A guideline implementation system using handheld computers for office management of asthma: effects on adherence and patient outcomes.
OBJECTIVE
To evaluate effects on the process and outcomes of care brought about by use of a handheld, computer-based system that implements the American Academy of Pediatrics guideline on office management of asthma exacerbations.


METHODS
A before-after trial with randomly selected, office-based Connecticut pediatricians. In both the control and intervention phases, physicians collected data from 10 patient encounters for acute asthma exacerbations. During the intervention phase, the computer provided for structured encounter documentation and offered recommendations based on the guideline of the American Academy of Pediatrics. Patients were contacted by telephone 7 to 14 days after the visit to assess outcomes.


RESULTS
Nine study-physicians enrolled 91 patients in the control phase and 74 in the intervention phase. Follow-up information was available for 93% of encounters. Use of the intervention was associated with increased mean frequency/visit of: 1) measurements of peak expiratory flow rate (2.18 vs 1.57) and oxygen saturation (1.12 vs.42), and 2) administration of nebulized beta2-agonists (1.25 vs.71). Visits in the intervention phase lasted longer and fees were higher ($145.61 vs $103.11). There were no significant differences in immediate disposition or subsequent emergency department visits, hospitalizations, missed school, or caretaker's missed work during the 7 days post visit.


CONCLUSIONS
Use of handheld computers that provide guideline-based decision support was associated with increased physician adherence to guideline recommendations; however, visits were prolonged, fees were higher, and no improvement could be demonstrated with regard to the observed intermediate-term patient outcomes. Guideline implementers (and users) should be cautious about putting unvalidated recommendations into practice.
Shiffman
R N
RN
Department of Pediatrics, Yale School of Medicine, New Haven, CT 06520-8009, USA. richard.shiffman@yale.edu
Freudigman
M d
Md
Brandt
C A
CA
Liaw
Y
Y
Navedo
D D
DD
D000293:Adolescent; D000553:Ambulatory Care; D001249:Asthma / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D003658:Decision Making, Computer-Assisted; D003661:Decision Support Techniques; D019983:Guideline Adherence; D006801:Humans; D009817:Office Management; D017410:Practice Guidelines as Topic; D016896:Treatment Outcome