PROCEDIMIENTOS PARA ANALIZAR FALLOS Y AVERÍAS

Several studies have looked at the usefulness of computer registers in the follow-up of chronic disease (Beilin et al 1974, Petrie et al 1985, Bulpitt et al 1976, Jones et al 1982) w i t h focus upon diabetes

in particular (Jones et al 1983). Computerised registers of hospital clinic attenders have been developed to generate structured records to act as implicit prompts for doctors to ask patients appropriate questions, perform particular clinical examinations, or request certain kinds of investigations. Such systems are designed to prompt only in the same sense in wh i c h a structured manual record, particularly if it contains time-related data, may also implicitly prompt doctors to perform certain procedures (Williams CD et al 1988). Such systems have not been confined to hospital clinics; some have also mailed structured letters and records to GPs and patients (Bulpitt 1976, Jones et al 1983, Morris et al 1984).

Outside the field of diabetic care, explicit computer generated prompts to doctors concerning the need for particular interventions, or follow-up, have shown that process of care can be improved according to agreed protocols (McDonald 1976, McDonald et al 1984, Turner et al 1990). Diabetologists in the U K have been in the forefront of developing clinical computing applications (Hill 1986a 1968b, Williams CD et al 1988) including an expert systems approach (Williams CD et al 1989). In Southampton, a computer system was set up in 1986 to prompt patients for blood tests w ith clinical review in either general practice or hospital (Callaway et al 1988). In 1988 73% of the estimated total district population of 5500 diabetic patients was registered on the computer wh i c h was able to support diabetic care in 15 general practices at that time. In Wakefield, a micro-computer has been programmed to send prompts for blood glucose estimations to Type II patients discharged from the hospital clinic w ho fail to have such tests performed 6 monthly. If patients miss their scheduled blood test by 2 months, or more, they are prompted and the appropriate GPs are notified. In addition, all patients are prompted for 3 yearly review in the hospital diabetic clinic. No evaluation of this system has yet been published, but it has been judged by the consultant in charge of the initiative *a qualified success* (Burr 1990).

As already mentioned, Baldwin et al (1992) have piloted a system of 4 monthly computer prompted requests to Type II diabetic patients

for fasting blood glucose, followed by GP review and annual review in the hospital clinic. It is not clear from the report whether this system also involved the use of structured records in general practice or hospital. However, a two year uncontrolled follow-up has

shown encouraging maintenance of glycaemic control in these

patients. Harvey et al (1992) have reported a randomised controlled trial of conventional hospital clinic care of Type I and II diabetes versus integrated patient care. In this scheme shared care consists of 4 monthly appointments and recall to GPs and annual hospital review coordinated by a main frame computer system. The study has shown no loss of glycaemic control in the integrated care group after 2 years of follow-up.

The Islington prompted care approach does more than simply 'nudge* patients, doctors and optometrists to comply w i t h a medical management regime. It also supplies participating GPs w i t h a time- related medical summary of information relevant to the diabetic care of each patient. Does the feedback role have an independent effect upon quality of care? A n interesting study in Toronto has looked at this question; it examined the role of computer feedback to GPs on hypertensive patients prompted to receive primary care according to an agreed protocol (McAlister 1986). The study showed that GPs who received computer feedback w hich included information about the stepped protocol of care in use, together w i t h ranked p a t i e n t s ’ diastolic blood pressure by percentiles, achieved a significantly greater reduction in the diastolic pressure of their patients than the prompted patients of GPs who received no such feedback. This study suggests that the structure provided by prompting, including feedback of relevant information, may be as important in the delivery of care as the prompting itself.

Prompting as in Islington has created opportunities for structured audit of diabetic care. The updated longitudinal record of the medical care of each patient, w h i c h is at the hub of the prompting system, could provide valuable data for on-going medical audit. The longitudinal record contains three types of data basic to audit:

providers including dietitians and chiropodists

2 Process of care measures gathered from the frequency of

laboratory estimations of glycaemic control and

albuminuria, and the frequency of process of care measures provided by feedback from consultations wit h GPs, hospital diabetic clinic doctors, optometry and hospital ophthalmic assessments

3 Outcome measures from the processes in 2 above.

Rev i e w of the above measures, at appropriate intervals, could