Decision Support for Improving Primary Care of Elderly Patients.

Problem:

Within the present healthcare organisation, elderly patients with complex problems often receive sub-optimal care. A necessary condition for improving their care is the continuous measuring and improvement of the quality of their care. The set of the ACOVE (Assessing Care Of the Vulnerable Elders) quality indicators (QIs) is emerging as an international standard for comprehensively measuring quality of care for elderly people. In essence, these quality indicators reflect "If-THEN" clinical rules that should be followed by care providers. However, the ACOVE indicators are still used to assess, rather than improve, care delivery.



Objective:

The primary objective in the ICOVE-PC (Improving Care of Vulnerable Elders - Primary Care) study is the systematic improvement of primary care for older persons by increasing adherence to a carefully selected set of ACOVE QIs. The selection of these QIs was arrived at by surveys and focus groups with general practitioners.



Approach:

After the selection of the ACOVE QIs we translated them into formal clinical rules for processing by a computer. The formal rules are then employed in a clinical decision support system (CDSS) that pro-actively reminds and alerts GPs to make the decisions consisten with the rules.



Intervention:

The GPs will be randomized into two trial arms. The GPs in the first arm will receive decision support pertaining only to (about) half of the selected clinical rules. The GPs in the second arm will receive decision support only for the other half of the rules. Hence, for each rule one arm will be its intervention arm and the other will be the control arm.



The reminders and alerts are not meant to be intrusive: They appear in a "ToDo" list which will be displayed at the edge of the computer screen of the GP. When GPs comply to a rule they will receive positive feedback. Color-coding will be used to display the status of the rule in terms of adherence.



Primary outcome:

Adherence to the selected clinical rules. This will be measured based on the (1) pass rates of the individual rules (2) general pass rates regardless of specific rules and (3) the number of rules with imroved pass rates.

User-driven computerized decision support provided to general practitioners will improve their adherence to clinical rules pertaining to primary care for elderly patients.

Measurements are automatically collected by the computer as soon as they become available. We will measure adherence at the end of the study.

A subset of clinical rules originating from the ACOVE-3 (Assessing care of Vulnerable Elders) complete set of rules has been selected based on surveys and focus groups with General Practitioners (GPs). In particular, GPs selected rules for which they said they would appreciate a decision support system to help them to comply with these rules ((by means of alerts and reminders).



The GPs will be randomized into two trial arms. For the GPs in the first arm the intervention consists of providing, when needed, alerts and reminders for only (about) half of the selected clinical rules. The GPs in the second arm will receive alerts and reminders only for the other half of the rules. Hence, for each rule one arm will be its intervention arm and the other will be the control arm.



The reminders and alerts are not meant to be intrusive: they appear in a "ToDo" list which will be displayed at the edge of the screen. When GPs comply to a rule they will receive positive feedback. Color-coding will be used to display the status of the rule in terms of adherence.