Discussion
CART use increased performance both in degree (percentage change) and in breadth (number of preventive services ordered appropriately). The primary outcome was the appropriateness of physician performance of preventive interventions. For example, if the patient is low-risk, then gonorrhea/chlamydia screening should not be performed, and appropriate physician behavior is to do no screening test. We did not give lectures or provide any other didactic preventive medicine training during the CART study period. But knowledge increased to a similar extent in both groups over that academic year. Nevertheless, the behavioral change seen in the treatment group was temporary; it returned to baseline in the post-intervention period. Therefore, it was the presence of the CART that improved physician behavior. The CART is comprehensive: It has prompts for up to 49 preventive recommendations. Physicians adhered significantly better to history and examination and laboratory recommendations when using the CART. The improvement in counseling was less impressive; physician behavior improved on only 4 of 6 counseling recommendations. It is likely that “form fatigue” was a factor, because the counseling recommendations were at the bottom of a page full of preventive recommendations. The difficulty of counseling, time constraints, and physician perception of the relative ineffectiveness of counseling may have also had an effect.
We believe that the primary reason for the success of the CART is immediate visual access to essential information. Computer reminders promote some behavioral change, but in other studies it was necessary to go to another computer screen for further information about a given test. Time pressure in the busy office makes this difficult. The CART gives physicians succinct information in a box adjacent to each preventive recommendation Table 1, including the recommended frequency, strength of recommendation, and appropriate groups to be screened for each intervention. Most other studies did not answer the question of whether increased knowledge over time was responsible for improved provider behavior. By removing the CART and reassessing physician behavior, we demonstrated that it was presence of the information in the CART format that was responsible for improving physician behavior.
Limitations
Our study has several limitations. We did not address the important issue of reminder systems or checklists. We only assessed the preventive services recommended by physicians during a single periodic health examination. We did not solve the problem of time constraint. It is difficult to cover every single preventive service recommendation in one visit. Our residents are less experienced and have more visit time than the average primary care provider. Finally, we only studied physician knowledge and behavior. We did not measure other important outcomes, such as patient satisfaction, adherence, morbidity, or mortality.
Conclusions
The nonspecific designation “tool” in the CART acronym implies potential future application of this concept for different subject matter and different formats. As we move inexorably toward universal electronic medical records, the CART can be adapted for electronic use. But whether on desktops, laptops, or hand-held computers, immediate visual access to information is essential. Combining the CART with computer reminder systems could yield significant improvement in patient outcomes when followed over time. Also, it would be interesting to incorporate the CART information into a computer-gathered patient history to create a partially completed history and physical examination form for provider use during the periodic health examination. This would save valuable office visit time. Many previous studies have focused on a small number of preventive services. We chose a comprehensive set of recommendations to more closely mimic the experience of primary care physicians who must cover many recommendations with patients. It is important that more studies use this approach. To maximize impact on the public health in an era of cost containment and to minimize physician error, we must enable physicians to efficiently apply a comprehensive set of preventive services in an appropriately focused manner. The CART is an effective step in the right direction.
Acknowledgments
We thank the Advocate Christ Hospital Med Fund for grant support. We would also like to thank Charles Warnell, MD, for his chart review work, and Carolyn Barsano for the literature review.