A Cluster Randomized Clinical Trial to Improve Prescribing Patterns in Ambulatory Pediatrics

Objectives: Having shown previously that an electronic prescription writer and decision support system improved pediatric prescribing behavior for otitis media in an academic clinic setting, we assessed whether point-of-care delivery of evidence could demonstrate similar effects for a wide range of other common pediatric conditions. Design: Cluster randomized controlled trial. Setting: A teaching clinic/clinical practice site and a primary care pediatric clinic serving a rural and semi-urban patient mix. Participants: A total of 36 providers at the teaching clinic/practice site and eight providers at the private primary pediatric clinic. Intervention: An evidence-based message system that presented real-time evidence to providers based on prescribing practices for acute otitis media, allergic rhinitis, sinusitis, constipation, pharyngitis, croup, urticaria, and bronchiolitis. Outcome measures: The proportion of prescriptions dispensed in accordance with evidence. Results: The proportion of prescriptions dispensed in accordance with evidence improved four percentage points, from 38% at baseline to 42% following the intervention. The control group improved by one percentage point, from 39% at baseline to 40% at trial's conclusion. The adjusted difference between the intervention and control groups was 8% (95% confidence interval 1%, 15%). Intervention effectiveness did not decrease with time. Conclusion: For common pediatric outpatient conditions, a point-of-care evidence-based prescription writer and decision support system was associated with significant improvements in prescribing practices.

[1]  David M. Smith,et al.  A controlled trial to increase office visits and reduce hospitalizations of diabetic patients , 1987, Journal of General Internal Medicine.

[2]  A D Oxman,et al.  No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. , 1995, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[3]  Marc Berg,et al.  Viewpoint Paper: Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors , 2003, J. Am. Medical Informatics Assoc..

[4]  David W. Bates,et al.  Reducing the frequency of errors in medicine using information technology. , 2001, Journal of the American Medical Informatics Association : JAMIA.

[5]  R. Haynes,et al.  Effects of Computer-based Clinical Decision Support Systems on Clinician Performance and Patient Outcome: A Critical Appraisal of Research , 1994, Annals of Internal Medicine.

[6]  M Eccles,et al.  Clinical guidelines: using clinical guidelines. , 1999, BMJ.

[7]  K. B. Johnson.  Barriers that impede the adoption of pediatric information technology. , 2001, Archives of pediatrics & adolescent medicine.

[8]  Phillip C. Gioia.  Quality improvement in pediatric well care with an electronic record , 2001, AMIA.

[9]  C. McDonald,et al.  Reminders to physicians from an introspective computer medical record. A two-year randomized trial. , 1984, Annals of internal medicine.

[10]  L. Kohn,et al.  COMMITTEE ON QUALITY OF HEALTH CARE IN AMERICA , 2000 .

[11]  J. Marshall.  Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis , 1997 .

[12]  T. Massaro.  Introducing Physician Order Entry at a Major Academic Medical Center: I. Impact on Organizational Culture and Behavior , 1993, Academic medicine : journal of the Association of American Medical Colleges.

[13]  K. Edwards,et al.  Differences in antibiotic prescribing patterns for children younger than five years in the three major outpatient settings. , 2004, The Journal of pediatrics.

[14]  R. Kravitz,et al.  Parent expectations for antibiotics, physician-parent communication, and satisfaction. , 2001, Archives of pediatrics & adolescent medicine.

[15]  J M Teich,et al.  Computerized physician order entry and quality of care. , 1994, Quality management in health care.

[16]  D. Bates,et al.  Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. , 2003, Archives of internal medicine.

[17]  Stephen B. Soumerai,et al.  Improving Drug-Therapy Decisions through Educational Outreach , 1983 .

[18]  P. Glasziou,et al.  Computerised reminders and feedback in medication management: a systematic review of randomised controlled trials , 2003, The Medical journal of Australia.

[19]  How the clinical customization of an EMR means good business: a case study of Queen City Physicians. , 2003, The Journal of medical practice management : MPM.

[20]  William W. Stead,et al.  Review: Computer-based Physician Order Entry: The State of the Art , 1994, J. Am. Medical Informatics Assoc..

[21]  J M Dean,et al.  Development and impact of a computerized pediatric antiinfective decision support program. , 2001, Pediatrics.

[22]  R. Hayes,et al.  Simple sample size calculation for cluster-randomized trials. , 1999, International journal of epidemiology.

[23]  D. Sackett.  Evidence-Based Medicine: How to Practice and Teach EBM , 2018 .

[24]  I McDowell,et al.  A Randomized Trial of Computerized Reminders for Blood Pressure Screening in Primary Care , 1989, Medical care.

[25]  C. McDonald.  Protocol-based computer reminders, the quality of care and the non-perfectability of man. , 1976, The New England journal of medicine.

[26]  William DuMouchel,et al.  A meta-analysis of 16 randomized controlled trials to evaluate computer-based clinical reminder systems for preventive care in the ambulatory setting. , 1996, Journal of the American Medical Informatics Association : JAMIA.

[27]  Joyce A. Mitchell,et al.  Effect of physician reminders on preventive care: meta-analysis of randomized clinical trials. , 1994, Proceedings. Symposium on Computer Applications in Medical Care.

[28]  D. Bates,et al.  Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. , 1998, JAMA.

[29]  J. Grimshaw,et al.  North of England evidence based guidelines development project: methods of guideline development , 1996, BMJ.

[30]  H. Bauchner,et al.  Use of an electronic medical record improves the quality of urban pediatric primary care. , 2003, Pediatrics.

[31]  R. Haynes,et al.  Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review. , 1998, JAMA.

[32]  Jeremy M. Grimshaw,et al.  Changing Provider Behavior: An Overview of Systematic Reviews of Interventions , 2001, Medical care.

[33]  Paul N. Gorman,et al.  Perceptions of house officers who use physician order entry , 1999, AMIA.

[34]  David Parkin,et al.  Effect of computerised evidence based guidelines on management of asthma and angina in adults in primary care: cluster randomised controlled trial , 2002, BMJ : British Medical Journal.

[35]  M Peters,et al.  Implementation of rules based computerised bedside prescribing and administration: intervention study , 2000, BMJ : British Medical Journal.

[36]  D. Bates,et al.  Computerized physician order entry systems in hospitals: mandates and incentives. , 2002, Health affairs.

[37]  G. Schiff,et al.  Computerized prescribing: building the electronic infrastructure for better medication usage. , 1998, JAMA.

[38]  Alastair Baker,et al.  Crossing the Quality Chasm: A New Health System for the 21st Century , 2001, BMJ : British Medical Journal.

[39]  C J McDonald,et al.  Physician response to computer reminders. , 1980, JAMA.

[40]  Janet M. Corrigan,et al.  Key Capabilities of an Electronic Health Record System: Letter Report , 2004 .

[41]  D M Rind,et al.  Effects of a knowledge-based electronic patient record in adherence to practice guidelines. , 1996, M.D. computing : computers in medical practice.

[42]  P. Shekelle,et al.  Clinical guidelines: developing guidelines. , 1999, BMJ.

[43]  F P Rivara,et al.  A randomized controlled trial of point-of-care evidence to improve the antibiotic prescribing practices for otitis media in children. , 2001, Pediatrics.

[44]  Dean F. Sittig,et al.  Clinician's assessments of outpatient electronic medical record alert and reminder usability and usefulness requirements , 2002, AMIA.

[45]  J. Avorn,et al.  Improving drug-therapy decisions through educational outreach. A randomized controlled trial of academically based "detailing". , 1983, The New England journal of medicine.

[46]  Paul N. Gorman,et al.  Investigating Physician Order Entry in the Field: Lessons Learned in a Multi-Center Study , 2001, MedInfo.

[47]  C. Mc Donald,et al.  Use of a computer to detect and respond to clinical events: its effect on clinician behavior. , 1976, Annals of internal medicine.

[48]  G J Kuperman,et al.  A randomized trial of a computer-based intervention to reduce utilization of redundant laboratory tests. , 1999, The American journal of medicine.

[49]  Joyce A. Mitchell,et al.  The clinical value of computerized information services. A review of 98 randomized clinical trials. , 1996, Archives of family medicine.

[50]  R. Platt,et al.  Reducing antibiotic use in children: a randomized trial in 12 practices. , 2001, Pediatrics.

[51]  T. Massaro,et al.  Introducing Physician Order Entry at a Major Academic Medical Center: II. Impact on Medical Education , 1993, Academic medicine : journal of the Association of American Medical Colleges.

[52]  Jonathan M. Teich,et al.  The Brigham integrated computing system (BICS): advanced clinical systems in an academic hospital environment , 1999, Int. J. Medical Informatics.

[53]  J. Marc Overhage,et al.  Editorial Comments: Physicians, Information Technology, and Health Care Systems: A Journey, Not a Destination , 2003, J. Am. Medical Informatics Assoc..

[54]  D L Sackett,et al.  A randomized trial of continuing medical education. , 1982, The New England journal of medicine.

[55]  K. Jones.  Evidence Based Medicine—How to Practice and Teach EBM , 1996 .

[56]  C. McDonald,et al.  Physician inpatient order writing on microcomputer workstations. Effects on resource utilization. , 1993, JAMA.

[57]  Jeremy M. Grimshaw,et al.  Using clinical guidelines , 1999 .

[58]  R N Shiffman,et al.  Transition to a computer-based record using scannable, structured encounter forms. , 1997, Archives of pediatrics & adolescent medicine.

[59]  A. Potts,et al.  Computerized physician order entry and medication errors in a pediatric critical care unit. , 2004, Pediatrics.