Use of reminders to increase compliance with tetanus booster vaccination.

OBJECTIVE: To assess the effect of three computerized reminder systems on compliance with tetanus vaccination. DESIGN: Prospective randomized controlled trial. SETTING: Ottawa Civic Hospital Family Medicine Centre. PARTICIPANTS: Of 8069 patients 20 years of age or more who were not in a hospital or institution 5589 were randomly assigned, by family, to a control group, a physician reminder group, a telephone reminder group or a letter reminder group. The remaining 2480 patients were not included in the randomized portion of the study but were monitored. Results are presented for the 5242 randomized patients and the 2369 nonrandomized patients for whom there was no up-to-date record of tetanus vaccination at the start of the trial. INTERVENTIONS: For the patients in the physician reminder group the physician was reminded at an office visit to assess the patient's tetanus vaccination status and to recommend vaccination; those in the other two reminder groups received a telephone call or letter enquiring about their tetanus vaccination status and recommending a booster dose. MAIN OUTCOME MEASURE: Proportion of patients who received tetanus toxoid during the study year or who had a claim of vaccination in the previous 10 years. MAIN RESULTS: The rate of recorded tetanus vaccination in the randomized control group was 3.2%. The difference between that rate and those for the three reminder groups was 19.6% in the physician reminder group (95% confidence interval [CI] 17.1% to 22.2%, p less than 0.00001), 20.8% in the telephone reminder group (95% CI 18.3% to 23.5%, p less than 0.00001) and 27.4% in the letter reminder group (95% CI 24.8% to 30.2%, p less than 0.00001)). The letter reminders were more effective than either the telephone reminders (p = 0.00013) or the physician reminders (p less than 0.00001) in improving compliance. The cost to the practice per additional vaccination recorded was 43 for the physician reminders, $5.43 for the telephone reminders and $6.05 for the letter reminders. CONCLUSIONS: Although all three reminder systems increased the rate of recorded tetanus vaccination they fell far short of achieving complete population coverage. More intensive interventions would be required to approach that goal. However, such interventions do not appear to be justified given the rarity of tetanus.     

Effect of patient reminder/recall interventions on immunization rates: A review

CONTEXT: Immunization rates for children and adults remain below national goals. While experts recommend that health care professionals remind patients of needed immunizations, few practitioners actually use reminders. Little is known about the effectiveness of reminders in different settings or patient populations. OBJECTIVES: To assess the effectiveness of patient reminder systems in improving immunization rates, and to compare the effectiveness of different types of reminders for a variety of patient populations. DATA SOURCES: A search was performed using MEDLINE, EMBASE, PsychINFO, Sociological Abstracts, and CAB Health Abstracts. Relevant articles, as well as published abstracts, conference proceedings, and files of study collaborators, were searched for relevant references. STUDY SELECTION AND DATA EXTRACTION: English-language studies involving patient reminder/recall interventions (using criteria established by the Cochrane Collaboration) were eligible for review if they involved randomized controlled trials, controlled before-after studies, or interrupted time series, and measured immunization rates. Of 109 studies identified, 41 met eligibility criteria. Studies were reviewed independently by 2 reviewers using a standardized checklist. Results of studies are expressed as absolute percentage-point changes in immunization rates and as odds ratios (ORs). Studies with similar characteristics of patients or interventions were pooled (random effects model). DATA SYNTHESIS: Patient reminder systems were effective in improving immunization rates in 33 (80%) of the 41 studies, irrespective of baseline immunization rates, patient age, setting, or vaccination type. Increases in immunization rates due to reminders ranged from 5 to 20 percentage points. Reminders were effective for childhood vaccinations (OR, 2.02; 95% confidence interval [CI], 1.49-2.72), childhood influenza vaccinations (OR, 4. 25; 95% CI, 2.10-8.60), adult pneumococcus or tetanus vaccinations (OR, 5.14; 95% CI, 1.21-21.78), and adult influenza vaccinations (OR, 2.29; 95% CI, 1.69-3.10). While reminders were most effective in academic settings (OR, 3.33; 95% CI, 1.98-5.58), they were also highly effective in private practice settings (OR, 1.79; 95% CI, 1. 45-2.22) and public health clinics (OR, 2.09; 95% CI, 1.42-3.07). All types of reminders were effective (postcards, letters, and telephone or autodialer calls), with telephone reminders being most effective but costliest. CONCLUSIONS: Patient reminder systems in primary care settings are effective in improving immunization rates. Primary care physicians should use patient reminders to improve immunization delivery. JAMA. 2000;284:1820-1827.     

Comparison of three methods of recalling patients for influenza vaccination.

Despite recommendations supporting annual influenza vaccination for people aged 65 years or older, vaccination rates remain low. Several studies have evaluated the effect of sending mailed reminders, but few have compared alternative ways of reminding patients to receive the vaccine. In a randomized trial of 939 patients aged 65 years or older in four family practices carried out between Oct. 23 and Dec. 31, 1984, we compared three ways of reminding elderly patients to receive the vaccine: personal reminder by the physician, telephone reminder by the nurse and reminder by letter. The vaccination rates for the three groups were 22.9%, 37% and 35.1% respectively. No reminder was issued to a control group, and the rate was 9.8%. Some patients could not be reached by telephone, and some did not see the physician during the specified time. Among the patients whom the nurse actually contacted, the vaccination rate was 43.5%; the rate for patients whom the doctor actually saw was 45.1%. Overall, a telephone reminder by the nurse was the most effective method, and at an hourly salary of $16 or less this method would also be the most cost-effective. The reminders used in this study were automatically generated from a computerized medical record system. The study shows how a computerized system can be used to identify patients for whom preventive procedures are due.     

Use of reminders for preventive procedures in family medicine.

OBJECTIVE: To compare the effectiveness of three computerized reminder systems in the delivery of five preventive procedures in family practice. DESIGN: Prospective, randomized, controlled study. SETTING: Ottawa Civic Hospital Family Medicine Centre. PARTICIPANTS: Of 8502 patients 15 years of age or more who were not in a hospital or institution 5883 were randomly assigned, by family, to a control group, a physician reminder group (passive) or a telephone or letter reminder group (active). The remaining 2619 patients were not included in the randomized portion of the study but were monitored. INTERVENTION: During 1 year the patients in the active reminder groups received a telephone call or letter reminding them of any overdue preventive procedures; for those in the passive reminder group the physician was reminded at an office visit to provide any overdue service. OUTCOME MEASURE: Rates of completion of the preventive procedures required. MAIN RESULTS: All three reminder systems significantly improved the delivery of preventive services (p less than 0.001). The procedure completion rates were 42.0% in the letter reminder group, 42.0% in the telephone reminder group, 33.7% in the physician reminder group and 14.1% in the randomized control group. The use of a letter was more cost-effective than the telephone system, but the physician reminder system was the most cost-effective. CONCLUSION: Computerized reminder systems do improve the delivery of preventive services in family practice.     

Evidence for the effectiveness of CME. A review of 50 randomized controlled trials.

OBJECTIVE--To assess the impact of diverse continuing medical education (CME) interventions on physician performance and health care outcomes. DATA SOURCES--Using continuing medical education and related phrases, we performed regular searches of the indexed literature (MEDLINE, Social Science Index, the National Technical Information Service, and Educational Research Information Clearinghouse) from 1975 through 1991. In addition, for these years, we used manual searches, key informants, and requests to authors to locate other indexed articles and the nonindexed literature of adult and continuing professional education. STUDY SELECTION--From the resulting database we selected studies that met the following criteria: randomized controlled trials; educational programs, activities, or other interventions; studies that included 50% or more physicians; follow-up assessments of at least 75% of study subjects; and objective assessments of either physician performance or health care outcomes. DATA EXTRACTION--Studies were reviewed for data related to physician specialty and setting. Continuing medical education interventions were classified by their mode(s) of activity as being predisposing, enabling, or facilitating. Using the statistical tests supplied by the original investigators, physician performance outcomes and patient outcomes were classified as positive, negative, or inconclusive. DATA SYNTHESIS--We located 777 CME studies, of which 50 met all criteria. Thirty-two of these analyzed physician performance; seven evaluated patient outcomes; 11 examined both measures. The majority of the 43 studies of physician performance showed positive results in some important measures of resource utilization, counseling strategies, and preventive medicine. Of the 18 studies of health care outcomes, eight demonstrated positive changes in patients' health care outcomes. CONCLUSION--Broadly defined CME interventions using practice-enabling or reinforcing strategies consistently improve physician performance and, in some instances, health care outcomes.     

Features and Effects of Information Technology-Based Interventions to Improve Self-Management in Chronic Kidney Disease Patients: a Systematic Review of the Literature

Slowing down the progression of chronic kidney disease (CKD) and its adverse health outcomes requires the patient’s self-management and attention to treatment recommendations. Information technology (IT)–based interventions are increasingly being used to support self-management in patients with chronic diseases such as CKD. We conducted a systematic review of randomized controlled trials (RCTs) to assess the features and effects of IT-based interventions on self-management outcomes of CKD patients. A comprehensive search was conducted in Medline, Scopus, and the Cochrane Library to identify relevant papers that were published until May 2016. RCT Studies that assessed at least one automated IT tool in patients with CKD stages 1 to 5, and reported at least one self-management outcome were included. Studies were appraised for quality using the Cochrane Risk of Bias assessment tool. Out of 12,215 papers retrieved, eight study met the inclusion criteria. Interventions were delivered via smartphones/personal digital assistants (PDAs) (three studies), wearable devices (three studies), computerized systems (one study), and multiple component (one study). The studies assessed 15 outcomes, including eight clinical outcomes and seven process of care outcomes. In 12 (80%) of the 15 outcomes, the studies had revealed the effects of the interventions as statistically significant positive. These positive effects were observed in 75% of the clinical outcomes and 86% of the process of care outcomes. The evidence indicates the potential of IT-based interventions (i.e. smartphones/PDAs, wearable devices, and computerized systems) in self-management outcomes (clinical and process of care outcomes) of CKD patients.     

An overview of interventions to improve compliance with appointment keeping for medical services.

OBJECTIVE--To determine, by a quantitative meta-analysis of randomized trials, the effectiveness of strategies to improve patient compliance with screening, referral, and clinic appointments for health services that are provided at the time of the visit. DATA SOURCES--Computerized searches of MEDLINE (1966 through 1990) were done using two search strategies: (1) (Patient Compliance OR Adhere* OR Dropout*) AND (Appointment*) AND (Screen* OR Follow* OR Refer*); and (2) (Patient Compliance OR Adhere* OR Dropout*) AND (Attend* OR Screen*) OR (Appointment*). A computerized search of PSYCHLIT was done with the terms Compliance AND Appointment*. In addition, the reference list of each retrieved article was reviewed and relevant citations retrieved. STUDY SELECTION--Only randomized trials with quantitative data concerning the effect of interventions to improve attendance at appointments for supervised administration of care were considered for detailed review. Studies of appointment keeping for self-administered treatments or tests were excluded. Two independent reviewers assessed each article for inclusion (kappa, for agreement, 0.66 for MEDLINE; 0.95 for PSYCHLIT) and validity (kappa, 0.62) using a priori criteria. Twenty-three (26%) of 88 relevant articles met all criteria. DATA EXTRACTION--Data on study populations, interventions, and outcomes were extracted and analyzed using pooled odds ratios (ORs). DATA SYNTHESIS--The average rate of compliance with appointments was 58%. Mailed reminders and telephone prompts were consistently useful in reducing broken appointments (OR, 2.2; 95% confidence interval [CI], 1.7 to 2.9; and OR, 2.9, CI, 1.9 to 4.3, respectively). An "orientation statement" (OR, 2.9; CI, 1.5 to 5.6), "contracting" with patients (OR, 1.9; CI, 1.04 to 3.5), and prompts from physicians (OR, 1.6; CI, 1.4 to 2.0) showed positive effects as well. CONCLUSIONS--In clinic settings where kept appointments can be an accurate measure of patient compliance with health care interventions, broken appointments can be reduced by mail, telephone, or physician reminders; orienting patients to the clinic; or contracting with patients.     

Actionable reminders did not improve performance over passive reminders for overdue tests in the primary care setting

Actionable reminders (electronic reminders linked to computerized order entry) might improve care by facilitating direct ordering of recommended tests. The authors implemented four enhanced actionable reminders targeting performance of annual mammography, one-time bone-density screening, and diabetic testing. There was no difference in rates of appropriate testing between the four intervention and four matched, control primary care clinics for screening mammography (OR 0.81, 95% CI 0.64 to 1.02), bone-density exams (OR 1.29, 95% CI 0.82 to 2.02), HbA1c monitoring (OR 0.91, 95% CI 0.58 to 1.42) and LDL cholesterol monitoring (OR 1.40, 95% CI 0.76 to 2.59). Of the survey respondents, 79% almost never used the system or were unaware of the functionality. In the 9/228 (3.9%) cases with indirect evidence of mammography reminder use, there was a significantly lower proportion with test performance. Our actionable reminders did not improve receipt of overdue testing, potentially due to limitations of workflow integration.     

Appointment reminders to reduce no-show rates. A stratified analysis of their cost-effectiveness

To determine whether reminders are cost-effective for an adult primary care internal medicine center, we randomized 590 scheduled, follow-up appointments to no reminder, computer-generated letter reminders, and telephoned reminders. The no-show rate was reduced from 24% in the control group to 14% in the reminder groups, and letter and telephoned reminders were equally effective. An economic analysis showed that about two thirds of the savings realized from reminders was generated in 23% of the patients whose prior predicted probability of a no-show appointment was above 20%. However, in our primary care center, computer-generated letter reminders were estimated to be cost-effective whenever the probability of a no-show was above 5%, and telephoned or manual letter reminders were estimated to be cost-effective whenever the probability of a no-show was above about 11%. Based on our sensitivity analysis, telephoned or manual letter reminders should be cost-effective in many other ambulatory settings as well, although in some settings, reminders may be restricted to patients at high risk for no-show behavior.     

Improving residents' compliance with standards of ambulatory care: results from the VA Cooperative Study on Computerized Reminders

CONTEXT: Computerized systems to remind physicians to provide appropriate care have not been widely evaluated in large numbers of patients in multiple clinical settings. OBJECTIVE: To examine whether a computerized reminder system operating in multiple Veterans Affairs (VA) ambulatory care clinics improves resident physician compliance with standards of ambulatory care. DESIGN, SETTING, AND PARTICIPANTS: A total of 275 resident physicians at 12 VA medical centers were randomly assigned in firms or half-day clinic blocks to either a reminder group (n = 132) or a control group (n = 143). During a 17-month study period (January 31, 1995-June 30, 1996), the residents cared for 12,989 unique patients for whom at least 1 of the studied standards of care (SOC) was applicable. MAIN OUTCOME MEASURES: Compliance with 13 SOC, tracked using hospital databases and encounter forms completed by residents, compared between residents in the reminder group vs those in the control group. RESULTS: Measuring compliance as the proportion of patients in compliance with all applicable SOC by their last visit during the study period, the reminder group had statistically significantly higher rates of compliance than the control group for all standards combined (58.8% vs 53.5%; odds ratio [OR], 1.24; 95% confidence interval [CI], 1.08-1.42; P =.002) and for 5 of the 13 standards examined individually. Measuring compliance as the proportion of all visits for which care was indicated in which residents provided proper care, the reminder group also had statistically significantly higher rates of compliance than the control group for all standards combined (17.9% vs 12.2%; OR, 1.57; 95% CI, 1.45-1.71; P<.001) and for 9 of the 13 standards examined individually. The benefit of reminders, however, declined throughout the course of the study, even though the reminders remained active. CONCLUSIONS: Our data indicate that reminder systems installed at multiple sites can improve residents' compliance to multiple SOC. The benefits of such systems, however, appear to deteriorate over time. Future research needs to explore methods to better sustain the benefits of reminders. JAMA. 2000;284:1411-1416.     

No magic bullets: a systematic review of 102 trials of interventions to improve professional practice.

OBJECTIVE: To determine the effectiveness of different types of interventions in improving health professional performance and health outcomes. DATA SOURCES: MEDLINE, SCISEARCH, CINAHL and the Research and Development Resource Base in CME were searched for trials of educational interventions in the health care professions published between 1970 and 1993 inclusive. STUDY SELECTION: Studies were selected if they provided objective measurements of health professional performance or health outcomes and employed random or quasi-random allocation methods in their study designs to assign individual subjects or groups. Interventions included such activities as conferences, outreach visits, the use of local opinion leaders, audit and feedback, and reminder systems. DATA EXTRACTION: Details extracted from the studies included the study design; the unit of allocation (e.g., patient, provider, practice, hospital); the characteristics of the targeted health care professionals, educational interventions and patients (when appropriate); and the main outcome measure. DATA SYNTHESIS: The inclusion criteria were met by 102 trials. Areas of behaviour change included general patient management, preventive services, prescribing practices, treatment of specific conditions such as hypertension or diabetes, and diagnostic service or hospital utilization. Dissemination-only strategies, such as conferences or the mailing of unsolicited materials, demonstrated little or no changes in health professional behaviour or health outcome when used alone. More complex interventions, such as the use of outreach visits or local opinion leaders, ranged from ineffective to highly effective but were most often moderately effective (resulting in reductions of 20% to 50% in the incidence of inappropriate performance). CONCLUSION: There are no "magic bullets" for improving the quality of health care, but there are a wide range of interventions available that, if used appropriately, could lead to important improvements in professional practice and patient outcomes.     

A review on systematic reviews of health information system studies

The purpose of this review is to consolidate existing evidence from published systematic reviews on health information system (HIS) evaluation studies to inform HIS practice and research. Fifty reviews published during 1994–2008 were selected for meta-level synthesis. These reviews covered five areas: medication management, preventive care, health conditions, data quality, and care process/outcome. After reconciliation for duplicates, 1276 HIS studies were arrived at as the non-overlapping corpus. On the basis of a subset of 287 controlled HIS studies, there is some evidence for improved quality of care, but in varying degrees across topic areas. For instance, 31/43 (72%) controlled HIS studies had positive results using preventive care reminders, mostly through guideline adherence such as immunization and health screening. Key factors that influence HIS success included having in-house systems, developers as users, integrated decision support and benchmark practices, and addressing such contextual issues as provider knowledge and perception, incentives, and legislation/policy.     

Interventions for the treatment and management of chronic fatigue syndrome: a systematic review

CONTEXT: A variety of interventions have been used in the treatment and management of chronic fatigue syndrome (CFS). Currently, debate exists among health care professionals and patients about appropriate strategies for management. OBJECTIVE: To assess the effectiveness of all interventions that have been evaluated for use in the treatment or management of CFS in adults or children. DATA SOURCES: Nineteen specialist databases were searched from inception to either January or July 2000 for published or unpublished studies in any language. The search was updated through October 2000 using PubMed. Other sources included scanning citations, Internet searching, contacting experts, and online requests for articles. STUDY SELECTION: Controlled trials (randomized or nonrandomized) that evaluated interventions in patients diagnosed as having CFS according to any criteria were included. Study inclusion was assessed independently by 2 reviewers. Of 350 studies initially identified, 44 met inclusion criteria, including 36 randomized controlled trials and 8 controlled trials. DATA EXTRACTION: Data extraction was conducted by 1 reviewer and checked by a second. Validity assessment was carried out by 2 reviewers with disagreements resolved by consensus. A qualitative synthesis was carried out and studies were grouped according to type of intervention and outcomes assessed. DATA SYNTHESIS: The number of participants included in each trial ranged from 12 to 326, with a total of 2801 participants included in the 44 trials combined. Across the studies, 38 different outcomes were evaluated using about 130 different scales or types of measurement. Studies were grouped into 6 different categories. In the behavioral category, graded exercise therapy and cognitive behavioral therapy showed positive results and also scored highly on the validity assessment. In the immunological category, both immunoglobulin and hydrocortisone showed some limited effects but, overall, the evidence was inconclusive. There was insufficient evidence about effectiveness in the other 4 categories (pharmacological, supplements, complementary/alternative, and other interventions). CONCLUSIONS: Overall, the interventions demonstrated mixed results in terms of effectiveness. All conclusions about effectiveness should be considered together with the methodological inadequacies of the studies. Interventions which have shown promising results include cognitive behavioral therapy and graded exercise therapy. Further research into these and other treatments is required using standardized outcome measures.     

Effects of computer-aided clinical decision support systems in improving antibiotic prescribing by primary care providers: a systematic review

Objective To assess the effectiveness of computer-aided clinical decision support systems (CDSS) in improving antibiotic prescribing in primary care.Methods A literature search utilizing Medline (via PubMed) and Embase (via Embase) was conducted up to November 2013. Randomized controlled trials (RCTs) and cluster randomized trials (CRTs) that evaluated the effects of CDSS aiming at improving antibiotic prescribing practice in an ambulatory primary care setting were included for review. Two investigators independently extracted data about study design and quality, participant characteristics, interventions, and outcomes.Results Seven studies (4 CRTs, 3 RCTs) met our inclusion criteria. All studies were performed in the USA. Proportions of eligible patient visits that triggered CDSS use varied substantially between intervention arms of studies (range 2.8–62.8%). Five out of seven trials showed marginal to moderate statistically significant effects of CDSS in improving antibiotic prescribing behavior. CDSS that automatically provided decision support were more likely to improve prescribing practice in contrast to systems that had to be actively initiated by healthcare providers.Conclusions CDSS show promising effectiveness in improving antibiotic prescribing behavior in primary care. Magnitude of effects compared to no intervention, appeared to be similar to other moderately effective single interventions directed at primary care providers. Additional research is warranted to determine CDSS characteristics crucial to triggering high adoption by providers as a perquisite of clinically relevant improvement of antibiotic prescribing.     

The role of computers in preventive medicine in a rural family practice.

Five family physicians in a group practice in rural Quebec have introduced a computer system to improve the delivery of preventive medicine. In addition to billing, the computer is used mainly to recall specific groups of patients for preventive measures, to prompt the physicians to carry out certain procedures at the patient's next visit, to indicate which procedures are required for the family members and to generate reminder letters. The physicians are conducting a randomized controlled trial to evaluate the impact of computer-generated reminder letters on patient compliance and disease prevention among families in their practice.     

Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes?

CONTEXT: Although physicians report spending a considerable amount of time in continuing medical education (CME) activities, studies have shown a sizable difference between real and ideal performance, suggesting a lack of effect of formal CME. OBJECTIVE: To review, collate, and interpret the effect of formal CME interventions on physician performance and health care outcomes. DATA SOURCES: Sources included searches of the complete Research and Development Resource Base in Continuing Medical Education and the Specialised Register of the Cochrane Effective Practice and Organisation of Care Group, supplemented by searches of MEDLINE from 1993 to January 1999. STUDY SELECTION: Studies were included in the analyses if they were randomized controlled trials of formal didactic and/or interactive CME interventions (conferences, courses, rounds, meetings, symposia, lectures, and other formats) in which at least 50% of the participants were practicing physicians. Fourteen of 64 studies identified met these criteria and were included in the analyses. Articles were reviewed independently by 3 of the authors. DATA EXTRACTION: Determinations were made about the nature of the CME intervention (didactic, interactive, or mixed), its occurrence as a 1-time or sequenced event, and other information about its educational content and format. Two of 3 reviewers independently applied all inclusion/exclusion criteria. Data were then subjected to meta-analytic techniques. DATA SYNTHESIS: The 14 studies generated 17 interventions fitting our criteria. Nine generated positive changes in professional practice, and 3 of 4 interventions altered health care outcomes in 1 or more measures. In 7 studies, sufficient data were available for effect sizes to be calculated; overall, no significant effect of these educational methods was detected (standardized effect size, 0.34; 95% confidence interval [CI], -0.22 to 0.97). However, interactive and mixed educational sessions were associated with a significant effect on practice (standardized effect size, 0.67; 95% CI, 0.01-1.45). CONCLUSIONS: Our data show some evidence that interactive CME sessions that enhance participant activity and provide the opportunity to practice skills can effect change in professional practice and, on occasion, health care outcomes. Based on a small number of well-conducted trials, didactic sessions do not appear to be effective in changing physician performance.     

特拉唑嗪治疗慢性前列腺炎/慢性盆腔疼痛综合征的系统评价

目的 评价特拉唑嗪治疗慢性前列腺炎／慢性盆腔疼痛综合征（CP／CPPS）的疗效与安全性。方法 采用Cochrane系统评价方法，电子检索Embase、Pubmed等国内、外数据库。纳入特拉唑嗪与安慰剂或其他疗法比较治疗CP／CPPS男性患者的随机对照试验（RCT）。由两名评价员独立评价文献质量和提取资料，用Stata9．2软件进行Meta分析。结果 检索结果获得9个随机对照实验，其中只有4个RCTs（369例）被纳入。本系统评价的meta分析结果显示特拉唑嗪治疗CP／CPPS的疗效优于安慰剂，能有效地改善CP／CPPS患者的NIH症状指数总评分、生活质量、疼痛及排尿症状，但其不良反应也高于安慰剂。结论 根据现有的证据，可以认为特拉唑嗪有改善CP／CPPS症状的作用。但鉴于目前评价其疗效和安全性的随机对照试验及病例数较少，研究质量普遍不高，有必要进一步开展高质量、大样本随机对照试验评价其疗效和安全性。     

The marginal value of pre-visit paper reminders when added to a multifaceted electronic health record based quality improvement system

Objective

We have reported that implementation of an electronic health record (EHR) based quality improvement system that included point-of-care electronic reminders accelerated improvement in performance for multiple measures of chronic disease care and preventive care during a 1-year period. This study examined whether providing pre-visit paper quality reminders could further improve performance, especially for physicians whose performance had not improved much during the first year.

Design

Time-series analysis at a large internal medicine practice using a commercial EHR. All patients eligible for each measure were included (range approximately 100–7500).

Measurements

The proportion of eligible patients in the practice who satisfied each of 15 quality measures after removing those with exceptions from the denominator. To analyze changes in performance for individual physicians, two composite measures were used: prescribing seven essential medications and completion of five preventive services.

Results

During the year after implementing pre-encounter reminders, performance continued to improve for eight measures, remained stable for four, and declined for three. Physicians with the worst performance at the start of the pre-encounter reminders showed little absolute improvement over the next year, and most remained below the median performance for physicians in the practice.

Conclusions

Paper pre-encounter reminders did not appear to improve performance beyond electronic point-of-care reminders in the EHR alone. Lagging performance is likely not due to providers'' EHR workflow alone, and trying to step backwards and use paper reminders in addition to point-of-care reminders in the EHR may not be an effective strategy for engaging slow adopters.     

Meta-analysis of benzodiazepine use in the treatment of insomnia

OBJECTIVE: To systematically review the benefits and risks associated with the use of benzodiazepines to treat insomnia in adults. DATA SOURCES: MEDLINE and the Cochrane Controlled Trials Registry were searched for English-language articles published from 1966 to December 1998 that described randomized controlled trials of benzodiazepines for the treatment of insomnia. Key words included "benzodiazepines" (exploded), "randomized controlled trial" and "insomnia." Bibliographies of relevant articles were reviewed for additional studies and manufacturers of benzodiazepines were asked to submit additional randomized controlled trial reports not in the literature. STUDY SELECTION: Articles were considered for the meta-analysis if they were randomized controlled trials involving patients with insomnia and compared a benzodiazepine with placebo or another active agent. Of the 89 trials originally identified, 45 met our criteria, representing a total of 2672 patients. DATA EXTRACTION: Data were extracted regarding the participants, the setting, details of the intervention, the outcomes (including adverse effects) and the methodologic quality of the studies. DATA SYNTHESIS: The meta-analyses of sleep records indicated that, when compared with placebo, benzodiazepines decreased sleep latency by 4.2 minutes (non-significant; 95% confidence interval (CI -0.7 to 9.2) and significantly increased total sleep duration by 61.8 minutes (95% CI 37.4 to 86.2). Patient-reported outcomes were more optimistic for sleep latency; those randomized to benzodiazepine treatment estimated a sleep latency decrease of 14.3 minutes (95% CI 10.6 to 18.0). Although more patients receiving benzodiazepine treatment reported adverse effects, especially daytime drowsiness and dizziness or light-headedness (common odds ratio 1.8, 95% CI 1.4 to 2.4), dropout rates for the benzodiazepine and placebo groups were similar. Cognitive function decline including memory impairment was reported in several of the studies. Zopiclone was not found to be superior to benzodiazepines on any of the outcome measures examined. INTERPRETATION: The use of benzodiazepines in the treatment of insomnia is associated with an increase in sleep duration, but this is countered by a number of adverse effects. Additional studies evaluating the efficacy of nonpharmacological interventions would be valuable.