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CPG 97-001 – HSR&D Study

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CPG 97-001
Computerized Guidelines Enhanced by Symptoms and History: Clinical Effects
William M. Tierney MD
Richard L. Roudebush VA Medical Center, Indianapolis, IN
Indianapolis, IN
Funding Period: August 1997 - February 2001

BACKGROUND/RATIONALE:
Physician compliance with practice guidelines is imperfect. Computer-generated reminders from electronic medical record systems have been shown to increase compliance with guidelines, but they often require symptom and history data, which limits computer facilitation. Heart failure is a serious condition for which compliance with established guidelines is suboptimal. Physicians’ compliance with heart failure guidelines may improve if such reminders use symptom and history data.

OBJECTIVE(S):
1) Program standard computer-based guidelines for heart failure using data from the electronic medical record systems at the Indianapolis and Seattle VAMCs. 2) Establish a system for capturing data on symptoms and history from heart failure patients before scheduled primary care visits. 3) Incorporate these data into enhanced computer reminders. 4) Conduct a randomized, controlled trial comparing these two types of reminders’ effects on physician prescribing, patient objective and subjective outcomes, and health care utilization.

METHODS:
This controlled trial targets patients with objective evidence of left ventricular dysfunction on cardiac imaging studies and a current outpatient diagnosis of heart failure. Primary care physicians in the Indianapolis and Seattle VAMCs have been randomized to receive either standard heart failure treatment reminders or reminders enhanced by history/symptom data. Study data come from the VAMCs electronic medical record systems (i.e., clinical data, utilization, and costs) and patient interviews (heart failure symptoms and medication compliance, heart failure-specific quality of life, and patients’ satisfaction with their primary care). Data analysis will be performed at the patient level using general estimating equations to account for patient and physician characteristics and clustering of patients within physicians.

FINDINGS/RESULTS:
The intervention has been established in both VAMCs and the controlled trial has been initiated at both sites. Data collection will be completed November 2001.

IMPACT:
The data from this study will help managers of VA primary care practices decide whether collecting subjective information from patients will improve physician prescribing for patients with heart failure and these patients’ clinical outcomes and health-related quality of life.

PUBLICATIONS:

Journal Articles

  1. Subramanian U, Fihn SD, Weinberger M, Plue L, Smith FE, Udris EM, McDonell MB, Eckert GJ, Temkit M, Zhou XH, Chen L, Tierney WM. A controlled trial of including symptom data in computer-based care suggestions for managing patients with chronic heart failure. The American journal of medicine. 2004 Mar 15; 116(6):375-84.
  2. Udris EM, Au DH, McDonell MB, Chen L, Martin DC, Tierney WM, Fihn SD. Comparing methods to identify general internal medicine clinic patients with chronic heart failure. American heart journal. 2001 Dec 1; 142(6):1003-9.
Conference Presentations

  1. Au D, Udris E, Fan V. Risk of Chronic Heart Failure Hospitalization and Mortality associated with inhaled beta-agonist among patients with known left ventricular systolic dysfunction. Paper presented at: VA HSR&D National Meeting; 2002 Jan 1; Washington, DC.
  2. Tierney W, Subramanian U, Plue L, Eckert G, Smith F, Temkit H, Weinberger M, Fihn S. Symptoms, Quality of Life and Satisfaction With Care among Patients With Chronic Heart Failure. Paper presented at: Society of General Internal Medicine Annual Meeting; 2001 May 1; San Diego, CA.


DRA: Health Systems
DRE: Technology Development and Assessment
Keywords: Chronic heart failure, Clinical practice guidelines, Decision support
MeSH Terms: none

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