Management of ocular hypertension and open angle glaucoma: Clinical practice and computer‐assisted decision‐making

Background The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering ‘computer reminders’. Objectives To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care. Search methods We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles. Selection criteria Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care. Data collection and analysis Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome. Main results Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering. In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase). Authors’ conclusions Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.

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The effects of on-screen, point of care computer reminders on processes and outcomes of care

Shojania

Jennings²,

Mayhew

et al. 2009

Cochrane Database of Systematic Reviews

360

339

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Working with glaucoma patients ‐ prospects for "shared care"

Martin

1999

Acta Ophthalmologica Scandinavica

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ABSTRACT.Purpose: To investigate the prospects for ''shared care'' by evaluating to what extent ophthalmic nurses are involved in ophthalmic care decision tasks in the management of glaucoma patients, how well prepared the nurses feel they are for these tasks and their level of satisfaction in those tasks they actually are performing. Methods: A questionnaire was sent to the ophthalmic nurses at 13 eye clinics in Sweden. The clinics were selected to represent different parts of Sweden as well as university clinics and smaller rural clinics. Results: A difference was found between clinics regarding the number of tasks independently performed by the ophthalmic nurses and a significant correlation was found between level of participation and satisfaction (pΩ0.008). The nurses felt prepared for (61/62) and satisfied (58/62) when performing the glaucoma management tasks, and a high and very significant correlation (rΩ0.96, pΩ 0.0001) was found between the mean preparedness and satisfaction scores for each of the 14 tasks. Conclusions:The findings in the study show that the ophthalmic nurses feel prepared for their tasks and regard their involvement in glaucoma care as subjectively satisfactory. These observations support the idea of ''shared care'' in glaucoma management.

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A 5‐year follow‐up study of disease incidence in men with an abnormal hormone pattern

Rosmond

Wallerius

Wanger

et al. 2003

Journal of Internal Medicine

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Abstract. Rosmond R, Wallerius S, Wanger P, Martin L, Holm G, Björntorp P (The Cardiovascular Institute, Sahlgrenska University Hospital, Göteborg; and Huddinge University Hospital, Huddinge; Sweden). A 5-year follow-up study of disease incidence in men with an abnormal hormone pattern. J Intern Med 2003; 254: 386-390.Objectives. Previous studies have suggested that abnormal levels of cortisol and testosterone might increase the risk of serious somatic diseases. To test this hypothesis, we conducted a 5-year follow-up study in middle-aged men. Methods. A population-based cohort study conducted in 1995 amongst 141 Swedish men born in 1944, in whom a clinical examination supplemented by medical history aimed to disclose the presence of cardiovascular disease (CVD) (myocardial infarction, angina pectoris, stroke), type 2 diabetes and hypertension were performed at baseline and at follow-up in the year 2000. In addition, salivary cortisol levels were measured repeatedly over the day. Serum testosterone concentrations were also determined. Using the baseline data, an algorithm was constructed, which classified the secretion pattern of cortisol and testosterone from each individual as being normal or abnormal. Results. By the end of follow-up, men with an abnormal hormone secretion pattern (n ¼ 73) had elevated mean arterial pressure (P ¼ 0.003), fasting insulin (P ¼ 0.009) and insulin : glucose ratio (P ¼ 0.005) compared with men with a normal secretion pattern (n ¼ 68). Body mass index, waist circumference, and waist : hip ratio were significantly elevated in both groups. However, the 5-year incidence of CVD, type 2 diabetes, and hypertension were significantly higher (P < 0.001) in men with an abnormal neuroendocrine secretory pattern compared to men with a normal pattern. Conclusions. These data suggest that an abnormal neuroendocrine secretory pattern is prospectively associated with an increased incidence of cardiovascular-related events and type 2 diabetes.

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Management of ocular hypertension and open angle glaucoma: Clinical practice and computer‐assisted decision‐making

Abstract: Clinical decision-making in the management of patients with ocular hypertension or open angle glaucoma can be implemented in a computer program. The optimum management protocol remains to be defined.

Cited by 5 publications

References 24 publications

The effects of on-screen, point of care computer reminders on processes and outcomes of care

The effects of on-screen, point of care computer reminders on processes and outcomes of care

Working with glaucoma patients ‐ prospects for "shared care"

A 5‐year follow‐up study of disease incidence in men with an abnormal hormone pattern

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