Computed critiquing integrated into daily clinical practice affects physicians' behavior--a randomized clinical trial with AsthmaCritic.

OBJECTIVE: We developed AsthmaCritic, a non-inquisitive critiquing system integrated with the general practitioners' electronic medical records. The system is based on the guidelines for asthma and chronic obstructive pulmonary disease (COPD) as issued by the Dutch College of General Practitioners. This paper assesses the effect of AsthmaCritic on monitoring and treatment of asthma and COPD by Dutch general practitioners in daily practice. METHODS: A randomized clinical trial in 32 practices (40 Dutch general practitioners) using electronic patient records. An intervention group was given the use of AsthmaCritic, a control group continued working in the usual manner. Both groups had the disposal of the asthma and COPD guidelines routinely distributed by the Dutch College of General Practitioners. We measured the average number of contacts, FEV 1 (forced expiratory volume), and peak-flow measurements per asthma/COPD patient per practice; and, the average number of antihistamine, cromoglycate, deptropine, and oral bronchodilator prescriptions per asthma/COPD patient per practice. RESULTS: The number of contacts increased in the age group of 12-39 years. The number of FEV1 , peak-flow measurements, and the ratio of coded measurements increased, whereas the number of cromoglycate prescriptions decreased in the age group of 12-39 years. CONCLUSIONS: Our study shows that the guideline-based critiquing system AsthmaCritic changed the manner in which the physicians monitored their patients and, to a lesser extent, their treatment behavior. In addition, the physicians changed their data-recording habits.

Low incidence of acute urinary retention in the general male population: the triumph project.

OBJECTIVE: To describe the incidence of acute urinary retention (AUR) in the general male population and in a population of men newly diagnosed with lower urinary tract symptoms suggestive of BPH (LUTS/BPH). METHODS: We performed a retrospective cohort study in the Integrated Primary Care Information (IPCI) database, a GP research database in The Netherlands, during the period 1995-2000. All males, > or =45 years, without a history of AUR or radical cystectomy were included in the study. In addition, we followed a sub-cohort of men, newly diagnosed with LUTS/BPH. AUR was defined as the sudden inability to urinate, requiring catheterization. RESULTS: Amongst 56,958 males with a mean follow-up of 2.8 years, 344 AUR cases occurred (incidence rate 2.2/1000 man-years) of whom more than 40% were precipitated. AUR was the first symptom of LUTS/BPH in 73 (49%) of the 149 AUR cases that occurred in men newly diagnosed with LUTS/BPH. The risk of AUR was 11-fold higher in patients newly diagnosed with LUTS/BPH (RR 11.5; 95%CI: 8.4-15.6) with an overall incidence rate of 18.3/1000 man-years (95%CI: 14.5-22.8). CONCLUSIONS: The incidence rate of AUR is low in the general population but substantial in a population of men newly diagnosed with LUTS/BPH. The incidence rate increases with age and AUR is precipitated in approximately 40% of all cases. Within the LUTS/BPH cohort, AUR is the first presenting symptom of BPH in 50% of all AUR cases.

[Summary of the Dutch College of General Practitioners' practice guideline 'Anemia']. / Samenvatting van de standaard 'Anemie' van het Nederlands Huisartsen Genootschap.

The Dutch College of General Practitioners' practice guideline concerning anaemia advises the general practitioner to carry out additional laboratory tests in patients with a decreased haemoglobin level (Hb) in order to establish the cause of the anaemia. In specified cases (premenopausal women with excessive vaginal bleeding and in some children with mild anaemia) these tests may initially be omitted. In these cases iron can be prescribed and, if a child has had an infectious disease within the previous month, to wait one month to see if levels return to normal. In older patients with iron-deficiency anaemia subsequent investigations should be performed in order to rule out gastro-intestinal neoplasm, even if the history and physical examination give no indication of this. In an anaemic patient at risk of thalassaemia trait, haemoglobin electrophoresis or chromatography should be performed if there is microcytosis and a serum ferritine level > 15 micrograms/l.

Assessment of the possibility to classify patients according to cholesterol guideline screening criteria using routinely recorded electronic patient record data.

BACKGROUND: Computerised decision support systems (CDSS) can be categorised as either being inquisitive or non-inquisitive. The non-inquisitive system uses routinely entered electronic patient data, to generate patient specific feedback based on guidelines. The Dutch College of General Practitioners' (DCGP) cholesterol guideline classifies patients into risk groups, eligible for screening. The availability of sufficient routinely recorded electronic patient data to classify patients according to the DCGP cholesterol guideline is unknown. OBJECTIVE: To assess whether it is possible to classify patients according to the screening criteria of the DCGP cholesterol guideline, using data routinely recorded by general practitioners. METHODS: We analysed the DCGP cholesterol guideline to identify selection criteria for screening. These selection criteria were subsequently used to create a cohort of patient records eligible for screening in the Integrated Primary Care Information (IPCI) Database. We calculated incidence and prevalence of risk factors and selected patient records for active management according to the identified screening selection criteria. RESULTS: 145866 valid patient records were selected for classification. In the retrieved records 9741 (13.6%) males and 5756 (7.8%) females were identified for active management according to the selection criteria of the DCGP cholesterol guideline. CONCLUSION: The classification of patients into risk groups, eligible for screening, according to the criteria of the DCGP cholesterol guideline using routinely recorded electronic patient data is feasible. Care should be taken when using only diagnostic codes, as it gives higher than expected incidence and prevalence of risk factors. Based on these findings we are currently building Cholgate, a non-inquisitive decision support system for cholesterol management.

Assessment of decision support for blood test ordering in primary care. a randomized trial.

BACKGROUND: Different methods for changing blood test-ordering behavior in primary care have been proven effective. However, randomized trials comparing these methods are lacking. OBJECTIVE: To compare the effect of two versions of BloodLink, a computer-based clinical decision support system, on blood test ordering among general practitioners. DESIGN: Randomized trial. SETTING: 44 practices of general practitioners in the region of Delft, the Netherlands. PARTICIPANTS: 60 general practitioners in 44 practices who used computer-based patient records in their practices. INTERVENTION: After stratification by solo practices and group practices, practices were randomly assigned to use BloodLink-Restricted, which initially displays a reduced list of tests, or BloodLink-Guideline, which is based on the guidelines of the Dutch College of General Practitioners. MEASUREMENTS: Average number of blood tests ordered per order form per practice. RESULTS: General practitioners who used BloodLink-Guideline requested 20% fewer tests on average than did practitioners who used BloodLink-Restricted (mean [+/-SD], 5.5 +/- 0.9 tests vs. 6.9 +/- 1.6 tests, respectively; P = 0.003, Mann-Whitney test). CONCLUSIONS: Decision support based on guidelines is more effective in changing blood test-ordering behavior than is decision support based on initially displaying a limited number of tests. Guideline-driven decision support systems can be effective in reducing the number of laboratory tests ordered by primary care practitioners.

Analysis of the practice guidelines of the Dutch College of General Practitioners with respect to the use of blood tests.

OBJECTIVE: To determine the consistency among the practice guidelines of the Dutch College of General Practitioners with respect to the use of blood tests. METHODS: The authors evaluated 64 practice guidelines of the Dutch College of General Practitioners. For each guideline, they analyzed each sentence that contained a reference to a blood test to determine the clinical situation in which the test should be performed (the indication) and to determine the tests that should be performed in that situation (the recommended test). An incomplete recommendation refers to a guideline that mentioned a blood test but did not identify the indication for that test. An inconsistency refers to the situation in which one guideline recommended a certain test for a given indication whereas another guideline mentioned the same indication but did not recommend the same test. RESULTS: Twenty-seven practice guidelines mentioned blood tests. Of these, three explicitly recommended not to request blood tests. Five guidelines contained incomplete recommendations, and the authors encountered two inconsistencies among the guidelines. Twenty-three guidelines mentioned blood tests and allowed the authors to identify indications and recommended tests. CONCLUSION: The identification of indications and recommended tests allows evaluation of consistency among practice guidelines. Although some incomplete recommendations and inconsistencies were discovered, the majority of the guidelines provide clear and unambiguous recommendations for blood-test ordering in primary care.

Postmarketing surveillance based on electronic patient records: the IPCI project.

Researchers claim that data in electronic patient records can be used for a variety of purposes including individual patient care, management, and resource planning for scientific research. Our objective in the project Integrated Primary Care Information (IPCI) was to assess whether the electronic patient records of Dutch general practitioners contain sufficient data to perform studies in the area of postmarketing surveillance studies. We determined the data requirements for postmarketing surveillance studies, implemented additional software in the electronic patient records of the general practitioner, developed an organization to monitor the use of data, and performed validation studies to test the quality of the data. Analysis of the data requirements showed that additional software had to be installed to collect data that is not recorded in routine practice. To avoid having to obtain informed consent from each enrolled patient, we developed IPCI as a semianonymous system: both patients and participating general practitioners are anonymous for the researchers. Under specific circumstances, the researcher can contact indirectly (through a trusted third party) the physician that made the data available. Only the treating general practitioner is able to decode the identity of his patients. A Board of Supervisors predominantly consisting of participating general practitioners monitors the use of data. Validation studies show the data can be used for postmarketing surveillance. With additional software to collect data not normally recorded in routine practice, data from electronic patient record of general practitioners can be used for postmarketing surveillance.