Background Despite increasing emphasis on the role of clinical decision-support systems (CDSSs) for improving care and reducing costs, evidence to support widespread use is lacking. Purpose To evaluate the effect of CDSSs on clinical outcomes, health care processes, workload and efficiency, patient satisfaction, cost, and provider use and implementation. Data sources MEDLINE, CINAHL, PsycINFO, and Web of Science through January 2011. Study selection Investigators independently screened reports to identify randomized trials published in English of electronic CDSSs that were implemented in clinical settings; used by providers to aid decision making at the point of care; and reported clinical, health care process, workload, relationship-centered, economic, or provider use outcomes. Data extraction Investigators extracted data about study design, participant characteristics, interventions, outcomes, and quality. Data synthesis 148 randomized, controlled trials were included. A total of 128 (86%) assessed health care process measures, 29 (20%) assessed clinical outcomes, and 22 (15%) measured costs. Both commercially and locally developed CDSSs improved health care process measures related to performing preventive services (n= 25; odds ratio [OR], 1.42 [95% CI, 1.27 to 1.58]), ordering clinical studies (n= 20; OR, 1.72 [CI, 1.47 to 2.00]), and prescribing therapies (n= 46; OR, 1.57 [CI, 1.35 to 1.82]). Few studies measured potential unintended consequences or adverse effects. Limitations Studies were heterogeneous in interventions, populations, settings, and outcomes. Publication bias and selective reporting cannot be excluded. Conclusion Both commercially and locally developed CDSSs are effective at improving health care process measures across diverse settings, but evidence for clinical, economic, workload, and efficiency outcomes remains sparse. This review expands knowledge in the field by demonstrating the benefits of CDSSs outside of experienced academic centers. Primary funding source Agency for Healthcare Research and Quality.

Effect of Clinical Decision-Support Systems: A Systematic Review

With recent improvements in the early detection, diagnosis, and treatment of cancer, people with cancer are living longer, and their cancer may be managed as a chronic illness. Cancer as a chronic illness places new demands on patients and families to manage their own care, and it challenges old paradigms that oncology's work is done after treatment. As a chronic illness, however, cancer care occurs on a continuum that stretches from prevention to the end of life, with early detection, diagnosis, treatment, and survivorship in between. In this article, self-management interventions that enable patients and families to participate in managing their care along this continuum are reviewed. Randomized controlled trials of self-management interventions with cancer patients and families in the treatment, survivorship, and end-of-life phases of the cancer care continuum are reviewed, and the Chronic Care Model is presented as a model of care that oncology practices can use to enable and empower patients and families to engage in self-management. It is concluded that the need for a common language with which to speak about self-management and a common set of self-management actions for cancer care notwithstanding, oncology practices can now build strong relationships with their patients and formulate mutually agreed upon care plans that enable and empower patients to care for themselves in the way they prefer.

https://onlinelibrary.wiley.com/doi/pdf/10.3322/caac.20093

Self-management: Enabling and empowering patients living with cancer as a chronic illness†‡

This review is published as a Cochrane Review in the Cochrane Database of Systematic Reviews 2012, Issue 10. Cochrane Reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and the Cochrane Database of Systematic Reviews should be consulted for the most recent version of the Review.

/pdf/collaborative-care-for-depression-and-anxiety-problems-1zevl94j7q.pdf

Collaborative care for depression and anxiety problems

OBJECTIVES: This study examined whether HIV counseling and testing leads to reductions in sexual risk behavior METHODS: The meta-analysis included 27 published studies that provided sexual behavior outcome data, assessed behavior before and after counseling and testing, and provided details sufficient for the calculation of effect sizes The studies involved 19,597 participants RESULTS: After counseling and testing, HIV-positive participants and HIV-serodiscordant couples reduced unprotected intercourse and increased condom use more than HIV-negative and untested participants HIV-negative participants did not modify their behavior more than untested participants Participants' age, volition for testing, and injection drug use treatment status, as well as the sample seroprevalence and length of the follow-up, explained the variance in results CONCLUSIONS: HIV counseling and testing appears to provide an effective means of secondary prevention for HIV-positive individuals but, as conducted in the review

Effects of HIV counseling and testing on sexual risk behavior: a meta-analytic review of published research, 1985-1997

This meta-analysis tested the major theoretical assumptions about behavior change by examining the outcomes and mediating mechanisms of different preventive strategies in a sample of 354 HIV-prevention interventions and 99 control groups, spanning the past 17 years. There were 2 main conclusions from this extensive review. First, the most effective interventions were those that contained attitudinal arguments, educational information, behavioral skills arguments, and behavioral skills training, whereas the least effective ones were those that attempted to induce fear of HIV. Second, the impact of the interventions and the different strategies behind them was contingent on the gender, age, ethnicity, risk group, and past condom use of the target audience in ways that illuminate the direction of future preventive efforts.

/pdf/a-test-of-major-assumptions-about-behavior-change-a-58nhe5pof8.pdf

A Test of Major Assumptions About Behavior Change: A Comprehensive Look at the Effects of Passive and Active HIV-Prevention Interventions Since the Beginning of the Epidemic

To assess sexual behavior changes after voluntary HIV testing and routine counseling the authors interviewed 235 persons at 2 anonymous test sites in North Carolina. Among the 57 (24%) persons returning for followup 1 year later 70% were male; 44% were black 37% were homosexual 10% were bisexual and 16% were HIV positive. Overall 28% of returnees at the initial visit and 33% on the followup visit admitted to having 2 or more sexual partners in the past month. At the initial interview and at followup 21% of returnees reported condom use in the past month. Homosexual men were significantly less likely to use condoms during anal sex over time (58% nonuse initially vs 74% nonuse at followup; p=0.04). No significant net change in high-risk sexual behavior was found at followup. Overall findings indicate that the standard HIV testing and counseling provided by health departments anonymously and free of charge does not result in elimination of high-risk sexual behaviors or initiation of safe sex behaviors among those at high risk for HIV infection. (authors)

Impact of HIV testing and counseling on subsequent sexual behavior.

Purpose The effectiveness and financial benefit of pharmacist-led annual wellness visits (AWVs) in conjunction with comprehensive medication management (CMM) for older, high-risk patients were examined.

Methods Eligible patients were 65 years of age or older with three or more chronic medical conditions, taking five or more long-term prescription or nonprescription medications and receiving primary care in a retirement community clinic. The intervention involved two components, an AWV and CMM. The AWV included all Medicare-required components. All participants saw a clinical pharmacist practitioner for an AWV with CMM and additional CMM visits at three and six months. Outcomes included completion of required AWV components, prevalence of medication-related problems (MRPs), classic return on investment, patient satisfaction, and change in rate of hospitalization.

Results Of the 60 eligible patients contacted, 53 (88%) agreed to participate. Patients’ mean ± S.D. age was 82.1 ± 5.5 years, and patients used a median of 12 medications (range, 5–27) at baseline. The pharmacist identified at least 1 MRP in 90.6% of patients at the AWV; all patients had at least 1 MRP identified over six months. A total of 278 MRPs were identified: suboptimal drug (32.7%), insufficient therapeutic monitoring (25.2%), undertreatment of chronic condition (16.9%), and suboptimal dose, frequency, or administration (15.8%). Revenue generated by the pharmacist exceeded costs by 38.1%. The rate of hospitalizations did not significantly change after the intervention.

Conclusion Pharmacists played a beneficial role in the provision of both AWVs and CMM, facilitating the completion of wellness visits and identifying and addressing MRPs in an older, high-risk population.

Provision of annual wellness visits with comprehensive medication management by a clinical pharmacist practitioner

BACKGROUND The Annual Wellness Visit was designed to enhance preventive services utilization among Medicare beneficiaries; Annual Wellness Visits are underutilized with sparse documented effectiveness. Patients of 3 community-based and 2 retirement community outpatient clinics in western North Carolina had team-based Annual Wellness Visits over a 20-month program, with the goal of improving the uptake and delivery of the Annual Wellness Visit. A clinical pharmacist saw high-complexity patients (≥5 medications) and a licensed practical nurse saw low-complexity patients. We examined the effectiveness of team-based Annual Wellness Visits on patients' use of preventive services.METHOD We conducted a retrospective chart review on a random sample of 500 patients for 12 months post-Annual Wellness Visit. Change over time in use of preventive services was assessed using McNemar's test. Adjusted relative risks of use within 6 months were calculated using generalized linear models with the Poisson loglinear function.RESULTS Overall, utilization of Annual Wellness Visit increased from 14% at baseline to 44% after the 20-month program. The percentage of patients up-to-date with all recommended services increased from 17.4% at the Annual Wellness Visit to 42% within 6 months. Age-appropriate preventive screens and vaccines demonstrated the most improvement (55.8% to 75.4% and 36% to 52.2%, respectively). Community-based patients were less likely to obtain recommended services (RR = 0.618; 95% confidence interval [CI], 0.442-0.865), while patients with supplemental insurance (RR = 1.484; 95% CI, 1.023-2.153), patients seen in subsequent Annual Wellness Visits (RR = 1.405; 95% CI, 1.062-1.858), and patients who were men (RR = 1.422; 95% CI, 1.053-2.041) were more likely to obtain recommended services.LIMITATIONS Generalization is limited by the pre-/post design of one organizational model.CONCLUSION Team-based Annual Wellness Visits with a clinical pharmacist or an LPN, who were supervised by physicians, were associated with significantly improved utilization of preventive services. Use will likely continue to improve as more patients access team-based Annual Wellness Visits yearly.

Improved Utilization of Preventive Services Among Patients Following Team-Based Annual Wellness Visits.

OBJECTIVE: To determine whether mothers feel comfortable with their infants providers discussing contraception with them at their infants well-child checks. METHODS: A cross-sectional survey was conducted using a convenience sample of 114 mothers presenting at a community family medicine residency program for well-child visits among infants up to 17 months old. RESULTS: Almost all mothers (87%) felt comfortable talking with their infants providers about contraception and were likely to accept the advice of their infants providers to see their own doctors regarding contraception (83%) or to use a prescription from their infants providers for contraception (75%). CONCLUSION: Many mothers miss or delay their postpartum visits but see their infants doctor multiple times within the first year. Mothers are comfortable talking with infant providers about contraception. By discussing contraception with mothers at well-child visits physicians may encourage mothers to use contraception and prevent unintended pregnancies.

A survey of mothers' comfort discussing contraception with infant providers at well-child visits.

Integrated collaborative care (ICC) combines medical and behavioral health services in the primary care setting. Our family medicine residency program implemented care across three different models of integration over five years, allowing retrospective, cohort evaluation of the changes in behavioral health services and patient outcomes for depression. We identified three time periods representing increasing levels of services: Colocation of behavioral health services in 2004-05 (CL), primary care behavioral health model (behavioral health providers embedded in primary care) in 2009 (PCBH), and a blended model of PCBH and care management for depression in early 2010 (BM). All adult patient charts (n = 552) with PHQ9 scores ≥10 were analyzed for number of provider contacts (physician and behavioral health) and changes in scores during the 12-week follow-up. The percent of patients receiving adequate care (≥3 provider contacts in 12 weeks) improved from 43.5% (CL) to 55.1% (PCBH) to 60.6% (BM; Pearson chi-square, p = .02). Forty-two percent of patients in BM achieved remission (PHQ9 ≤ 4), 25.2% in PCBH and 12% in CL (Pearson chi-square, p = .02). The Blended Model resulted in better access to behavioral health care and outcomes for patients with depression symptoms.

Effects of different models of integrated collaborative care in a family medicine residency program.

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