Our reminder system may have appeared ineffective in changing physician behavior for a number of reasons. First, patients may have had contraindications to medications that prevented physicians from using these therapies. We found, however, that 64% of patients did not receive aspirin and 82% of patients did not receive β-blockers, proportions that are much larger than expected based on the prevalence of contraindications in similar patient groups.5,6
Second, patients may have obtained aspirin over-the-counter; therefore, the rates of actual aspirin use may have been higher. Third, patients had an average LDL level of 115 mg/dL at the beginning of the study, making it difficult for any intervention to improve on this successful management, especially in the study's short timeframe.
A number of factors related to implementation of the reminder system may have resulted in its failure.7
First, physicians in our study did not participate in the design of the reminder system and, as has been shown in other studies, this “lack of buy-in” may lead to poor compliance. Second, our reminders were fixed rather than dynamic, so physicians may have become desensitized. Finally, study physicians may have felt they were too busy to comply with the guidelines.8
Busy physicians have been shown to be less compliant with preventive services as well as less responsive to reminders because of intense time pressures.
In summary, the results of our study showed that a computerized and written reminder system did not increase the use of aspirin and β-blockers or improve cholesterol management in patients with coronary artery disease. Our findings imply that using fixed reminders to improve disease management may be ineffective. Other types of reminder systems, including those with real-time feedback, are warranted to find new ways of improving the management of patients with coronary artery disease.