Can computer-generated evidence-based care suggestions enhance evidence-based management of asthma and chronic obstructive pulmonary disease? A randomized, controlled trial

Health Services Research, April, 2005 by William M. Tierney, J. Marc Overhage, Michael D. Murray, Lisa E. Harris, Xiao-Hua Zhou, George J. Eckert, Faye E. Smith, Nancy Nienaber, Clement J. McDonald, Fredric D. Wolinsky

In 2001, the Institute of Medicine documented the gap between recommended and actual practice of medicine in the United States (Institute of Medicine 2001). Many proven interventions were not routinely being used. Reactive airways diseases, asthma and chronic obstructive pulmonary disease (COPD), are an example. They are common, morbid, and costly conditions (McFadden and Gilbert 1992). Despite widely accepted evidence-based treatment guidelines (Canadian Thoracic Society Workshop Group 1992; National Asthma Education Program Expert Panel Report. Executive Summary." Guidelines for the Diagnosis and Management of Asthma 1994), many physicians do not prescribe such treatments to patients who might benefit from them (Cabana et al. 2001).

The Institute of Medicine has also stated that electronic medical record systems are "an essential technology for health care" (Institute of Medicine, Committee on Improving the Medical Record 1991) that could improve medical practice (Johnston et al. 1994; Tierney 2001). However, clinical information systems are expensive (Dambro, Weiss, and McClure 1988), potentially intrusive (Krall and Sittig 2001), and have not always improved care (Johnston et al. 1994). We have previously shown that computer-based interventions can increase preventive care (McDonald et al. 1984; Tierney, Hui, and McDonald 1986; McDonald et al. 1999; Tierney 2001) and reduce costs (Tierney, Miller, and McDonald 1990; Tierney et al. 1993). We have had less success affecting chronic management of renal disease (Harris et al. 1998) or heart disease (Tierney et al. 2003; Subramanian et al. 2004). We assessed whether guideline-based care suggestions delivered via physicians' and pharmacists' computer workstations could improve the outpatient management and outcomes among patients with asthma or COPD.

METHODS

Setting and Subjects

This study was approved by the University Institutional Review Board (study #9211-26) and took place in Indiana University Medical Group-Primary Care (IUMG-PC), an inner-city primary care practice-based research network (Tierney et al. 1991). This study utilized four hospital-based academic practices where 25 faculty general internists and more than 100 internal medicine residents cared for approximately 13,000 patients during 50,000 annual visits. These practices have separate nursing and clerical staff but share paper and electronic medical records (McDonald et al. 1999). At the beginning of each academic year, new physicians were randomly assigned to practices of departing physicians (Tierney et al. 1991). Physicians were assigned to half-day sessions in a single practice: faculty attended 2-5 half-day sessions per week while residents attended one half-day session per week. Prior studies have shown no systematic differences in practice patterns or clinical outcomes between the four practices (McDonald et al. 1984; Tierney, Miller, and McDonald 1990). Each physician cared for an assigned panel of patients. Faculty and residents practiced side by side. Residents briefly presented each patient to a faculty physician yet made all diagnostic and therapeutic decisions for their patients.

This study also included outpatient pharmacists. We separately randomized the 11 full-time and 9 part-time pharmacists to intervention or control status.

Patients were eligible if they were at least 18 years old, had either previously visited the study practices in the past year, and had either (1) the diagnosis of asthma or COPD recorded during any inpatient, emergency, or outpatient visit; (2) emphysema recorded as a reading on any prior chest radiograph or CT scan; or (3) two or more prescriptions for inhaled [beta]-agonists, corticosteroids, ipratropium, or cromolyn, or oral [beta]-agonists or theophylline. Prior studies (Murray et al. 1995) and repeated internal audits have shown that 95 percent of patients visiting these study practices receive all of their medications from the hospital's outpatient pharmacy.

Study Design and Randomization

This study used a 2 x 2 factorial design to study the relative and additive effects of separate physician and pharmacist interventions. We randomized all half-day sessions to intervention or control status via a coin flip. Because faculty physicians practiced in more than one half-day session per week, this procedure resulted in a few physicians having sessions with both intervention and control sessions. A biostatistician blinded to their names switched sessions so that the number of intervention and control sessions per practice were equal and all physicians practiced only in sessions with the same study status. To minimize contamination, all physicians in each half-day session shared the same study status. Patients shared their assigned primary care physicians' study status.

As patients were enrolled, they were randomly assigned by computer to receive all of their outpatient drugs from intervention or control pharmacists. Randomizing both practice sessions and patients resulted in four groups of patients: physician intervention only, pharmacist intervention only, both pharmacist and physician interventions, and no intervention (controls).