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

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

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

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

Identification of acute myocardial infarction from electronic healthcare records using different disease coding systems

Objective: To evaluate positive predictive value (PPV) of different disease codes and free text in identifying acute myocardial infarction (AMI) from electronic healthcare records (EHRs). Design: Validation study of cases of AMI identified from general practitioner records and hospital discharge diagnoses using free text and codes from the International Classification of Primary Care (ICPC), International Classification of Diseases 9th revision-clinical modification (ICD9-CM) and ICD-10th revision (ICD-10). Setting: Population-based databases comprising routinely collected data from primary care in Italy and the Netherlands and from secondary care in Denmark from 1996 to 2009. Participants: A total of 4 034 232 individuals with 22 428 883 person-years of follow-up contributed to the data, from which 42 774 potential AMI cases were identified. A random sample of 800 cases was subsequently obtained for validation. Main outcome measures: PPVs were calculated overall and for each code/free text. 'Best-case scenario' and 'worst-case scenario' PPVs were calculated, the latter taking into account non-retrievable/non-assessable cases. We further assessed the effects of AMI misclassification on estimates of risk during drug exposure. Results: Records of 748 cases (93.5% of sample) were retrieved. ICD-10 codes had a 'best-case scenario' PPV of 100% while ICD9-CM codes had a PPV of 96.6% (95% CI 93.2% to 99.9%). ICPC codes had a 'best-case scenario' PPV of 75% (95% CI 67.4% to 82.6%) and free text had PPV ranging from 20% to 60%. Corresponding PPVs in the 'worst-case scenario' all decreased. Use of codes with lower PPV generally resulted in small changes in AMI risk during drug exposure, but codes with higher PPV resulted in attenuation of risk for positive associations. Conclusions: ICD9-CM and ICD-10 codes have good PPV in identifying AMI from EHRs; strategies are necessary to further optimise utility of ICPC codes and free-text search. Use of specific AMI disease codes in estimation of risk during drug exposure may lead to small but significant changes and at the expense of decreased precision

A promising approach in comparative research on care for the elderly

Long-term care (LTC) in the form of care provided in nursing homes, homes for the aged and home care is considered an appropriate answer to the growing needs of the aging populations of the industrialized world. However, the provision of and expenditures on LTC vary considerably between these industrialized countries. Although one would expect LTC to be subject to many internationally comparative studies, including all European countries, this is not the case. A paper presented by Damiani et al. in BMC Health Services Research contains an internationally comparative model regarding the development of LTC in Europe (2003 to 2007). They achieve an intriguing compromise between depth and width in the sparsely populated domain of internationally comparative research on LTC by characterizing countries' LTC and interpreting the large north/south differences found. Their results also show that 'cash for care' schemes form a substantial alternative to traditional LTC provision. An additional time series analysis showed that many countries seem to be engaged in reorganizing the LTC sector. This study widens knowledge in a neglected area of health services research and should serve as a source of inspiration for further studies

Prevalence and incidence rate of hospital admissions related to medication between 2008 and 2013 in The Netherlands

PURPOSE: In 2009 a Dutch guideline was published containing recommendations to reduce Hospital Admissions Related to Medications (HARMs). This study aims to examine time-trends of HARMs and their potential preventability between 2008 and 2013 in The Netherlands. METHODS: A retrospective prevalence study was conducted using the Dutch PHARMO Database Network. A semi-automated pre-selection was used to make a crude identification of possible HARMs of which four samples were selected. These were independently assessed with respect to causality and potential preventability by a physician and pharmacist. The results were stratified by age into 18-64 years and 65 years and older. For these groups the net prevalences and incidence rates of HARMs and potentially preventable HARMs were calculated for the years 2008, 2009, 2011 and 2013. RESULTS: Four samples of 467 (2008), 447 (2009), 446 (2011) and 408 (2013) admissions were assessed. The net prevalence of HARMs in the 18-64 years group was approximately four times smaller compared to the older group with a mean prevalence of 2.7% (95% confidence interval [CI]:2.4%-3.0%) and 10.2% (95%CI: 9.7%-10.7%) respectively. The potential preventability was 25.1% (18.4%-31.8%) and 48.3% (95%CI: 44.8%-51.8%), respectively. The prevalence of HARMs in both groups did not change significantly between 2008 and 2013 with 2.4% (95%CI: 1.9%-3.0%) and 10.0% (95%CI: 9.0%-11.0%) in 2008 and 3.1% (2.7%-3.5%) and 10.4% (95%CI: 9.4%-11.4%) in 2013, respectively. CONCLUSION: Despite efforts to reduce HARMs, the prevalence did not decrease over time. Additional measures are therefore necessary, especially in the elderly population

Impact of different assumptions on estimates of childhood diseases obtained from health care data: A retrospective cohort study

Purpose: Accurate estimates of disease incidence in children are required to support pediatric drug development. Analysis of electronic health care records (EHR) may yield such estimates but pediatric-specific methods are lacking. We aimed to understand the impact of assumptions regarding duration of disease episode and length of run-in period on incidence estimates from EHRs. Methods: Children aged 0 to 17 years (5-17 years for asthma) registered in the Integrated Primary Care Information database between 2002 and 2014 were studied. We tested the impact of the following: max

Risks and clinical predictors of cirrhosis and hepatocellular carcinoma diagnoses in adults with diagnosed NAFLD: real-world study of 18 million patients in four European cohorts

Background: Non-alcoholic fatty liver disease (NAFLD) is a common condition that progresses in some patients to stea

Guillain-Barré syndrome and adjuvanted pandemic influenza A (H1N1) 2009 vaccines: A multinational self-controlled case series in Europe

Background: The risk of Guillain-Barré syndrome (GBS) following the United States' 1976 swine flu vaccination campaign in the USA led to enhanced active surveillance during the pandemic influenza (A(H1N1)pdm09) immunization campaign. This study aimed to estimate the risk

Prevalence and incidence rate of hospital admissions related to medication between 2008 and 2013 in The Netherlands

Purpose: In 2009 a Dutch guideline was published containing recommendations to reduce Hospital Admissions Related to Medications (HARMs). This study aims to examine

Bismarck or Beveridge: a beauty contest between dinosaurs

<p>Abstract</p> <p>Background</p> <p>Health systems delivery systems can be divided into two broad categories: National Health Services (NHS) on the one hand and Social Security (based) Health care systems (SSH) on the other hand. Existing literature is inconclusive about which system performs best. In this paper we would like to improve the evidence-base for discussion about pros and cons of NHS-systems versus SSH-system for health outcomes, expenditure and population satisfaction.</p> <p>Methods</p> <p>In this study we used time series data for 17 European countries, that were characterized as either NHS or SSH country. We used the following performance indicators: For health outcome: overall mortality rate, infant mortality rate and life expectancy at birth. For health care costs: health care expenditure per capita in pppUS$ and health expenditure as percentage of GDP. Time series dated from 1970 until 2003 or 2004, depending on availability. Sources were OECD health data base 2006 and WHO health for all database 2006. For satisfaction we used the Eurobarometer studies from 1996, 1998 and 1999.</p> <p>Results</p> <p>SSH systems perform slightly better on overall mortality rates and life expectancy (after 1980). For infant mortality the rates converged between the two types of systems and since 1980 no differences ceased to exist.</p> <p>SSH systems are more expensive and NHS systems have a better cost containment. Inhabitants of countries with SSH-systems are on average substantially more satisfied than those in NHS countries.</p> <p>Conclusion</p> <p>We concluded that the question 'which type of system performs best' can be answered empirically as far as health outcomes, health care expenditures and patient satisfaction are concerned. Whether this selection of indicators covers all or even most relevant aspects of health system comparison remains to be seen. Perhaps further and more conclusive research into health system related differences in, for instance, equity should be completed before the leading question of this paper can be answered. We do think, however, that this study can form a base for a policy debate on the pros and cons of the existing health care systems in Europe.</p