Copyright © 2004 Royal Australian College of General Practitioners Copyright to Australian Family Physician. Reproduced with permission. Permission to reproduce must be sought from the publisher, The Royal Australian College of General Practitioners.BACKGROUND: Preventive care is an important role for general practitioners, yet opportunities for prevention are often missed. METHOD: We provided an automatic electronic record preventive care reminder system for 12 preventive care activities for one 10 doctor practice. All patients who attended were randomised by the terminal digit of their record number. RESULTS: The control uptake of opportunistic prevention was low; ranging from 1.5% (tetanus immunisation) to 27% (influenza immunisation). The reminders increased this by significant but small amounts for four out of 12 activities (immunisation for tetanus and pneumococcus and recording of allergies and weight), insignificant increases for four (mumps, measles and rubella immunisation, recording of smoking, and taking of cervical smears and of blood pressure), and insignificantly decreased influenza immunisation, and screening for diabetes and hyperlipidaemia. DISCUSSION: Opportunistic electronic reminders have the potential to increase preventive care in general practice.Oliver Frank, John Litt and Justin Beilb

Beilby, J.

Frank, O.

Litt, J.

Adelaide Research &amp; Scholarship

Reprinted from Australian Family Physician Vol. 33, No. 1/2, January/February 200487Prevention is an important task of generalpractice. As 85% of Australians visit a generalpractitioner every year,1,2 there are manyopportunities for this to take place. AustralianGPs are increasingly using computers forpatient case notes.3 More patients receivepreventive care when doctors arereminded.4–11 Most evidence for this comesfrom trials conducted in North American hos-pital based or academic practices with paperbased reminders. A trial of on-screenreminders generated by the doctor’s com-puter in one general practice demonstratedeffectiveness.12 In Australia, preventive careincreased after the introduction of opportunis-tic on-screen reminders in one practice.13–17A more sensitive measure is the uptake ofopportunities rather than of patients offeredprevention. In a North American academicprimary health care clinic trial, the proportionof opportunities taken to provide influenzaimmunisation by doctors using computer gen-erated medical records and remindersincreased in comparison with those usingpaper medical records and no reminders.18We set out to increase opportunistic preven-tion of Austral ian GPs using computermedical records with reminders. MethodsWe designed a quasi randomised controlledtrial in a practice (Figure 1) where none of theauthors practised. The practice GPs agreedon the prevention activities for which theywould receive reminders, with the relevantpatient age group and intervals. These werelargely concordant with the then currentRoyal Austral ian College of GeneralPractitioners’ Guidelines19 (Table 1). We were unable to measure advice topatients about screening mammographybecause we did not ask the GPs specificallyto record such advice, and because of waitingtimes at the local screening mammographyunit that also recalled patients directly. Also,patients could refer themselves directly.The main outcome measure was the pro-portions of preventive care opportunitiestaken for patients in the intervention andcontrol groups for each preventive activity.The GPs were not blinded to the allocation ofpatients to the intervention or control groups.Data were analysed by ‘intention to treat’using univariate log binomial regression usinggeneralised estimating equations.Ethical approval was obtained from theUniversity of Adelaide and Flinders University,South Australia.ResultsThe baseline characteristics of the patientsallocated to the two experimental groupswere similar (Table 2). The overall control takeup of opportunistic preventive activities waslow – 27% for influenza immunisation, and aslow as 1.5% for tetanus immunisation (Table 3).The GPs took significantly greater opportuni-ties for patients in the intervention groupcompared to patients in the control group forfour items: recording of allergies, recording ofOpportunistic electronicremindersImproving performance of preventive care in general practiceOliver Frank, MBBS, FRACGP, is Partner, Hampstead Medical Clinic, Hampstead Gardens, South Australia, and Clinical Lecturerand PhD candidate, Department of General Practice, University of Adelaide, South Australia. John Litt, MBBS, DipRACOG, MSc (Epid), FRACGP, FAFPHM, is Senior Lecturer, Department of General Practice, FlindersUniversity, South Australia.Justin Beilby, MBBS, MD, MPH, FRACGP, is Professor, Department of General Practice, University of Adelaide, South Australia. BACKGROUNDPreventive care is an important role forgeneral practitioners, yet opportunitiesfor prevention are often missed.METHODWe provided an automatic electronicrecord preventive care remindersystem for 12 preventive care activitiesfor one 10 doctor practice. All patientswho attended were randomised by theterminal digit of their record number.RESULTSThe control uptake of opportunisticprevention was low; ranging from1.5% (tetanus immunisation) to 27%(influenza immunisation). Thereminders increased this by significantbut small amounts for four out of 12activities (immunisation for tetanusand pneumococcus and recording ofallergies and weight), insignificantincreases for four (mumps, measlesand rubella immunisation, recording ofsmoking, and taking of cervical smearsand of blood pressure), andinsignificantly decreased influenzaimmunisation, and screening fordiabetes and hyperlipidaemia.DISCUSSIONOpportunistic electronic remindershave the potential to increasepreventive care in general practice.RESEARCHweight, pneumococcal immunisation, andtetanus immunisation. There were no signifi-cant increases for measles mumps andrubella immunisation, recording of smoking,cervical screening, or blood pressure. Therewere insignificant decreases for diabetesscreening, influenza immunisation, and lipidscreening. One GP chose to use the oldermethod of recording case notes and thereforedid not receive any reminders.DiscussionThe GPs’ uptake of preventive activities oppor-tunistically was low. Possible reasons includepriority for dealing with the patient’s acute andchronic health problems, over riding precedentfor serious illness or crisis, the perverse incen-tives for better fee-for-service payment forshorter consultations, and the absence ofexplicit Medicare rebates for providing preven-tive care (other than childhood immunisation). The reminders caused only a modestincrease in opportunistic uptake. There areseveral possible reasons for this: one may bethat the reminders were displayed by dateorder of when due, rather than any morelogical priority. Another is that the remindersmay have made the GPs more aware of thepreventive care needs of all their patients,with the result that they increased their provi-sion of preventive care to patients in thecontrol group. The GP who used the oldermethod of recording his consultation notescould not have been influenced by thereminders. All of these factors will probablyhave decreased any intervention effect. The GPs took 26% of opportunities toadminister influenza vaccine to interventionpatients and 27% for control patients. Thiscontrasts with the findings of a trial ofreminders only for influenza vaccine, in whichdoctors who received reminders took 61% of88Reprinted from Australian Family Physician Vol. 33, No. 1/2, January/February 2004Research: Opportunistic electronic reminders – improving performance of preventive care in general practiceFigure 1. Trial designFigure 2. The appearance of computergenerated reminders for preventive care SettingAn outer urban general practice of 4 women and 6 men fully qualifiedexperienced GPs who have used computer medical records for 8 yearsData collectionAutomatic recording of preventive care opportunities and their uptakeData analysisCompare preventive care opportunities taken for patients in each groupEnrolment and randomisationPatients attending 9 March 1998 – 8 March 1999 randomised by lastdigit of their family’s practice medical record number(last digit 0–4 = experimental group, 5–9 = control group)Intervention groupn=5118 patientsControl groupn=5389 patientsInterventionIn consultation remindersabout 12 outstandingpreventive activitiesUsual careReprinted from Australian Family Physician Vol. 33, No. 1/2, January/February 2004 89Research: Opportunistic electronic reminders – improving performance of preventive care in general practiceTable 1. Comparison of recommendations in the RACGP Guidelines for Preventive Activities in General Practice19and intentions of GPs in the studyPreventive activity RACGP guidelines Study GPs’ intentionsSmoking status From 18 years: no interval specified At least once from 17 yearsRecording of allergies Not mentioned At least once from birthBlood pressure to screen for hypertension Every 1–2 years from 16 years Biennially from 20 yearsWeight measurement At least every few years Every year from 20 yearsSerum glucose to screen for diabetes Not routinely: based on risk factors, including age Every 5 years from 65 yearsScreening for hyperlipidaemia At least once for men aged 45–65 years Every 5 years from 20 years, forboth gendersCervical (Pap) test Biennially from 18–70 years (Same) Screening mammography for breast cancer Biennially from 50–70 years (Same) Tetanus vaccine Primary course starting at 2 months, then 10 yearly (Same)from 15 yearsMeasles, mumps and rubella vaccine First dose at 1 year, second at 10–16 years (Same) Influenza vaccine Every year from 65 years (Same) Pneumococcal vaccine Consider once over 65 years Every 5 years from 65 yearsTable 2. Baseline comparison of experimental groupsCharacteristic of patients Intervention Control Proportion women, % 56 57Mean age at end of trial, years (standard deviation) 36.0 (21.7) 35.4 (21.9)Median number of services in 6 months before start of trial, median (interquartile range) 1 (0–2) 1 (0–2)Median fees charged per consultation in 6 months before trial, median (interquartile range) $21 ($0–59) $21 ($0–56)Median number of long term problems coded before trial, median (interquartile range) 0 (0–1) 0 (0–1)Table 3. Effect of reminders on the uptake of preventive activitiesPreventive opportunities Opportunities taken for Relative changes in  preventive activity preventive activities performedn n (%) (95% CI)Preventive activity Control Intervention Control InterventionTetanus immunisation 15 089 11 947 222 (1.5) 333 (2.8) 1.89 (1.59, 2.25)Recording of allergies 13 713 10 991 682 (5.0) 991 (9.0) 1.81 (1.63, 2.02)Pneumococcal immunisation 2370 2079 39 (1.6) 58 (2.8) 1.70 (1.10, 2.62)Recording of weight 11 592 10 476 567 (4.9) 654 (6.2) 1.28 (1.13, 1.44)Measles, mumps and rubella immunisation 523 446 43 (8.2) 46 (10.3) 1.25 (0.82, 1.93)Smoking status 9407 8908 171 (1.8) 181 (2.0) 1.12 (0.90, 1.39)Cervical smear 4833 4387 348 (7.2) 343 (7.8) 1.09 (0.91, 1.29)Blood pressure 4404 4370 666 (15.1) 677 (15.5) 1.02 (0.90, 1.16)Diabetes screening 1900 1858 47 (2.5) 45 (2.4) 0.98 (0.65, 1.48)Influenza immunisation 912 935 248 (27.2) 245 (26.2) 0.96 (0.78, 1.18)Lipid screening 7929 7268 215 (2.7) 176 (2.4) 0.89 (0.73, 1.09)opportunities, compared to 37% for doctorswho did not receive reminders.18 Differencesin setting, design, outcome measurementsand the numbers of preventive activities forwhich reminders were issued may explainthe apparently greater absolute uptake ofinfluenza vaccine and greater effect ofreminders in the latter trial. There was possible information overloadfrom the multiple reminder messages pre-sented. In future both these problems couldbe addressed. Nevertheless, despite the dis-appointing absolute effect, the relativeincreases in preventive care activities in ourfindings suggest that automated opportunis-tic reminders have the potential to improvethe provision of preventive care in Australiangeneral practice. AcknowledgmentsThanks to Medical Benefits Fund of Australia andSmithKlineBeecham for funding, to the GPs whoparticipated, Dr Jan Ravet for the use of his originalreminder programs and his technical advice, NicolePratt, Heather McElroy and Kristyn Willson for theirstatistical assistance.Conflict of interest: none declared.References1. Commonwealth of Australia. General Practice inAustralia: 2000. Canberra: AGPS, 2000.2. Australian Bureau of Statistics. AustralianDemographic Statistics, 2003.3. Western M DK, Makkai T, et al. Measuring ITuse in Australian general practice 2001: GeneralPractice Computing Group, Canberra: 2001.4. Buntinx F, Winkens R, Grol R, Knottnerus JA.Influencing diagnostic and preventive perfor-mance in ambulatory care by feedback andreminders. A review. Fam Pract 1993;10:219–228.5. Austin SM, Balas EA, Mitchell JA, Ewigman BG.Effect of physician reminders on preventivecare: meta-analysis of randomised clinical trials.Proc Annu Symp Comput Appl Med Care1994;121–124.6. Davis DA, Thomson MA, Oxman AD, HaynesRB. Changing physician performance. A system-atic review of the effect of continuing medicaleducation strategies. JAMA 1995;274:700–705.7. Hulscher MEJL WM, van der Weijden T, Grol R.Interventions to implement prevention inprimary care. The Cochrane Library, 2003.8. Mitchell E, Sullivan F. A descriptive feast but anevaluative famine: systematic review of pub-lished articles on primary care computingduring 1980-1997. BMJ 2001;322:279–282.9. Oxman AD, Thomson MA, Davis DA, HaynesRB. No magic bullets: a systematic review of102 trials of interventions to improve profes-sional practice. CMAJ 1995;153:1423–1431.10. Shea S, DuMouchel W, Bahamonde L. A meta-analysis of 16 randomised controlled trials toevaluate computer based clinical remindersystems for preventive care in the ambulatorysetting. J Am Med Inform Assoc 1996;3:399–409.11. Johnston ME, Langton KB, Haynes RB, MathieuA. Effects of computer based clinical decisionsupport systems on clinician performance andpatient outcome. A critical appraisal ofresearch. Ann Intern Med 1994;120:135–142.12. Weingarten MA, Bazel D, Shannon HS.Computerised protocol for preventive medi-cine: a controlled self audit in family practice.Fam Pract 1989;6:120–124.13. Ravet J. Tetanus immunisation. Med J Aust1987;146:170.14. Ravet J. Opportunistic recall: a plateau. Med JAust 1988;148:211.15. Ravet J. Pap smear reminder systems. Med JAust 1992;156:663.16. Ravet J. Flu vaccination recall database. Med JAust 1994;160:45.17. Ravet JL. Are Papanicolaou recalls worthwhile?Med J Aust 1993;158:794.18. Tang PC, LaRosa MP, Newcomb C, Gorden SM.Measuring the effects of reminders for outpa-tient influenza immunisations at the point ofclinical opportunity. J Am Med Inform Assoc1999;6:115–121.19. Royal Australian College of GeneralPractitioners. Guidelines for PreventiveActivities in General Practice. 4th edn. SouthMelbourne: RACGP, 1996.90Reprinted from Australian Family Physician Vol. 33, No. 1/2, January/February 2004Research: Opportunistic electronic reminders – improving performance of preventive care in general practiceCorrespondenceEmail: oliver.frank@adelaide.edu.auAFP• GPs take few opportunities during con-sultations to provide recommendedpreventive care.• They can be reminded to do so during con-sultations by clinical electronic recordadditions.• The small increases in preventionsuggest this system should be refinedfor greater effect.Implications of this study for general practice

Opportunistic electronic reminders : improving performance of preventive care in general practice

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Opportunistic electronic reminders : improving performance of preventive care in general practice

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Opportunistic electronic reminders : improving performance of preventive care in general practice

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