OBJECTIVE: We assessed the effect of the Comprehensive Annotated Reminder Tool (CART) on physician adherence to preventive services recommendations.
STUDY DESIGN: Using a randomized pretest/posttest control group design, we assigned physicians to the CART group or the control group, followed up prospectively, and evaluated for appropriate adherence to guidelines. The 3 age-specific versions of the CART annotated history and physical examination form contained up to 49 preventive services recommendations.
POPULATION: All resident physicians in a large family practice residency program were studied over the course of 1 academic year.
OUTCOMES MEASURED: We performed blinded chart reviews to assess the appropriateness of preventive services ordered by the physicians before the introduction of the CART, during its use, and after its removal. A multiple-choice test completed before and after the use of the CART forms assessed knowledge.
RESULTS: When the CART was used, the appropriateness of physician preventive behavior increased by 21% overall. The appropriateness of history, physical examination, and laboratory interventions increased by 33%. When the CART was removed, physician behavior returned to baseline (P≤.0025 for 16 of 20 interventions). No significant differences were observed in the control group over time. Knowledge increased during the study period for all physicians (P <.005) but did not differ significantly between the treatment and control groups (P=.608).
CONCLUSIONS: Use of the CART significantly improved physician performance in the appropriate delivery of preventive care.
Frame and Carlson1 published a critical review of periodic health screenings in The Journal of Family Practice in 1975. Such efforts, currently manifested in the United States Preventive Services Task Force (USPSTF), have had a profound impact on the practice of family physicians. Increased oversight of family physicians’ preventive practices by third parties and the increased medical sophistication of the public have fueled demand for preventive health services. Family physicians are experiencing increased accountability to their patients and communities for the effective delivery of preventive medical care.2-4
A number of systems have been developed to assist physicians with the implementation of evidence-based preventive services guidelines. Over the past 15 years, numerous researchers have studied the effects of interventions using flow charts,5-7 checklists,8 computer-based reminders,9-14 and educational programs15-19 for delivery of preventive services. Ornstein and colleagues10 found that the use of a computer-based tracking and reminder system for preventive services, together with a physician education program, modestly increased the frequency of counseling and screening services for patients. Similarly, Cheney and Ramsdell8 found that physicians who received an age- and sex-specific checklist in their patients’ medical charts performed significantly more age- and sex-appropriate preventive services than control physicians. But physician compliance with screening tools is often a problem.6 In the Cheney and Ramsdell study, only 39% of physicians used the available checklist to screen patients. Another study14 found a greater percentage of appropriate health screens by physicians using computerized reminders. However, many physicians did not make use of the available resource. Some studies found only minimal increases in screening rates with interventions such as educational seminars.19 One study5 used a simple flow sheet to analyze appropriate health service needs and noted that their results suggest that a flow sheet, although helpful, is not enough. Indeed, accomplishing sustained improvement in preventive services clinical outcomes is a complex process.20
We investigated the effect of combining a complete set of annotated recommendations with a history and physical examination form on the rate of appropriate application of preventive service recommendations. We suspected that busy practitioners would need preventive services guidelines available at the point of care to be able to adhere closely, so we created a form that is very user-friendly. We also studied the effect of removing the screening tool after the intervention, to evaluate whether the behavioral effect was due to education or to the presence of the chart tool, a question that has not been resolved in several previous studies.
Methods
Study Setting and Instrument
Our study was conducted between June 1997 and June 1998 at a community hospital continuity clinic. Age-appropriate screening history questions, age-specific reminders, and test frequency recommendations drawn from the 1996 USPSTF were integrated into a form for documenting history and physical examinations. This Comprehensive Annotated Reminder Tool (CART) contained 8 sections: history, screening history, physical examination, screening mnemonics, laboratory screens, prophylaxis, counseling, and the assessment/plan section. CART forms were developed for patients aged 19-39, 40-64, and 65 or older. Table w1,Table w2, Table w3 3* Each of these 3-page forms contained guidelines for up to 49 preventive interventions. Twenty recommendations were evaluated in this study. Because nursing has been primarily responsible for ensuring immunization compliance in our setting, we did not expect an effect and only evaluated one immunization.