Supporting the Patient's Role in Guideline Compliance: A Controlled Study

Volume 14: 737-744 November 2008 Number 11

Supporting the Patient's Role in Guideline Compliance: A Controlled Study

Stephen N. Rosenberg, MD, MPH; Tatiana L. Shnaiden, MD, MS; Arnold A. Wegh, MS; and Iver A. Juster, MD

Objective: Clinical messages alerting physicians to gaps in the care of specific patients have been shown to increase compliance with evidence-based guidelines. This study sought to measure any additional impact on compliance when alerting messages also were sent to patients.

Study Design: For alerts that were generated by computerized clinical rules applied to claims, compliance was determined by subsequent claims evidence (eg, that recommended tests were performed). Compliance was measured in the baseline year and the study year for 4 study group employers (combined membership >100,000) that chose to add patient messaging in the study year, and 28 similar control group employers (combined membership >700,000) that maintained physician messaging but did not add patient messaging.

Methods: The impact of patient messaging was assessed by comparing changes in compliance from baseline to study year in the 2 groups. Multiple logistic regression was used to control for differences between the groups. Because a given member or physician could receive multiple alerts, generalized estimating equations with clustering by patient and physician were used.

Results: Controlling for differences in age, sex, and the severity and types of clinical alerts between the study and control groups, the addition of patient messaging increased compliance by 12.5% (P <.001). This increase was primarily because of improved responses to alerts regarding the need for screening, diagnostic, and monitoring tests.

Conclusion: Supplementing clinical alerts to physicians with messages directly to their patients produced a statistically significant increase in compliance with the evidence-based guidelines underlying the alerts.

(Am J Manag Care. 2008;14(11):737-744)

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Numerous studies have documented the slow dissemination of new medical knowledge^1,2 and the failure of many patients to receive important evidence-based clinical services.^3,4 Clinical alerts can accelerate the dissemination of new knowledge and increase the use of evidence-based services by providing information on important drugs, tests, or other services that appear to be missing from a patient’s treatment.^5-7 However, when alerts are sent only to physicians, these improvements often do not reach optimal levels.^8,9 Busy physicians are inundated with messages from health plans and care management programs. Because of this, and the fact that messages from some sources may be perceived as unreliable, physicians may pay little attention to any clinical alerts. If physicians do take action based on alerts, their patients may not understand the recommendations or their importance, or may fail to fill the prescriptions or obtain the recommended tests.

These problems suggest that supplementing alerts to physicians with notices to their patients might be beneficial—encouraging patients to follow their physicians’ advice or to remind their physicians about overlooked guidelines. Patients and health plan members increasingly want to play an active part in their own care.¹⁰ Yet few consumer decision support programs are designed to empower the consumer at a point in time when a potential problem of clinical quality or safety has been detected, and fewer still are integrated with systems of physician alerts. As Glasziou and Haynes pointed out, full implementation of improvements in medical care requires not just dissemination of abstract knowledge, but also application of that knowledge by physicians to individual patients and, in most cases, actions by the patients themselves.¹¹ It is not enough that a physician knows that medication X is now the drug of choice for condition Y. The physician must recognize that medication X is appropriate for patient Z and must write a prescription, and patient Z must fill and adhere to that prescription. Clearly, enhanced knowledge diffusion in the medical community alone is not enough. Clinical alerts to physicians concerning gaps in the care of specific patients can provide a useful reinforcement by directly addressing the applicability of new knowledge to individual patients. However, getting all the way to our goal may require including the patient in the system.

We studied the impact of a patient- messaging program designed to address these needs. Several previous studies documented the value of clinical alerts to physcians,^5-7,12and this study did not reexamine that issue. Our focus was on the incremental impact of supplementing a physician clinical alert system with information sent directly to patients concerning possible gaps in evidence-based care for their condition, with the 2 messages coordinated to enable the patient and physician to collaborate in closing those gaps.

STUDY DESIGN
The alerting program we studied was built around a rulebased artificial intelligence expert system combined with a message generator that conveys clinical recommendations and supporting literature citations to treating physicians. More recently, as an option available to health plan sponsors (insurers and employers), messages also can be sent to patients. Health plans began to implement patient messaging in January 2006, providing the opportunity to conduct a controlled study of its incremental value.

The system develops an integrated patient record (reflecting a patient’s care history across multiple providers) through frequently updated data that include physician, hospital, outpatient facility, laboratory, pharmacy, and medical equipment claims; laboratory test results; information reported by patients on health risk assessments and to disease management nurses; and physician responses to alerts they have received. The records are evaluated for potential gaps in care through identification of medical conditions, the presence or absence of appropriate diagnostic and therapeutic interventions, and clinical situations under which a specific alert should not be generated (eg, the presence of a contraindication).

Clinical issues for inclusion in the rules engine are identified by an in-house committee of clinicians and a multispecialty consultant panel of medical school faculty physicians, based on multicenter clinical trials, federal government and specialty society guidelines, and US Food and Drug Administration– approved pharmaceutical labeling.

The system’s output—currently approximately 900 types of clinical alerts—represents patient-specific discrepancies between the care that is actually being received (as reflected in claims and lab data) and the care that patients should be receiving according to the evidence-based literature. These discrepancies fall into a variety of clinical categories, addressing various aspects of patient safety and the quality of care. These are listed, with examples, in Table 1.

Alerts vary in their clinical and temporal urgency. Level 1 alerts address potentially life-threatening situations and are communicated to treating physicians via telephone, followed up by fax. Level 2 alerts concern serious but not immediately life-threatening situations and are faxed to physicians. Level 3 alerts apply to routine monitoring and issues of a preventive/wellness nature and are distributed by mail.

At the option of the health plan, copies of the alerts, in lay language, also are mailed to their members—with a delay of 10 working days to allow physicians to contact their patients first, if they choose, or to indicate via fax or phone that there are clinical reasons why alerts do not apply (eg, an allergy not revealed by claims data). In such cases, the patient version of the message is not sent out and the new information is entered into the rules engine, so that that patient will never again trigger an alert suggesting the use of that medication. Examples of the physician and patient versions of an alert are shown in the Figure.

The study group consisted of 4 large employers that had physician alert messaging throughout 2005, implemented patient messaging on January 1, 2006, and maintained both physician and patient messaging throughout 2006. The control group comprised 28 employers that were matched as closely as possible to the study group employers. The control group employers also participated in physician messaging throughout 2005 and 2006, but did not choose to add patient messaging in 2006. This study is based on the secondary analysis of data from claims processed on behalf of these 32 employers, after removal of all data elements identifying individuals and employers. Therefore, the study was not submitted to an institutional review board.

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