Family Practice Vol. 18, No. 6, 602-604
© Oxford University Press 2001
Original Paper |
The impact of medical informatics on the confidence of rural physicians caring for patients with chronic hepatitis C viral infections
Liver Diseases Unit, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
Dr GY Minuk, Liver Diseases Unit, John Buhler Research Centre, 803F-715 McDermot Avenue, Winnipeg, Manitoba R3E 3P4, Canada.
Zdanuk S, Gimpel J, Uhanova J, Kaita KDE and Minuk GY. The impact of medical informatics on the confidence of rural physicians caring for patients with chronic hepatitis C viral infections. Family Practice 2001; 18: 602–604.
Received 8 December 2000; Revised 4 April 2001; Accepted 9 July 2001.
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Abstract |
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Objective. The purpose of the present study was to determine whether CD-based medical informatics enhances rural physicians' confidence in the management of patients with chronic hepatitis C viral infections.
Methods. A total of 385 Canadian rural physicians were mailed a CD-based medical software programme that outlines all aspects of HCV care including diagnosis, counselling, treatment and follow-up. Accompanying the CD was a brief questionnaire that addressed physicians' confidence in the following areas: (i) identifying HCV patients in their practice; (ii) laboratory use and interpretation; (iii) patient counselling; (iv) selection of candidates for treatment; (v) sharing treatment delivery; and (vi) providing follow-up. Three months thereafter, the same questionnaire was repeated.
Results. Of the 385 mailings, 59 (15%) physicians returned the initial questionnaire and 57 (15%) the follow-up questionnaire. Twenty-five (44%) respondents indicated they had used the CD. Baseline physician confidence was low in three of the six areas addressed. At follow-up, in addition to now being confident in all areas, CD users were significantly more confident than those who had not used the CD. Increases in physician confidence for CD users were ~150–300% in the six areas addressed. The value assigned the CD programme was 8/10.
Conclusion. The results of this study indicate that: (i) rural physicians are uncomfortable in dealing with many aspects of HCV management; (ii) CD-ROM-based medical informatics can significantly enhance rural physicians' confidence in these areas; (iii) ~50% of physicians will employ CD-ROM-based medical informatics in their offices; and (iv) physician level of satisfaction with such programmes is high.
Keywords. CD-ROMs, health care, hepatitis C, medical education, medical informatics, rural medicine.
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Introduction |
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To date, much of the responsibility for care of patients with chronic hepatitis C virus (HCV) infections has fallen to specialists or subspecialists in urban centres. The large patient to specialist ratio that characterizes this scenario has resulted in long delays in health care delivery and frustration for anxious patients and their referring physicians.
A common explanation for why family physicians have not become more involved in HCV care is their discomfort in dealing with important aspects of the disorder including diagnosis, counselling, treatment and follow-up.1,2 Such discomfort is understandable given that HCV is a relatively new virus, having only been discovered in 1989, long after many physicians had graduated from their medical schools and post-graduate training programmes.3 Moreover, significant and rapid changes have occurred in our understanding and treatment of HCV over the past decade.4,5 Thus, one of the challenges facing the health care system as it relates to HCV is how to improve physician confidence and, thereby, the quality of patient care in this area.
Recently, opinion leaders developed a series of CD-ROM-based medical software programmes that address common but rapidly evolving problems in medicine. The objectives of the programmes were to create software that was: (i) non-threatening and non-dictatorial in nature; (ii) sufficiently ‘user friendly’ that all health care personnel, regardless of their computer training (or lack thereof), could access the content; (iii) clear and concise in presentation so as to be applicable to busy office practices; (iv) likely to limit the number of unnecessary tests, procedures, treatments and referrals and thereby limit health care costs; and (v) promoting a more active role for family practitioners in the management of challenging patients.
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Methods |
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Six brief questions were mailed to all 385 rural physicians listed with the Manitoba College of Physicians and Surgeons in the province of Manitoba, Canada. Accompanying the questionnaire was the most recent version of the HCV CD-ROM Program (Mayer Zev Enterprises Ltd, Winnipeg, Canada). A visual analogue scale (VAS) from 0 to 10 was used to indicate physician confidence in the following areas: (i) identification of HCV patients within their practices; (ii) laboratory utilization and interpretation of results; (iii) patient counselling; (iv) identification of candidates for treatment; (v) participation in treatment delivery; and (vi) provision of long-term follow-up. Three months thereafter, the same questionnaire plus an additional question regarding whether the CD was used and if so, how useful it was, was repeated, and the results of the two mailings (submitted under code) were compared.
Student's t-test and Wilcoxon signed-rank test were used for statistical analyses.
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Results |
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Of the 385 initial mailings, 59 (15%) physicians completed the initial and 57 (15%) the follow-up questionnaires. Nine (16%) of the 57 follow-up responses did not contain a code number, 38 (67%) a code number that could not be matched and 10 (18%) the same baseline and follow-up code number. Of the 57 physicians who returned the follow-up questionnaire, 25 (44%) stated they had used the CD while 32 (56%) had not. Of the 10 matched responses, six used the CD while four did not.
At baseline, physicians felt uncomfortable (mean VAS < 5) in the following three areas: ability to identify candidates for treatment (3.8 ± 2.6), initiating and/or sharing HCV treatment (3.3 ± 2.3) and providing follow-up (3.9 ± 2.6).
At follow-up, regardless of CD usage (i.e. intention to treat analysis), physician confidence increased in all six areas. The increases were statistically significant in the areas of initiating and/or sharing treatment delivery (baseline: 3.2 ± 2.3 versus follow-up: 4.2 ± 2.8, P < 0.05) and providing follow-up (baseline: 3.9 ± 2.6 versus follow-up: 5.0 ± 2.8, P < 0.05).
When CD users were compared with non-users, the former were found to be more confident at follow-up in all areas tested. It is of note that the differences were significant in the same areas where baseline confidence levels were lowest; identifying candidates for therapy (CD users: 5.9 ± 2.6 versus non-users: 3.5 ± 2.4, P < 0.001), initiating and/or sharing treatment delivery (CD users: 5.7 ± 2.5 versus non-users: 3.2 ± 2.5, P < 0.0005) and providing follow-up (CD users: 6.0 ± 2.7 versus non-users: 4.3 ± 2.7, P < 0.05).
In those physicians in whom baseline and follow-up questionnaires could be matched, confidence increased 150–300% in all areas (Figure 1
). Thus, confidence in identifying patients with HCV increased 150% (baseline: 4.9 ± 2.2 versus follow-up: 7.5 ± 1.7, P < 0.0005); laboratory utilization, 157% (baseline: 4.2 ± 2.3 versus follow-up: 6.6 ± 6.1, P = 0.06); counselling, 171% (baseline: 4.1 ± 2.8 versus follow-up: 7.0 ± 2.9, P < 0.01); identifying candidates for treatment, 210% (baseline: 2.9 ± 2.6 versus follow-up: 6.1 ± 2.6, P < 0.05); initiating and/or sharing treatment delivery, 290% (baseline: 2.0 ± 1.9 versus follow-up: 5.8 ± 2.6, P < 0.005); and providing follow-up, 291% (baseline: 2.2 ± 1.8 versus follow-up: 6.4 ± 2.8, P < 0.001).
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When the matched group were separated into CD users and non-users, increases in physician confidence (changes from baseline) for CD users were even more striking (1.7- to 15.2-fold higher than non-users in all areas).
The perceived value of the CD-ROM programme was 8/10 in the 24 CD users.
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Discussion |
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The results of this study reveal a number of interesting findings relevant to the role of family physicians in the care of patients with HCV infections and what impact CD-based medical informatics might have on that role. Specifically, the study demonstrated that physicians feel uncomfortable in dealing with many aspects of HCV management, particularly those pertaining to identifying patients that might benefit from treatment, providing or assisting in the provision of that treatment and carrying out long-term follow-up. The results also show that CD-ROM-based medical informatics can significantly enhance physician confidence in these and other areas within a relatively short period of time. Finally, the results indicate that ~50% of physicians will employ CD-ROM-based medical informatics in their offices, and their level of satisfaction for such programmes is high. Taken together, these findings indicate that CD-ROM-based medical informatics can be of practical value to community-based physicians.
To our knowledge, there are no comparative data documenting the impact of CD-ROM-based medical informatics on physician confidence in providing patient care. That this approach might be of more value than providing similar information in the form of review articles and/or position papers is suggested by a comparison with the results of a similar study reported by Shehab et al.6 In that study, hard copies of the National Institutes of Health guidelines on HCV management which covers the same topics as those outlined in the CD-ROM were mailed to 1233 office-based physicians in the state of Michigan. Physician awareness of risk factors and approach to the management of hypothetical HCV cases were documented at baseline and 1 month after receipt of the position paper. The results demonstrated that physician management did not improve following provision of information in this format.
It should be noted that a minority (18%) of responding physicians provided matching codes for the baseline and follow-up questionnaire. Thus, it is conceivable that many of the physicians who completed the baseline questionnaire were not the same physicians as those who completed the follow-up form. The similar numbers of physicians responding at baseline and follow-up argue against that possibility.
In addition to the high numerical value assigned to the programme by physicians, feedback in the form of written comments emphasized their approval of the programmes and this form of information delivery. Respondents wrote they were particularly appreciative of the fact the programmes were developed by authorities independently of the pharmaceutical industry. On numerous occasions it was commented that it was the intent of the respondent to become more involved in HCV management and, at the very least, share with specialists some of the monitoring and post-treatment follow-up of HCV patients.
In summary, the results of this study indicate that family physician confidence in managing patients with chronic HCV can be significantly enhanced with the provision of CD-ROM-based medical informatics. The results also demonstrate that physicians are receptive to this means of medical education and view such technology as being of value in their provision of health care.
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Acknowledgments |
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This study was supported by Health Canada and the Canadian Society of Rural Physicians
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References |
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1 Singh S, Miller R, Madge S, Patch D. The impact of hepatitis C in general practice. Br J Gen Pract 2000; 50: 532–536.[Medline]
2 Lionis C, Frangoulis E, Skliros S, Alexandrakis E, Kouroumatis E. How greek GPs manage hepatitis C infected patients: experiences gained from a primary health care district in rural Crete. Aust Fam Phys 1999; 25: 207.
3 Choo QL, Kuo G, Weiner AJ, Overby LR, Bradley DW, Houghton M. Isolation of a cDNA clone derived from a blood-borne non-A, non-B viral hepatitis genome. Science 1989; 88: 359–362.
4 Public Health Laboratory Service (http://phls.co.uk/cdsc).
5 World Organization (http://www.who.ch).
6 Shehab TM, Sonnad SS, Jeffries M, Gunaratnum M, Lok ASF. Current practice patterns of primary care physicians in the management of patients with hepatitis C. Hepatology 1999; 30: 794–800.[Web of Science][Medline]
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