Christianne L. Roumie, MD; Eric L. Grogan, MD; William Falbe, PharmD; Joseph Awad, MD; Theodore Speroff, PhD; Robert S. Dittus, MD, MPH; Tom A. Elasy, MD, MPH
Grant Support: Drs. Roumie and Grogan were supported by the Office of Academic Affiliations, Department of Veterans Affairs, and the National Quality Scholars Program. Dr. Dittus received support from the Geriatrics Research and Education Clinical Center and the Tennessee Valley Health Services Research Center. Drs. Speroff and Elasy received support from the Veterans Affairs Targeted Research Enhancement Program. The resources and facilities at the Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, were used to support this paper.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Christianne L. Roumie, MD, Nashville Veterans Affairs Medical Center, Geriatrics Research and Education Clinical Center 4A120, 1310 24th Avenue South, Nashville, TN 37212; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Roumie, Grogan, Speroff, Dittus, and Elasy: Vanderbilt University, Departments of Medicine and Surgery, Nashville Veterans Affairs Medical Center, Geriatrics Research and Education Clinical Center, 1310 24th Avenue South, Nashville, TN 37212.
Drs. Fable and Awad: Nashville Veterans Affairs Medical Center, Pharmacy Services, 1310 24th Avenue South, Nashville, TN 37212.
Slow adaptation of new information by providers may result in suboptimal care.
To evaluate changes in prescriptions for combination hormone replacement therapy (HRT) after a multicomponent intervention to deliver new information to patients and providers.
Quasi-experimental study with multiple baselines.
Veterans Affairs Tennessee Valley Healthcare System (VA-TVHS).
Female veterans age 50 to 79 years who had a prescription filled at the VA-TVHS for combination HRT between 1 January 2002 and 1 July 2002.
Discontinuation of HRT.
A 3-part intervention consisted of 1) notifying patients who were using combination HRT of the results of the Women's Health Initiative study (patient education component), 2) sending all providers an e-mail with the Women's Health Initiative study results (provider education component), and 3) placing an electronic alert in each eligible patient's chart (provider care component). The alert asked providers to reevaluate the need for combination HRT. The intervention was implemented at different VA-TVHS sites in a stepwise fashion to differentiate intervention effect from media effect. Study follow-up continued through 31 December 2002.
The total rate of discontinuation of combination HRT was 70.3% in 2002. The proportion of discontinuation from time of media release until intervention was 23.3%. After initiation of the intervention, an additional 43% of the original cohort discontinued use of HRT; this percentage represents a 59% relative decrease in HRT use among patients. After adjustment for time, the discontinuation rate per day was 4.9 times higher after the multifacted intervention than after the media release (95% CI, 1.8 to 13.1).
A true control group is lacking.
A multifaceted approach in an integrated health care system with standardized methods of communication is an effective way to implement patient-centered, effective, and timely care with changing medical knowledge.
Evidence documents that months to years often elapse before physicians adopt clinical practices supported by randomized, controlled trials. These researchers studied interventions to decrease this lag time after publication of the Women's Health Initiative, a trial that concluded that the overall risks of combination hormone replacement therapy exceeded its benefits.
A multicomponent intervention (patient notification, provider education, electronic alert in patient chart) seemed to increase the discontinuation rate of hormone replacement therapy use after release of study results from the Women's Health Initiative in July 2002.
The study did not include a true control group.
Table 1. Characteristics of the Tennessee Valley Healthcare System Cohort
Table 2. Discontinuation of Hormone Replacement Therapy by Site of Care over Time
Discontinuation of hormone replacement therapy (HRT).
Provider education e-mail.
Patient education letter.
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Roumie CL, Grogan EL, Falbe W, Awad J, Speroff T, Dittus RS, et al. A Three-Part Intervention To Change the Use of Hormone Replacement Therapy in Response to New Evidence. Ann Intern Med. ;141:118–125. doi: 10.7326/0003-4819-141-2-200407200-00010
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Published: Ann Intern Med. 2004;141(2):118-125.
Endocrine and Metabolism.
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