Recordatorios generados por ordenador entregados en papel a los profesionales sanitarios: efectos en la práctica profesional y los resultados de la atención médica
Información
- DOI:
- https://doi.org/10.1002/14651858.CD001175.pub4Copiar DOI
- Base de datos:
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- Cochrane Database of Systematic Reviews
- Versión publicada:
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- 06 julio 2017see what's new
- Tipo:
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- Intervention
- Etapa:
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- Review
- Grupo Editorial Cochrane:
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Grupo Cochrane de Práctica y organización sanitaria efectivas
- Copyright:
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- Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cifras del artículo
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Autores
Contributions of authors
CA led the update process. CA extracted and analyzed the updated data. CA amended the text of the review. BB reviewed the updated review. MR and PD read and commented on the final version.
Sources of support
Internal sources
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Health Services Research Unit, University of Aberdeen, UK.
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Centre Hospitalier Vaudois and University of Lausanne, Switzerland.
External sources
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Loterie Romande, Lausanne, Switzerland.
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Department of Community Medicine and Community Healthcare, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
Research Grant
Declarations of interest
Chantal Arditi: none known.
Myriam Rège‐Walther: none known.
Pierre Durieux: none known.
Bernard Burnand: none known.
Acknowledgements
For this update, we would like to acknowledge the contribution of the following individuals who helped with data selection and extraction: Julia Worswick (JW), Sebastien Bacher (SB), and Sharlini Yogasingam (SY).
We would also like to acknowledge the support of the National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to the Effective Practice and Organisation of Care (EPOC) Group, and the Ottawa Hospital Research Institute (OHRI) supporting JW and SY. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, National Health Service (NHS), or the Department of Health.
We were unable to contact Jeremy Wyatt (co‐author of the original version of the review) for this update. We acknowledge here his contribution to the original version of the review.
Version history
| Published | Title | Stage | Authors | Version |
| 2017 Jul 06 | Computer‐generated reminders delivered on paper to healthcare professionals: effects on professional practice and healthcare outcomes | Review | Chantal Arditi, Myriam Rège‐Walther, Pierre Durieux, Bernard Burnand | |
| 2012 Dec 12 | Computer‐generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes | Review | Chantal Arditi, Myriam Rège‐Walther, Jeremy C Wyatt, Pierre Durieux, Bernard Burnand | |
| 2010 May 12 | Computer‐generated paper reminders: effects on professional practice and health care outcomes | Protocol | Chantal Arditi, Myriam Rège‐Walther, Bernard Burnand, Jeremy Wyatt | |
| 1998 Jul 27 | Computer‐generated paper reminders: effects on professional practice and health care outcomes | Protocol | Paul Gorman, Craig Redfern, Teng Liaw, Susan Carson, Jeremy Wyatt, Rachel Rowe, Jeremy Grimshaw | |
Differences between protocol and review
The search strategies were revised and updated by Paul Miller, the Information Specialist at EPOC. Text sections of the review were updated to reflect the latest Cochrane and EPOC guidance for conducting and reporting reviews.(e.g. certainty of evidence).
We changed the wording of the outcomes: instead of 'process adherence outcomes', we now use 'quality of care outcomes', and instead of 'clinical outcomes', we now use 'patient outcomes', in line with EPOC guidelines (EPOC 2015d). We classified quality of care outcomes as primary outcomes and patient outcomes as secondary outcomes. We added adverse effects outcomes as secondary outcomes and added a subgroup analysis on disadvantaged populations.
Keywords
MeSH
Medical Subject Headings (MeSH) Keywords
- *Medical Records;
- *Outcome and Process Assessment, Health Care;
- *Practice Patterns, Physicians' [standards];
- *Reminder Systems [classification, standards];
- Clinical Competence;
- Non‐Randomized Controlled Trials as Topic [statistics & numerical data];
- Patient Compliance;
- Quality of Health Care;
- Randomized Controlled Trials as Topic [statistics & numerical data];
Medical Subject Headings Check Words
Humans;
PICO
Study flow diagram
*Ineligible comparison or inappropriate control: e.g. physician reminder combined with another intervention vs usual care, physician reminder with a specific feature vs physician reminder without it, physician reminder vs another intervention
$Not a provider reminder: e.g. audit and feedback, changes in medical records system, expert system for estimating diagnosis/risk/dosage, patient‐mediated intervention
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
Absolute improvement of quality of care by study, using the primary outcome defined by authors (represented by a red dot), and median improvement by study, using the median outcome of all reported quality of care outcomes (represented by a blue square (the median) and blue line (interquartile range))
Median effect and interquartile range (IQR) across comparisons by reminder feature (P values reflect Mann–Whitney test)
Median effect and interquartile range (IQR) across comparisons by study feature (*Kruskall–Wallis test; other P values reflect Mann–Whitney test)
| Computer‐generated reminders delivered on paper to healthcare professionals, alone or in addition to co‐intervention(s), compared with usual care or the co‐intervention(s) without the reminder component | ||||
| Patient or population: Healthcare professionals Settings: Outpatient care in Canada, France, Israel, Kenya and USA Intervention: Reminders automatically generated through a computerized system (computer‐generated) and delivered on paper to healthcare professionals, alone or in addition to one or more co‐interventions, aimed at enhancing compliance with preventive guidelines (e.g. cancer screening tests, vaccination) or disease management guidelines for acute or chronic conditions (e.g. annual follow‐ups, laboratory tests, medication adjustment, counseling) Comparison: Usual care or co‐intervention(s) without reminder component | ||||
| Outcomes | Median improvement | Number of studies (comparisons) | Certainty of the evidence | Comments |
| Quality of care | Pooling data across the 40 comparisons, the median improvement in quality of care associated with the reminder intervention was 6.8% (IQR 3.8% to 17.5%). | 34 studies (40 comparisons) | ⊕⊕⊕⊝ | Quality of care was measured by various rates: e.g. test ordering rates, vaccination rates, follow‐up rates, prescription rates, overall compliance rate. |
| Patient outcomes | Not estimable | 6 studies (7 comparisons) | ⊕⊝⊝⊝ | No measurable effect on i) blood pressure, glycated hemoglobin and cholesterol levels, ii) reaching blood pressure, glycated hemoglobin and cholesterol targets, and iii) mortality. |
| Adverse effects | Not reported | ‐ | ‐ | None of the included studies reported outcomes related to harms or adverse effects of reminders. |
| IQR: interquartile range | ||||
| GRADE Working Group grades of evidence | ||||
| 1 We downgraded the level of certainty of the evidence from high to moderate because of methodological limitations in the included studies and possible publication bias. We did not find other serious limitations in the other factors (indirectness of evidence, inconsistency of results, and imprecision of results). 2 We downgraded the level of certainty of the evidence from high to very low because of methodological limitations in the included studies, imprecision of results (wide confidence intervals) and inconsistency of the results. | ||||
| Computer‐generated reminders delivered on paper to healthcare professionals alone (single‐component intervention) compared with usual care | ||||
| Patient or population: Healthcare professionals Settings: Outpatient care in Canada, France, Israel, Kenya and USA Intervention: Computer‐generated reminders delivered on paper alone (single‐component intervention) Comparison: Usual care | ||||
| Outcomes | Median improvement | Number of studies (comparisons) | Certainty of the evidence | Comments |
| Quality of care | Pooling data across the 27 comparisons, the median improvement in quality of care associated with the reminder intervention was 11.0% (IQR 5.4% to 20.0%) | 27 studies (27 comparisons) | ⊕⊕⊕⊝ | Quality of care was measured by various rates: e.g. test ordering rates, vaccination rates, follow‐up rates, prescription rates, overall compliance rate. |
| Patient outcomes | Not estimable | 4 studies (4 comparisons ) | ⊕⊝⊝⊝ | No measurable effect on i) blood pressure, glycated hemoglobin and cholesterol levels, ii) reaching blood pressure, glycated hemoglobin and cholesterol targets, and iii) mortality. |
| Adverse effects | Not reported | ‐ | ‐ | None of the included studies reported outcomes related to harms or adverse effects of reminders. |
| IQR: interquartile range | ||||
| GRADE Working Group grades of evidence | ||||
| 1 We downgraded the level of certainty of the evidence from high to moderate because of methodological limitations in the included studies and possible publication bias. We did not find other serious limitations in the other factors (indirectness of evidence, inconsistency of results, and imprecision of results). 2 We downgraded the level of certainty of the evidence from high to very low because of methodological limitations in the included studies, imprecision of results (wide confidence intervals) and inconsistency of the results. | ||||
| Computer‐generated reminders delivered on paper to healthcare professionals in addition to one or more co‐interventions (multi‐component intervention) compared with the co‐intervention(s) without the reminder component | ||||
| Patient or population: Healthcare professionals Settings: Outpatient care in Canada and USA Intervention: Computer‐generated reminders delivered on paper in addition to one or more co‐interventions (multi‐component intervention) Comparison: Co‐intervention(s) without the reminder component | ||||
| Outcomes | Median improvement (interquartile range) | Number of studies (comparisons) | Certainty of the evidence | Comments |
| Quality of care | Pooling data across the 13 comparisons, the median improvement in quality of care associated with the reminder intervention was 4.0% (3.0% to 6.0%) | 11 studies (13 comparisons) | ⊕⊕⊕⊝ | Quality of care was measured by various rates: e.g. test ordering rates, vaccination rates, follow‐up rates, prescription rates, overall compliance rate. |
| Patient outcomes | Not estimable | 2 studies (3 comparisons) | ⊕⊝⊝⊝ | No measurable effect on i) blood pressure, glycated hemoglobin and cholesterol levels, ii) reaching blood pressure, glycated hemoglobin and cholesterol targets, and iii) mortality. |
| Adverse effects | Not reported | ‐ | ‐ | None of the included studies reported outcomes related to harms or adverse effects of reminders. |
| IQR: interquartile range | ||||
| GRADE Working Group grades of evidence | ||||
| 1 We downgraded the level of certainty of the evidence from high to moderate because of methodological limitations in the included studies and possible publication bias. We did not find other serious limitations in the other factors (indirectness of evidence, inconsistency of results, and imprecision of results). 2 We downgraded the level of certainty of the evidence from high to very low because of methodological limitations in the included studies and imprecision of results (wide confidence intervals). | ||||
| Study ID | Primary outcome | Other outcomes (n) | Absolute improvement ‐ using primary outcome | Median absolute improvement ‐ using other outcomes (interquartile range) |
|
| percentage of eligible patients with: blood pressure values on record, follow‐up (2) |
| 38.8% (18.4% to 59.1%) | |
| overall compliance rate with preventive care recommendations | percentage of eligible patients with: dental check, ocular pressure check, FOBT, flu vacc, pneumo vacc, tetanus vacc, mammography, pap smear (8) | 4.7% | 5.8% (3.0% to 10.2%) | |
| percentage of eligible patients with pap smear |
| 7.6% |
| |
| percentage of eligible patients with mammography |
| 6.0% |
| |
| percentage of eligible patients with mammography |
| 4.0% |
| |
| percentage of eligible patients with pap smear |
| 1.0% |
| |
| percentage of eligible patients with pap smear |
| 3.0% |
| |
| percentage of eligible patients with mammography |
| 7.1% |
| |
| percentage of eligible patients with flu vacc |
| 20.7% |
| |
|
| percentage of eligible patients with: discussion of directives, completion of directives (2) |
| 9.2% (6.1% to 12.3%) | |
| percentage of patients with adequate monitoring, percentage of eligible patients with initiation or up‐titration of statin therapy, percentage of eligible patients with up‐titration (3) | 5.4% (1.2% to 6.1%) | |||
| percentage of eligible patients with ACE inhibitor prescription |
| 11.5% |
| |
| percentage of eligible patients with any β‐blocker prescription | percentage of eligible patients with recommended β‐blocker prescription | 7.9% | 6.7% (5.4% to 7.9%) | |
| percentage of eligible patients with advance directives | percentage of eligible patients with: discussion or completion of directives, completion of healthcare proxy, completion of living will (3) | ‐0.2% | ‐0.3% (‐0.9% to ‐0.2%) | |
| compliance rate with prescription reminders (start a new drug) (denominator: reminders) |
| 7.0% |
| |
| adherence to colorectal cancer screening | 1.7% | |||
| overall physician compliance rate | physician compliance rate with: foot exam, physical exam, glycated hemoglobin, urine protein determination, cholesterol level, eye exam, flu vacc, pneumo vacc (8) | 16.4% | 22.7% (11.0% to 28.4%) | |
| overall compliance rate with prescription reminders | percentage of eligible patients with: ACE inhibitor or ARB therapy prescription, statins prescription | 6.0% | 9.0% (0.0% to 18.0%) | |
|
| physician compliance rate with: glycated hemoglobin, fasting blood glucose, home‐monitored blood glucose, diet clinic referral, oral hypoglycemic agents (5) |
| 4.0% (4.0% to 5.0%) | |
| overall compliance rate with prescription reminders | percentage of eligible patients with: statins, standardized statin dose, another lipid‐lowering drug, acetylsalicylic acid, acetylsalicylic acid or thienopyridine, ACE inhibitor, ACE inhibitor or ARB, β‐blocker, triple therapy (8) | 6.6% | 0.5% (‐0.4% to 2.2%) | |
| overall compliance rate with prescription reminders (denominator: reminders) | compliance with: observing a physical finding or inquiring about a symptom, ordering a diagnostic study, changing or initiating a therapeutic regimen (3) | 28.9% | 24.7% (21.1% to 38.8%) | |
| overall compliance rate with reminders (denominator: reminders) | percentage of patients with: test order, therapeutic change (2) | 23.5% | 20.3% (14.9% to 25.7%) | |
| overall compliance rate with reminders (denominator: reminders) |
| 18.6% |
| |
| overall compliance rate with reminders | percentage of patients with: FOBT, pap smear, chest roentgenogram, pneumo vacc, tuberculosis skin test, serum potassium, mammogram, flu vacc, diet, digitalis, antacids, β‐blockers (12) | 20.0% | 13.0% (10.5% to 24.5%) | |
|
| physician compliance rate with: FOBT, rectal exam, sigmoidoscopy, pap smear, pelvic exam, breast exam, mammography (7) |
| 23.0% (20.0% to 33.0%) | |
|
| physician compliance rate with: breast exam, mammography (2) |
| 23.2% (20.0% to 26.5%) | |
|
| percentage of patients with: blood group and type, syphilis serology, prenatal counseling, pregnancy diet counseling, sickle cell preparation (5) |
| 0.1% (‐1.9% to 2.0%) | |
| overall physician compliance rate with reminders |
| 3.9% |
| |
|
| percentage of eligible patients with: FOBT, mammography, tetanus vacc, cholesterol, pap smear (5) |
| 4.4% (3.9% to 6.9%) | |
|
| percentage of eligible patients with: FOBT, mammography, tetanus vacc, cholesterol, pap smear (5) |
| 6.1% (3.9% to 7.0%) | |
| overall compliance rate | percentage of eligible patients with: flu vacc, tetanus vacc, BP reading, pap smear (4) | 19.2% | 11.4% (6.0% to 16.4%) | |
| percentage of eligible patients with prescription change |
| 11.0% |
| |
| compliance rate with reminders |
| 12.9% |
| |
|
| physician compliance rate with: FOBT, pneumo vacc, antacids, TB skin testing, β‐blockers, nitrates, anti‐depressants, calcium supplements, pap smear, mammography, metronidazole, digitalis, salicylates (13) |
| 1.5% (0.5% to 11.0%) | |
|
| physician compliance rate with: FOBT, pneumo vacc, antacids, TB skin testing, β‐blockers, nitrates, anti‐depressants, calcium supplements, pap smear, mammography, metronidazole, digitalis, salicylates (13) |
| 1.0% (‐0.5% to 2.0%) | |
|
| physician compliance rate with: FOBT, rectal exam, pap smear, breast exam, mammography (5) |
| 3.6% (‐5.8% to 10.1%) | |
| completion of overdue clinical tasks (denominator: reminders) | completion of overdue clinical task for: ordering chest x‐ray, ordering 18‐mo human immunodeficiency virus enzyme‐linked immunosorbent assay, ordering other laboratory tests, beginning antiretroviral therapy, referring to nutritional support (5) | 50.0% | 39.0% (26.0% to 54.0%) | |
| compliance rate with reminders (denominator: reminders) |
| 12.0% |
| |
| physician compliance rate |
| 0.2% |
| |
| physician compliance rate |
| 0.7% |
| |
| ACE: angiotensin‐converting enzyme, ARB: angiotensin II receptor blockers, BP: blood pressure, flu: influenza, FOBT: fecal occult blood test, pneumo: pneumococcal, TB: tuberculosis, Vacc: vaccination | ||||
| Median improvement (interquartile range) | |||
| Using primary (or median) outcome | Using largest outcome | Using smallest outcome | |
| All (n = 40) | 6.8% (3.8% to 17.5%) | 12.0% (6.1% to 20.2%) | 4.0% (0.5% to 11.3%) |
| Reminders alone (n = 27) | 11.0% (5.4% to 20.0%) | 12.3% (7.0% to 33.5%) | 6.1% (1.2% to 12.9%) |
| Reminders with co‐intervention(s) (n = 13) | 4.0% (3.0% to 6.0%) | 9.8% (3.9% to 12.5%) | 0.7% (‐1.9% to 3.6%) |
| Study ID | Patient outcome: percentage difference between groups at follow‐up | Patient outcome: mean difference between groups at follow‐up |
| Percentage of patients with BP<100 or receiving treatment at 12 mo: 18.1% | ||
| Event‐free survival: ‐2.1% | LDL level: ‐2.4 mg/dL | |
| Mortality: hazard ratio: 0.98 (95% CI: 0.78 to 1.23) | Diastolic BP: 0 Systolic BP: 0 | |
| Mortality: 1% | ||
| Diastolic BP: ‐4 Systolic BP: 0 | ||
| Percentage of patients with Hba1c<7.0%: OR: 0.98 (95% CI: 0.86 to 1.12) Percentage of patients with systolic BP<130: OR: 1.04 (95% CI: 0.94 to 1.16) Percentage of patients with LDL<100: OR 0.92 (95% CI: 0.79 to 1.08) | Hba1c: 0.1 Systolic BP: ‐1.2 LDL level: 2.5 mg/dL | |
| Percentage of patients with Hba1c<7.0%: OR: 0.99 (95% CI: 0.82 to 1.19) Percentage of patients with systolic BP<130: OR: 0.92 (95% CI: 0.79 to 1.06) Percentage of patients with LDL<100: OR 1.05 (95% CI: 0.84 to 1.31) | Hba1c: 0.4 Systolic BP: 0.8 LDL level: 3.0 mg/dL | |
| BP: blood pressure, Hba1c: glycated hemoglobin, LDL: low‐density lipoprotein, mo: months | ||
