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The Impact of Clinical Prompts on Prenatal Care at Two Family Medicine Teaching Clinics The Impact of Clinical Prompts on Prenatal Care at Two Family Medicine Teaching Clinics Maggie Riley, MD Academic Fellow University of Michigan Dept of Family Medicine

Goals of Research n To determine how well FM physicians meet the standards for Goals of Research n To determine how well FM physicians meet the standards for prenatal care n To assess whether a clinical intervention can improve compliance to prenatal care standards n To improve prenatal care provided at our teaching clinics

Factors when considering a clinical intervention n Impact on existing clinical system n Ease Factors when considering a clinical intervention n Impact on existing clinical system n Ease of implementation n Ease of provider/staff use n Cost of intervention n Long-term utility of intervention n Effectiveness of intervention

Utility of Clinical Prompts n Improve quality of patient care n Track chronic disease Utility of Clinical Prompts n Improve quality of patient care n Track chronic disease management n Track health maintenance screening n Increase provider efficiency n Useful for pay-for-performance evaluations

Clinical Prompts “The Utility of an Evidence-Based Lecture and Clinical Prompt as Methods to Clinical Prompts “The Utility of an Evidence-Based Lecture and Clinical Prompt as Methods to Improve Quality of Care in Colorectal Cancer Screening” n Assessed screening rate at baseline, after evidence-based lecture, and after instituting point-of-care clinical prompt Seres KA, et al. Am J of Gastroenterol 2007; 102: 1 -6

Colorectal Clinical Prompts n Significantly improved attempts at screening as compared to baseline (39. Colorectal Clinical Prompts n Significantly improved attempts at screening as compared to baseline (39. 6% vs. 67. 6%, p<0. 0001) n Significantly increased ordering of colon imaging (24 vs. 46%, p<0. 0001) n Prompts are superior to lecture n Low cost intervention

Clinical Prompts n Clinfo. Tracker = Clinical Reminder System (CRS) n Provides up to Clinical Prompts n Clinfo. Tracker = Clinical Reminder System (CRS) n Provides up to date information regarding needed preventive and disease management services at the point of care

Research Population n Pregnant females of any age seen at University of MI Ypsilanti Research Population n Pregnant females of any age seen at University of MI Ypsilanti or Chelsea FM clinic for their prenatal care n Both sites are teaching clinics and have varying patient demographics

Research Methods n Implement prompts through Clinfo. Tracker n Compare pre- to post-intervention percent Research Methods n Implement prompts through Clinfo. Tracker n Compare pre- to post-intervention percent adherence during a four month time period (Nov to March ‘ 06 -07 and ‘ 07 -08) n Determine if study site or level of experience impact adherence to those standards

Prompts Generated Prenatal labs (RPR, rubella, Hep. Bs. Ag, T&S, CBC, pap, GC/CT, HIV, Prompts Generated Prenatal labs (RPR, rubella, Hep. Bs. Ag, T&S, CBC, pap, GC/CT, HIV, urine culture) n Offer genetic testing (cystic fibrosis, Tay. Sachs, hemoglobinopathies) n First trimester screen (11 to 14 weeks) n Quad screen or MSAFP (15 to 20 6/7 weeks) n Influenza vaccine (if pregnant during flu season) n Consider fetal survey n

Prompts Generated n One-hour glucose tolerance test n 3 rd Trimester Antibody Screen and Prompts Generated n One-hour glucose tolerance test n 3 rd Trimester Antibody Screen and Rho. Gam – Rh Negative patients ONLY n 2 nd/3 rd trimester CBC n Consider Repeat GC/CT Screen in High Risk Populations n GBS culture n Antenatal testing

Compliance to Standard n Result documented within EMR n Patient declined test and decline Compliance to Standard n Result documented within EMR n Patient declined test and decline documented n Test documented as ordered n Patient not a candidate for the test

Results n Total number of patients: – – – n 144 pre-intervention (53. 5% Results n Total number of patients: – – – n 144 pre-intervention (53. 5% followed by residents) 115 intervention (60% followed by residents) 161 Ypsilanti and 98 Chelsea patients Adherence to ALL prenatal care standards: – – – 18. 6% of baseline patients 57. 1% of intervention patients Statistically significant improvement (P<0. 005)

Most Commonly Missed Services n First trimester aneuploidy screening n Genetic screening n HIV Most Commonly Missed Services n First trimester aneuploidy screening n Genetic screening n HIV testing n Repeat gonorrhea/Chlamydia screening for high risk patients at 28 weeks gestation n Influenza vaccination

Statistically Significant Results Statistically Significant Results

Study Site and Experience n Ypsilanti providers were significantly more likely to offer HIV Study Site and Experience n Ypsilanti providers were significantly more likely to offer HIV and GC/Chl testing (P<0. 05) n Residents were significantly more likely than attending physicians to offer HIV testing regardless of site (P=0. 009)

Conclusions n Adherence to prenatal care standards by FM providers at baseline was low Conclusions n Adherence to prenatal care standards by FM providers at baseline was low n Overall, level of experience and study site did not impact adherence to standards n Intervention significantly improved adherence to early screening for genetic abnormalities, STI screening, and influenza vaccination

Conclusions n Results support the use of automated prenatal care reminders as an effective Conclusions n Results support the use of automated prenatal care reminders as an effective way to aid FM physicians in meeting prenatal care standards n Further research should assess the effect of prenatal reminders on efficiency, cost, and perinatal outcomes

References 1) Seres KA, Kirkpatrick AC, Tierney WM. The Utility of an Evidence-Based Lecture References 1) Seres KA, Kirkpatrick AC, Tierney WM. The Utility of an Evidence-Based Lecture and Clinical Prompt as Methods to Improve Quality of Care in Colorectal Cancer Screening. Am J of Gastroenterol 2007; 102: 1 -6. n 2) Zoschnick LB, Brackbill EL, Green LA, Van Harrison R, Shumacher RE. University of Michigan Prenatal Care Guideline. Updated 6/2006. Available at: http: //www. med. umich. edu/1 info/fhp/practicegu ides/newpnc/pnc 2006. pdf n