Automated reminders do not always improve follow-up of abnormal test results

In an attempt to increase the rate of documented follow-up of abnormal lab test results, an automated one-week-later reminder module was added to our lab data system. Provision of reminders to providers did not produce the expected improvement. It appears that in clinics with difficult access to conventional patient records, reminders do not improve documentation, and may elicit resistance and resentment.     

Text messaging reminders to reduce non-attendance in chronic disease follow-up: a clinical trial

Background

Non-attendance results in administrative problems and disruption in patient care. Several interventions have been used to reduce non-attendance, with varying degree of success. A relatively new intervention, text messaging, has been shown to be as effective as telephone reminders in reducing non-attendance. However, no study has looked specifically at using text messaging reminders to reduce non-attendance in chronic disease care.

Aim

To determine if text messaging would be effective in reducing non-attendance in patients on long-term follow-up, compared with telephone reminders and no reminder.

Design of study

A randomised controlled trial with three arms: text messaging reminder, telephone reminder, and control.

Setting

Two primary care clinics in Malaysia.

Method

A total of 931 subjects who had been on at least 6 months of follow-up were randomised into the three groups. Demographic variables were recorded at the first visit. In the intervention arms, a reminder was sent 24–48 hours prior to the appointment. Non-attendance rate was documented at the second visit. Non-attenders were defined as those who did not attend, attended early, or attended late without rescheduling their appointment. Attenders were defined as participants who had turned up for their scheduled appointment and those who had changed or cancelled their appointment with notification.

Results

The non-attendance rates in the text messaging group (odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.41 to 0.93, P = 0.020) and the telephone reminder group (OR = 0.53, 95% CI = 0.35 to 0.81), P = 0.003) were significantly lower than the control group. The absolute non-attendance rate for telephone reminders was lower by 2% compared to the text messaging group. This difference was not found to be statistically significant (P = 0.505).

Conclusion

Text messaging was found to be as effective as telephone reminder in reducing non-attendance in patients who required long-term follow-up for their chronic illnesses in this study. It could be used as an alternative to conventional reminder systems.     

Factors associated with improved completion of computerized clinical reminders across a large healthcare system

OBJECTIVE: To analyze the relationship of completion rates for a standardized set of computerized clinical reminders across a large healthcare system to practice and provider characteristics. METHODS: The relationship between completion rate for 13 standardized reminders at 49 primary care practices in the VA New England Healthcare System for a 30-day period and practice characteristics, provider demographics and, via survey, provider attitudes was analyzed. RESULTS: There was no difference in clinical reminder completion rate between staff physicians versus nurse practitioners/physician assistants (87.6% versus 88.1%) but both were better than residents (76.6%, p<0.0001). With residents excluded, there were no differences between hospital and community-based clinics or between teaching and non-teaching sites. Clinical reminder completion rate was lower for sites that did not fully utilize support staff in completion process versus sites that did (82.4% versus 88.1%, p<0.0001). Analysis of survey results showed no correlation of completion rate with provider demographics or attitudes towards reminders. However there was significant correlation with frequency of receiving individual feedback on reminder completion (r=0.288, p=0.004). CONCLUSION: Completion of computerized clinical reminders was not affected by a variety of provider characteristics, including professional training, demographics and provider attitude, although was lower among residents than staff providers. However incorporation of support staff into clinic processes and individualized feedback to providers were strongly associated with improved completion. These findings demonstrate the importance of considering practice and provider factors and not just technical elements when implementing informatics tools.     

Electronic reminders for pathologists promote recognition of patients at risk for Lynch syndrome: cluster-randomised controlled trial

We investigated success factors for the introduction of a guideline on recognition of Lynch syndrome in patients recently diagnosed with colorectal cancer (CRC) below age 50 or a second CRC below age 70. Pathologists were asked to start microsatellite instability (MSI) testing and report to surgeons with the advice to consider genetic counselling when MSI test or family history was positive. A multicentre cluster-randomised controlled trial (ClinicalTrials.gov, number NCT00141466) was performed in 12 pathology laboratories (clusters), serving 29 community hospitals. All received an introduction to the new guideline. In the intervention group, surgeons received education and tumour test result reminders; pathologists were provided with inclusion criteria cards, an electronic patient inclusion reminder system and feedback on inclusion. Two hundred sixty-six CRC patients were eligible for recognition as at risk for Lynch syndrome. The actual recognition was 18% more successful in the intervention as compared to the control arm (77% (120 of 156) compared to 59% (65 of 110)), with an adjusted odds ratio (OR) = 2.8 (95% confidence interval (CI) 1.1–7.0). The electronic reminder system for pathologists was most strongly associated with recognition of high-risk patients, OR = 4.2 (95% CI 1.7–10.1). An electronic reminder system for pathologists appeared effective for adherence to a new complex guideline and will enhance the recognition of Lynch syndrome.     

Psychosocial and educational outcomes associated with home- and clinic-based pretest education and cystic fibrosis carrier testing among a population of at-risk relatives

We report on the psychosocial and knowledge outcomes of two different approaches to cystic fibrosis (CF) gene pretest education and carrier testing offered to 288 proactively recruited first-, second-, and third-degree relatives of people with CF. One group received pretest education and gene testing in a clinical setting from a certified genetic counselor. The other group received pretest education in their homes from a specially prepared pamphlet and were asked to send in a buccal cell sample for genotyping. No statistically significant differences between groups were noted on measures of CF knowledge, anxiety, and positive or negative affect, either while waiting for their test results or within a few weeks after they had learned their results. At both measurement points, participants who had received home education and testing reported that the testing was more convenient, but that they had received less information than they would have liked, and they were more likely to report being confused by the testing, although their level of CF knowledge was comparable to that of people who had been seen by a genetic counselor. In light of the increasing interest in home-based medical testing of all kinds, this study suggests that CF carrier testing in the home warrants further consideration as one possible approach to facilitating access to testing. Am. J. Med. Genet. 75:461–468, 1998. © 1998 Wiley-Liss, Inc.     

Incorporating genetics services into adult kidney disease care

Studies have shown that as many as 1 in 10 adults with chronic kidney disease has a monogenic form of disease. However, genetic services in adult nephrology are limited. An adult Kidney Genetics Clinic was established within the nephrology division at a large urban academic medical center to increase access to genetic services and testing in adults with kidney disease. Between June 2019 and December 2021, a total of 363 patients were referred to the adult Kidney Genetics Clinic. Of those who completed genetic testing, a positive diagnostic finding was identified in 27.1%, a candidate diagnostic finding was identified in 6.7% of patients, and a nondiagnostic positive finding was identified in an additional 8.6% of patients, resulting in an overall yield of 42.4% for clinically relevant genetic findings in tested patients. A genetic diagnosis had implications for medical management, family member testing, and eligibility for clinical trials. With the utilization of telemedicine, genetic services reached a diverse geographic and patient population. Genetic education efforts were integral to the clinic's success, as they increased visibility and helped providers identify appropriate referrals. Ongoing access to genomic services will remain a fundamental component of patient care in adults with kidney disease.     

Clinical effect of computer generated physician reminders in health screening in primary health care--a controlled clinical trial of preventive services among the elderly

OBJECTIVES: To apply and evaluate the effects of a program for computer generated physician reminders, integrated with an electronic patient record (EPR) system, for opportunistic health screening in elderly patients. DESIGN: A pilot study designed as a 20-month clinical trial with a control group and a 20-month non-intervention follow-up using a computer reminder program that selects patients for screening in five intervention areas (diabetes, hypertension, cobalamin deficiency, hypothyroidism and anaemia). SETTING: Four primary health care (PHC) centres in suburban Stockholm. SUBJECTS: The intervention was designed for patients 70 years or older from one health care centre who visited a general practitioner (GP) during the first 20-month period. Patients from the three remaining centres served as controls. MAIN OUTCOME MEASURES: The number of patients who underwent the tests, who had pathological test results, new diagnoses and new pharmacological treatments in both patient groups. RESULTS: In total, 602 patients underwent screening and 1989 were controls. There was a statistically significant, moderate or marked increase (13-75%) in the number of patients who were tested in all five intervention areas. An increase in pathological test results (1-8%) was found in two areas: hypertension and cobalamin deficiency. There was an increase in the number of patients with the diagnosis of cobalamin deficiency during the study. At follow-up a decrease in new diagnoses for anaemia was found. CONCLUSION: The system seems to be associated with a moderate to large increase in laboratory and manual screening tests for both established and new screening areas. The effect on clinical outcomes was found mainly in a not-yet-established screening area (cobalamin deficiency), indicating that the system may be clinically useful when introducing new screening services.     

Cue enhancement and the long-term practice of breast self-examination

This study investigates the stimulus control of breast self-examination (BSE) using two methods of cue enhancement: self-managed use of calendars with sticker reminders and monthly reminder postcards. One hundred eighty-nine women patient volunteers with or without menstrual cycles ("cyclic" or "non-cyclic") were randomly assigned to experimental conditions after an initial interview and teaching session. Their monthly BSE records, returned by mail during the 6-month experimental period, constituted the major dependent measure of the study. Results indicate an overall positive effect of postcard reminders and a positive effect for self-management for the cyclic women only. In addition, noncyclic women practiced BSE at a higher rate than cyclic women. A subsequent analysis clarified these results substantially by showing that timing of the postcard and use of self-management account for these group differences. Thus, the interventions seem to be extraordinarily effective in obtaining high rates of BSE over 6 months provided only that they can be appropriately instituted. During the postexperimental period, the rate of BSE practice declined, especially in the postcard conditions. Results are discussed in terms of the applicability of behavioral analysis to intractable problems of patient compliance.     

Validation of a knowledge based reminder system for diagnostic test ordering in general practice.

We describe the validation of a real-time automated reminder system that assists General Practitioners (GP) in appropriate test ordering. We compared the comments of human experts with the comments of the reminder system using a retrospective random selection of 253 request forms. A panel of three expert physicians judged the requested tests independently based on their interpretations of the practice guidelines. The majority assessment of the physicians was compared with the assessment of the reminder system. In case the system's output differed from the majority assessment the written practice guidelines were consulted. On average 1.75 reminders were produced per form. In total 32 of the 442 given reminders (7%) were given incorrectly. The amount of information and the level of detail (the specificity of the terms) in which the GP describes the patients' medical status are crucial for the reminder system to react correctly.     

Recruitment of women by GPs for pap tests: a meta-analysis.

General practitioners (GPs) have a pivotal role to play in recruiting women for Pap tests. In recent times, considerable attention has been paid to the role of reminder systems in encouraging women to have regular Pap tests. Although a number of studies have investigated the effectiveness of reminder systems, there has been no comprehensive review. This paper aims to determine the effectiveness of patient and GP reminders in increasing the proportion of women screened for cervical cancer. Two electronic databases were searched for English-language randomized controlled trials conducted in a general practice or family medicine setting, and examining the effectiveness of GP and patient reminders in increasing the proportion of women screened for cervical cancer. Ten trials were identified, and meta-analytic techniques were employed to analyse the data from these trials. The women whose GPs had been prompted to remind them to have a Pap test were significantly more likely to do so than were control women (typical risk difference (TRD) = 6.6%, 95% CI = 5.2%-8.0%). The typical risk difference for the patient reminder studies was 4.9% (95% CI = 2.6%-7.2%). In both cases, sensitivity analysis revealed that one study stood out as an exceptional result. The omission of this study induced homogeneity among the remaining studies. Once this study was removed, the TRDs for the GP reminder and patient reminder studies were 7.9% (95% CI = 6.5%-9.4%) and 10.8% (95% CI = 8.1%-13.6%), respectively. The results strongly suggest that GPs should make use of GP and patient reminder systems.     

Long‐term maintenance of infant memory

The present experiments with human infants asked whether periodic nonverbal reminders could maintain a memory established at 2 months of age over a substantial period of development. In Experiment 1, a reactivation reminder recovered infants' forgotten memory after 3 weeks, but a reinstatement reminder did not. In Experiment 2, 2‐month‐olds received a reminder every 3 weeks through 6½ months of age and a final test at 7¼ months of age. A preliminary retention test preceded each reminder; which type of reminder (reinstatement or reactivation) infants received depended on performance during this test. Infants exhibited significant retention 4½ months later, and most remembered 5¼ months later, when infants outgrew the task. Untrained controls exhibited no retention after any delay. These data confirm that periodic reminders can maintain early memories over significant periods of development and challenge popular claims that preverbal human infants cannot maintain memories over the long term because of neural immaturity or an inability to rehearse experiences by talking about them. © 1999 John Wiley & Sons, Inc. Dev Psychobiol 35: 91–102, 1999     

Association between health-service use and multiplex genetic testing

PurposeThe objective of this work was to examine whether offers of multiplex genetic testing increase health-care utilization among healthy patients aged 25–40 years. The identification of genetic variants associated with common disease is accelerating rapidly. “Multiplex tests” that give individuals feedback on large panels of genetic variants have proliferated. Availability of these test results may prompt consumers to use more health-care services.MethodsA total of 1,599 continuously insured adults aged 25–40 years were surveyed and offered a multiplex genetic susceptibility test for eight common health conditions. Health-care utilization from automated records was compared in 12-month pre- and posttest periods among persons who completed a baseline survey only (68.7%), those who visited a study website but opted not to test (17.8%), and those who chose the multiplex genetic susceptibility test (13.6%).ResultsIn the pretest period, persons choosing genetic testing used an average of 1.02 physician visits per quarter as compared with 0.93 and 0.82 for the baseline-only and Web-only groups, respectively (P < 0.05). There were no statistically significant differences by group in the pretest use of any common medical tests or procedures associated with four common health conditions. When changes in physician and medical test/procedure use in the posttest period were compared among the groups, no statistically significant differences were observed for any utilization category.ConclusionsPersons offered and completing multiplex genetic susceptibility testing used more physician visits before testing, but testing was not associated with subsequent changes in use. This study supports the supposition that multiplex genetic testing offers can be provided directly to the patients in such a way that use of health services is not inappropriately increased.Genet Med 2012:14(10):852–859     

Genetic disorders that masquerade as multiple sclerosis

There are many genetic disorders that have signs and symptoms suggestive of multiple sclerosis and that may easily be overlooked in the evaluation of both adult and pediatric multiple sclerosis patients. The recognition of a genetic disorder as the cause of a patient's “multiple sclerosis” phenotype has important implications not only for the patient, but often also for others in the patient's family who may be at risk for the same disease. We present here a review of single gene disorders that can masquerade as multiple sclerosis. For each disorder, the major clinical and biochemical characteristics are discussed, together with the appropriate testing to screen for and confirm the diagnosis. In addition, guidelines are presented for when to suspect an underlying genetic condition in a patient with a diagnosis of definite or probable multiple sclerosis. The great variety of genetic disorders that can masquerade as multiple sclerosis and the many implications of a genetic diagnosis underscore the importance of recognizing genocopies of multiple sclerosis. © 1994 Wiley-Liss, Inc.     

A computerized reminder system to increase the use of preventive care for hospitalized patients

BACKGROUND: Although they are effective in outpatient settings, computerized reminders have not been proved to increase preventive care in inpatient settings. METHODS: We conducted a randomized, controlled trial to determine the effects of computerized reminders on the rates at which four preventive therapies were ordered for inpatients. During an 18-month study period, a computerized system processed on-line information for all 6371 patients admitted to a general-medicine service (for a total of 10,065 hospitalizations), generating preventive care reminders as appropriate. Physicians who were in the intervention group viewed these reminders when they were using a computerized order-entry system for inpatients. RESULTS: The reminder system identified 3416 patients (53.6 percent) as eligible for preventive measures that had not been ordered by the admitting physician. For patients with at least one indication, computerized reminders resulted in higher adjusted ordering rates for pneumococcal vaccination (35.8 percent of the patients in the intervention group vs. 0.8 percent of those in the control group, P<0.001), influenza vaccination (51.4 percent vs. 1.0 percent, P< 0.001), prophylactic heparin (32.2 percent vs. 18.9 percent, P<0.001), and prophylactic aspirin at discharge (36.4 percent vs. 27.6 percent, P<0.001). CONCLUSIONS: A majority of hospitalized patients in this study were eligible for preventive measures, and computerized reminders significantly increased the rate of delivery of such therapies.     

Commercialization of BRCA1/2 testing: practitioner awareness and use of a new genetic test

It was our purpose to determine the characteristics of practitioners in the United States who were among the first to inquire about and use the BRCA1 and BRCA2 (BRCA1/2) genetic tests outside of a research protocol. Questionnaires were mailed to all practitioners who requested information on or ordered a BRCA1/2 test from the University of Pennsylvania (UPenn) Genetic Diagnostics Laboratory (GDL) between October 1, 1995 and January 1, 1997 (the first 15 months the test was available for clinical use). The response rate was 67% of practitioners; 54% (121/225) were genetic counselors, 39% (87/225) were physicians or lab directors. Most physicians were oncologists, pathologists, or obstetrician/gynecologists, but 20% practiced surgery or internal or general medicine. Fifty-six percent (125/225) had ordered a BRCA1/2 test for a patient; most of the rest had offered or were willing to offer testing. Of those who had offered testing, 70% had a patient decline BRCA1/2 testing when offered. Practitioners perceived that patients' fear of loss of confidentiality was a major reason for declining. Nearly 60% of practitioners reported that their patients had access to a genetic counselor, but 28% of physicians who ordered a BRCA1/2 test reported having no such access, despite the GDL's counseling requirement. The proportion of physicians reporting no access to genetic counselors for their patients increased from 22.4% in the first half of the study to 50% in the last half. Many practitioners have an interest in BRCA1/2 testing, despite policy statements that discourage its use outside of research protocols. Practitioner responses suggest that patient interest in testing seems to be tempered by knowledge of potential risks. An apparent increase in patient concern about confidentiality and inability to pay for testing could indicate growing barriers to testing. Although most practitioners reported having access to counseling facilities, perceived lack of such access among an increasing proportion of practitioners indicates that lab requirements for counseling are difficult to enforce and suggests that an increasing proportion of patients may not be getting access to counseling.     

Incentive and Reminder Strategies to Improve Response Rate for Internet-Based Physician Surveys: A Randomized Experiment

BackgroundMost research on how to enhance response rates in physician surveys has been done using paper surveys. Uncertainties remain regarding how to enhance response rates in Internet-based surveys.ObjectiveTo evaluate the impact of a low-cost nonmonetary incentive and paper mail reminders (formal letter and postcard) on response rates in Internet-based physician surveys.MethodsWe executed a factorial-design randomized experiment while conducting a nationally representative Internet-based physician survey. We invited 3966 physicians (randomly selected from a commercial database of all licensed US physicians) via email to complete an Internet-based survey. We used 2 randomly assigned email messages: one message offered a book upon survey completion, whereas the other did not mention the book but was otherwise identical. All nonrespondents received several email reminders. Some physicians were further assigned at random to receive 1 reminder via paper mail (either a postcard or a letter) or no paper reminder. The primary outcome of this study was the survey response rate.ResultsOf the 3966 physicians who were invited, 451 (11.4%) responded to at least one survey question and 336 (8.5%) completed the entire survey. Of those who were offered a book, 345/2973 (11.6%) responded compared with 106/993 (10.7%) who were not offered a book (odds ratio 1.10, 95% CI 0.87-1.38, P=.42). Regarding the paper mail reminder, 168/1572 (10.7%) letter recipients, 148/1561 (9.5%) postcard recipients, and 69/767 (9.0%) email-only recipients responded (P=.35). The response rate for those receiving letters or postcards was similar (odds ratio 1.14, 95% CI 0.91-1.44, P=.26).ConclusionsOffering a modest nonmonetary incentive and sending a paper reminder did not improve survey response rate. Further research on how to enhance response rates in Internet-based physician surveys is needed.     

Pre‐test genetic counseling services for hereditary breast and ovarian cancer delivered by non‐genetics professionals in the state of Florida

Genetic counseling and testing for hereditary breast and ovarian cancer now includes practitioners from multiple healthcare professions, specialties, and settings. This study examined whether non‐genetics professionals (NGPs) perform guideline‐based patient intake and informed consent before genetic testing. NGPs offering BRCA testing services in Florida (n = 386) were surveyed about clinical practices. Among 81 respondents (response rate = 22%), approximately half reported: sometimes scheduling a separate session for pre‐test counseling lasting 11–30 min prior to testing, discussing familial implications of testing, benefits and limitations of risk management options, and discussing the potential psychological impact and insurance‐related issues. Few constructed a three‐generation pedigree, discussed alternative hereditary cancer syndromes, or the meaning of a variant result. This lack of adherence to guideline‐based practice may result in direct harm to patients and their family members. NGPs who are unable to deliver guideline adherent cancer genetics services should focus on identification and referral of at‐risk patients to in person or telephone services provided by genetics professionals.