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Monday, 18 October 2004

This presentation is part of: Poster Session - CEA: Methods and Applications; Health Services Research

PROVIDER ADHERENCE WITH QUALITY IMPROVEMENT STRATEGIES FOR MANAGEMENT OF HYPERTENSION: A SYSTEMATIC REVIEW

Judith Walsh, MD, MPH1, Kathryn M. McDonald, MM2, Kaveh G. Shojania, MD1, Vandana Sundaram, MPH3, Robyn Lewis, MA4, Smita Nayak, MD4, Jody Mechanic, RN4, Douglas K. Owens, MD, MS3, and Mary K. Goldstein, MD4. (1) University of California, San Francisco, Department of Medicine, San Francisco, CA, (2) Stanford University, Center for Primary Care and Outcomes Reasearch, Stanford, CA, (3) VA Palo Alto Health Care System, AIDS Research Center, Palo Alto, CA, (4) Stanford University, Center for Primary Care and Outcomes Research, Stanford, CA

Purpose: We systematically assessed the effect of quality improvement (QI) strategies on provider adherence to recommendations for management of hypertension.

Methods: We searched MEDLINE, Cochrane databases, and article bibliographies for experimental evaluations of QI interventions targeting provider adherence with recommendations for evaluation and management of hypertension. Two reviewers independently abstracted data and classified each intervention into one or more of the following: provider education, provider reminders, facilitated relay of clinical information, patient education, audit and feedback or organizational change. Provider adherence outcomes were defined by each study and included adherence to guidelines for the following: evaluation of hypertensive patients, choice of medications, monitoring of blood pressure and counseling of patients. We combined all reported outcomes and calculated a summary provider adherence measure. We compared different QI strategies in terms of the median effects on improvement in proportion of provider adherence (%IMPROVE) to recommended practices for the evaluation or management of hypertension.

Results: 9 articles reporting 11 comparisons met inclusion criteria. Most studies included more than one QI strategy. Across all studies, the median %IMPROVE was 3.3% (interquartile range (IQR): 1.3, 6.4). The largest %IMPROVE was seen in studies that included provider reminders (10.4% (IQR: 7.0, 13.8)). Although the two studies that assessed provider reminders used different approaches, both included a paper reminder placed at the front of the patient’s chart at the time of the physician visit. Provider education as a QI strategy was associated with a %IMPROVE of 3.7% (IQR: 1.7, 6.2), facilitated relay of clinical data was 3.3% (IQR: 2.0, 4.0), audit and feedback was 2.7% (IQR: -0.4, 3.7), and organizational change was associated with a %IMPROVE of 2.0% (IQR: -1.3, 3.3). Patient education was associated with a %IMPROVE of 2.0%, but was only included in one study. An increasing number of QI strategies was not associated with increasing provider adherence.

Conclusion: Although several QI strategies have been evaluated, most interventions had small effects on provider adherence. Provider reminders were assessed in two studies and seemed to have the largest effect, improving adherence by 10.4%. Provider behavior is difficult to change. Future studies should investigate innovative approaches to improving provider adherence with hypertension guidelines and should perhaps include simple chart reminders as part of the QI intervention.


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