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 Ameri can Academy of Pediatrics guideline on office management of asthma exacerba tions. Design. A before-after trial with randomly selected, office-based Connectic ut pediatricians. In both the control and intervention phases, physicians c ollected data from 10 patient encounters for acute asthma exacerbations. Du ring the intervention phase, the computer provided for structured encounter documentation and offered recommendations based on the guideline of the Am erican 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 an d 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 nebulize d beta 2-agonists (1.25 vs .71). Visits in the intervention phase lasted lo nger and fees were higher 6$145.61 vs $103.11). There were no significant d ifferences in immediate disposition or subsequent emergency department visi ts, hospitalizations, missed school, or caretaker's missed work during the 7 days post visit. Conclusion. Use of handheld computers that provide guideline-based decision support was associated with increased physician adherence to guideline rec ommendations; however, visits were prolonged, fees were higher, and no impr ovement could be demonstrated with regard to the observed intermediate-term patient outcomes. Guideline implementers land users) should be cautious ab out putting unvalidated recommendations into practice.