Automated attention flags in chronic disease care planning.

OBJECTIVES: To assess the value of computerised decision support in the management of chronic respiratory disease by comparing agreement between three respiratory specialists, general practitioners (care coordinators), and decision support software. METHODS: Care guidelines for two chronic obstructive pulmonary disease projects of the SA HealthPlus Coordinated Care Trial were formulated. Decision support software, Care Plan On-Line (CPOL), was created to represent the intent of these guidelines via automated attention flags to appear in patients' electronic medical records. For a random sample of 20 patients with care plans, decisions about the use of nine additional services (eg, smoking cessation, pneumococcal vaccination) were compared between the respiratory specialists, the patients' GPs and the CPOL attention flags. RESULTS: Agreement among the specialists was at the lower end of moderate (intraclass correlation coefficient [ICC], 0.48; 95% CI, 0.39-0.56), with a 20% rate of contradictory decisions. Agreement with recommendations of specialists was moderate to poor for GPs (kappa, 0.49; 95% CI, 0.33-0.66) and moderate to good for CPOL (kappa, 0.72; 95% CI, 0.55-0.90). CPOL agreement with GPs was moderate to poor (kappa, 0.41; 95% CI, 0.24-0.58). GPs were less likely than specialists or CPOL to decide in favour of an additional service (P<0.001). CPOL was 87% accurate as an indicator of specialist decisions. It gave a 16% false-positive rate according to specialist decisions, and flagged 61% of decisions where GPs said No and specialists said Yes. CONCLUSIONS: Automated decision support may provide GPs with improved access to the intent of guidelines; however, further investigation is required.

Chronic disease coordinated care planning: flexible, task-centered decision support.

SA HealthPlus is a trial of coordinated care enrolling 4000 high-use patients in South Australia in 10 groups including diabetes, cardiac, aged care and lung disease. These patients each have a designated general practitioner (GP) care coordinator who formulates an individualized care plan designed to keep them as healthy as possible. An on-line interface to SA HealthPlus has been developed for the care coordinators. The Care Plan On-Line (CPOL) system provides a single coherent source whereby the GP can review the available information on a HealthPlus patient in the context of devising a care plan of prospective services and medications. In the same application environment CPOL provides access to care guidelines tailored for SA HealthPlus.

Changes in sleepiness and body temperature precede nocturnal sleep onset: evidence from a polysomnographic study in young men.

Recent research has shown a close temporal relationship between the nocturnal decrease in rectal core temperature and the initiation of sleep. However, there is not yet a clear temporal relationship between changes in peripheral and core temperatures and nocturnal sleep onset. We recorded body temperatures in 14 adult males (age +/- SEM = 22.1 +/- 0.6 y), who attended the sleep laboratory for an adaptation night and two counterbalanced experimental sessions. Subjects self-selected lights-out on one experimental night (the Habitual Sleep condition). To determine the relationship between body temperature changes and sleep onset, lights out was delayed until after 01.00 hours on the other experimental night (Delayed Sleep condition). Individual datasets in both conditions were expressed relative to the time of sleep onset in the Habitual Sleep condition only, so that they were aligned at identical clock times. Saliva samples confirmed that mean dim light melatonin onset (DLMO) occurred at 00.10 +/- 00.16 hours in the Delayed Sleep condition, which was after habitual sleep onset at 23.44 +/- 00.08 hours. Rectal core temperature (Tc) decreased significantly over time only in the Habitual Sleep condition (P < 0.01). For the 20 min before habitual sleep onset, Delayed Sleep Tc was on average 0.1 degree C higher than Tc in the Habitual Sleep condition (P < 0.01). The greater decline in Habitual Sleep Tc was associated with significantly increased peripheral hand and foot skin temperatures before sleep (both P < 0.05). Subjective sleepiness measures were higher in the Habitual Sleep onset condition from 150 min prior until sleep onset (P < 0.01). From these results it is reasonable to infer that a sequence of thermoregulatory and sleep propensity changes occur before, but are associated with habitual sleep onset, as the changes are significantly attenuated if sleep is delayed.