Does Training Rural PCPs in the Use of PDAs for Clinical Decision-Making Change Their Clinical Behavior? Fred Tudiver, MD, Doug Rose, MD, Rick Wallace, MSLS, Debi Pfortmiller, MA East Tennessee State University

Support Intramural Primary Care Research Fund, ETSU Dept. Family Medicine

Background PCPs’ knowledge deteriorates over time Ely & Ebell, 1999 –Only 64% MDs seek to answer clinical questions –MDs sought only 2 answers to 1101 clinical questions with a formal literature search Especially tough for rural PCPs to answer their clinical questions and keep up-to- date, and at the point-of-care

Background By 2005: >50% of MDs use PDAs –most for “Outlook” functions Half (25% overall) use for clinical decision support, mostly for drugs PDAs can provide rapid access to current best evidence And have good clinical decision support software PDAs for best evidence/clinical support –Not yet assessed for rural PCPs –Not yet assessed how they affect clinical behavior

Purpose Test the feasibility and effectiveness of providing best evidence at the point of clinical decision-making with PDAs in rural primary care settings –Would they use PDAs for decision support? –How would they use them for decisions? –What clinical behaviors would change?

Methods Design: –simple pre-post experimental design –Single focus group at end of analyses Population and Recruitment: –Convenience sample PCPs –Recruited from Rural Health Services Consortium –Excluded: Residents Fulltime academics <25 outpatient hours/week Did not attend kids and adults

Methods - Interventions PCPs given Dell Axim PDA (March 2004) –Loaded with clinical software: InfoRetriever tm, Outlook functions –Two 2-hour trainings: Software; highlighted 3 “tracer” conditions –Help access to medical student, investigators

InfoRetriever tm Drug database All Cochrane systematic review abstracts Evidence-based clinical decision support Indexed search engine with 1000s prevalidated summaries –e.g., clinical rules

Outcome Measures Tracer Conditions –Sore throat/strep –Acute sinusitis –Ankle sprain

Outcome Measures Data collected: –Detailed chart abstraction of clinical decisions for 3 tracers (two raters) Study period (March 04-Aug 04) Same months in 2003 (March 03-Aug 03) –All InfoRetriever usage files Primary outcomes: –Antibiotics for sore throat/pharyngitis –Antibiotics for acute sinusitis –X-rays for an acute ankle injury

Demographic Characteristics of the PCPs Characteristic (N=11) Male (%) 5 (45.5) Female (%) 6 (54.5) Mean Age (range) 51 (32-76) Mean Years in Practice (range) 20 (6-44) Family Physician (%) 5 (45.4) General Internist (%) 3 (27.3) Nurse Practitioner (%) 3 (27.3)

Databases Searched thru Info- Retriever DatabaseNumber of searches (%) Clinical Rule/Calculator158 (33.1) 5 Minute Clinical Consult91 (19.1) Diagnostic Tests69 (14.5) InfoPoems64 (13.4) Practice Guidelines or NNT55 (11.5) History and Physical Test25 (5.2) Cochrane Abstracts14 (2.9) AAFP Patient Handouts1 (0.2) Total N=477

Outcomes for Sinusitis

Outcomes for Pharyngitis/Sore Throat

Outcomes for Ankle Injury

Discussion Antibiotic prescribing for sore throat/pharyngitis & sinusitis decreased very slightly (3.1% and 2.4%). Why? –Low usage rates (477 searches); most in month 1 –Similar rates among learners (SUNY, 2002) –Higher rates in UK study (10/d)-only for 2 weeks –Perhaps little need after initial learning period X-rays for ankle injuries increased from 73.3% to 80%! Why? –X-ray technicians hired in several sites during study

Discussion Three significant (surprise) findings: –Sinusitis Antihistamines/Decong use fell (71% to 58%) Nasal inhalers increased (26.8% to 36.8%) –Sore throat Symptomatic relief fell (79.3% to 69%) Why?

Potential Biases Weak design – simple pre-post experiment Very small numbers Usual problems with chart extraction

Summary PDA Intervention: –Did not change antibiotic prescribing for sore throat/pharyngitis & sinusitis –Or the ordering of x-rays for acute ankle injuries –But it may have decreased prescribing of various OTCs for symptomatic relief of these common conditions –More rigorous research is needed to help further explain these changes.