatient management of asthma shows poor compliance with International Consensus Guidelines. Chest 1999; 116 (06) 1638-45.
• 2 Legorreta AP, Liu X, Zaher CA, Jatulis DE. Variation in managing asthma: experience at the medical group level in California. Am J Manag Care 2000; 6 (04) 445-53.
• 3 Rabe KF, Vermeire PA, Soriano JB, Maier WC. Clinical management of asthma in 1999: the Asthma Insights and Reality in Europe (AIRE) study. Eur Respir J 2000; 16 (05) 802-7.
• 4 Geijer RMM, Thiadens HA, Smeele IJM, van der Zwan AAC, Sachs APE, Bottema BJAM. et al NHG-Standaard COPD en astma bij volwassenen: Diagnostiek (Guidelines of the Dutch College of General Practitioners: Chronic Obstructive Respiratory Diseases and Asthma in Adults: Diagnostics). Huisarts en Wetenschap 1997; 40 (09) 415-28.
• 5 Geijer RMM, van Hensbergen W, Bottema BJAM, van Schayck CP, Sachs APE, Smeele IJM. et al NHG-Standaard astma bij volwassenen: Behandeling (Guidelines of the Dutch College of General Practitioners: Asthma in Adults: Therapy). Huisarts en wetenschap 1997; 40 (09) 443-54.
• 6 Geijer RMM, van Schayck CP, van Weel C, Sachs APE, van der Zwan AAC, Bottema BJAM. et al NHG-Standaard COPD: Behandeling (Guide lines of the Dutch College of General Practitioners: Chronic Obstructive Respiratory Diseases: Therapy). Huisarts en wetenschap 1997; 40 (09) 430-42.
• 7 Dirksen WJ, Geijer RMM, De Haan M, De Koning G, Flikweert S, Kolnaar BGM. NHGstandaard astma bij kinderen (Guidelines of the Dutch College of General Practitioners: Asthma in Children). Huisarts en wetenschap 1998; 41 (03) 130-43.
• 8 Smeele I, van Schayck CP, van den Bosch WJ, van den Hoogen HJ, Muris JW, Grol RP. Discrepancy between the guidelines and practice by family physicians in treating adults with an exacerbation of asthma or chronic obstructive pulmonary disease. (Article in Dutch.) Nederlands Tijdschrift voor Geneeskunde. 1998; 142: 2304-8.
• 9 Crim C. Clinical practice guidelines vs actual clinical practice: the asthma paradigm. Chest 2000; 118 (2 Suppl) 62S-64S.
• 10 Vermeire PA, Rabe KF, Soriano JB, Maier WC. Asthma control and differences in management practices across seven European countries. Respir Med 2002; 96 (03) 142-9.
• 11 Stoloff S. Current asthma management: the performance gap and economic consequences. Am J Manag Care 2000; 6 (17 Suppl) S 918-25. discussion S925-9
• 12 Morris AH. Developing and implementing computerized protocols for standardization of clinical decisions. Ann Intern Med 2000; 132 (05) 373-83.
• 13 van der Lei J. Closing the loop between clinical practice, research, and education: the potential of electronic patient records. Methods Inf Med 2002; 41 (01) 51-4.
• 14 Fieschi M, Dufour JC, Staccini P, Gouvernet J, Bouhaddou O. Medical decision support systems: old dilemmas and new paradigms?. Methods Inf Med 2003; 42 (03) 190-8.
• 15 Elson RB, Faughnan JG, Connelly DP. An industrial process view of information delivery to support clinical decision making: implications for systems design and process measures. J Am Med Inform Assoc 1997; 4 (04) 266-78.
• 16 Kuilboer MM, van Wijk MA, Mosseveld M, van der Does E, Ponsioen BP, de Jongste JC. et al Feasibility of Asthma Critic, a decision-support system for asthma and COPD which generates patient- specific feedback on routinely recorded data in general practice. Fam Pract 2002; 19 (05) 442-7.
• 17 Boersma JJ. ICPC: International classification of primary care: short titels and Dutch subtitels. Utrecht: Nederlands Huisartsen Genootschap 1995
• 18 WHO. The Anatomical Therapeutic Chemical Classification System with Defined Daily Doses (ATC/DDD). Available at http://www.who.int/classifications/atcddd/en/Accessed July 19 2005
• 19 Dirksen WJ, Geyer RMM, De Haan M, Kolnaar BGM, Merkx JAM, Romeijnders ACM. et al NHG Standaard Astma bij Kinderen (Guidelines of the Dutch College of General Practitioners: Asthma in Children). Huisarts en Wetenschap 1992; 35 (09) 355-62.
• 20 Bottema BJAM, Fabels EJ, Van Grunsven PM, Van Hensbergen W, Muris JWM, Van Schayck CP. et al NHG Standaard CARA bij Volwassenen: Diagnostiek (Guidelines of the Dutch College of General Practitioners: Chronic Respiratory Diseases in Adults: Diagnostics). Huisarts en Wetenschap 1992; 35 (011) 430-6.
• 21 Van der Waart MAC, Dekker FW, Nijhoff S, Thiadens HA, van Weel C, Helder M. et al NHG Standaard CARA bij Volwassenen: Behandeling. (Guidelines of the Dutch College of General Practitioners: Chronic Respiratory Diseases in Adults: Therapy). Huisarts en Wetenschap 1992; 35 (011) 437-43.
• 22 Kerry SM, Bland JM. Trials which randomize practices I: how should they be analysed?. Fam Pract 1998; 15 (01) 80-3.
• 23 Eccles M, Grimshaw J, Steen N, Parkin D, Purves I, McColl E. et al The design and analysis of a randomized controlled trial to evaluate computerized decision support in primary care: the COGENT study. Fam Pract 2000; 17 (02) 180-6.
• 24 Grol R, Dalhuijsen J, Thomas S, Veld C, Rutten G, Mokkink H. Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. Bmj 1998; 317 7162 858-61.
• 25 Burgers JS, Cluzeau FA, Hanna SE, Hunt C, Grol R. Characteristics of high-quality guidelines: evaluation of 86 clinical guidelines developed in ten European countries and Canada. Int J Technol Assess Health Care 2003; 19 (01) 148-57.
• 26 Van Wijk MA, van der Lei J, Mosseveld M, Bohnen AM, van Bemmel JH. Compliance of general practitioners with a guideline-based decision support system for ordering blood tests. Clin Chem 2002; 48 (01) 55-60.
• 27 Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. Bmj 2005; 330 7494 765
• 28 Gardner RM. Computerized clinical decisionsupport in respiratory care. Respir Care 2004; 49 (04) 378-86. discussion 386-8