A Review of:
McGowan, Jessie, William Hogg, Craig Campbell, and Margo Rowan. “Just-in-Time Information Improved Decision-Making in Primary Care: A Randomized Controlled Trial.” PLoS ONE 3.11 (2008): e3785. 10 Mar 2009
Objectives – To determine whether a point-of-care librarian consultation service for primary care practitioners (PCPs) improves the quality of PCPs’ decision-making; saves PCPs time; reduces the number of point-of-care questions that go unanswered due to time constraints; and is cost-effective. Overall PCP satisfaction with the service was also assessed.
Design – Randomized controlled trial.
Setting – Four Family Health Networks (FHNs) and 14 Family Health Groups (FHGs) in Ontario, Canada. These represent new models for primary care service delivery in Ontario.
Subjects – PCPs working within the selected FHNs and FHGs. The majority of these were physicians, but the sample also contained one resident, one nurse, and four nurse-practitioners.
Methods – Subjects were trained in the use of a Web-based query form or mobile device to submit their point-of-care questions electronically. They were also trained in query formulation using PICO (patient, intervention, comparison, and outcome).
Allocation was concealed by an independent company hired to manage data for the project. Participants were not randomized; rather the questions were randomized using a random-number generator.
To ensure blinding of the librarians, all questions submitted were answered by a librarian. Answers to questions in the intervention group were relayed by a third party to the practitioner within minutes. Answers to the questions in the control group were not communicated to the physician. Blinding of the PCP subjects was not possible, as they either received or did not receive an answer.
Subjects were asked to respond to a questionnaire 24 hours after submitting their question. If the question was in the control group, subjects were asked to indicate whether they had let the question remain unanswered or pursued an answer on their own. In order to assess cognitive impact of both librarian-provided information and self-sought information, respondents were asked to rate information on a scale from high positive to negative impact on decision making.
Two linear regression models were run on the data, with participant response time as the dependent variable in the first model, and librarian response time as the dependent variable in the second.
Main Results – The service received a total of 1,889 questions, of which 472 (25%) were randomized to the control group, and 1,417 (75%) to the intervention group. Analysis run on both groups found that the types and complexity of questions were similar between the two groups, as was librarian response time. Questions were rated for complexity (the rating scale is included in the article), and most (85%) had a Level 1 complexity rating, meaning there was only one concept listed for each PICO element.
The primary outcome measure was the amount of time required to answer the question. Average librarian time to respond to questions was 13.68 minutes per question. Average PCP time to find answers to their own questions was 20.29 minutes; however, subjects only attempted to answer 40.5% of control-group questions themselves. Cost-effectiveness analysis was run on these times, and the authors found that the average per-question salary cost for a librarian to answer these questions (based on 15 minutes per question) was $7.15, while average salary cost for a PCP to spend 15 minutes searching for information ranged from $20.75 to $27.69.
The results of the questionnaire indicated a significant positive impact of the information on clinician decision-making. Approximately 60% of the questions in the control group went unanswered, whereas all of the questions in the intervention group were answered. Of the questions answered by the information service, 63.7% of the answers were rated by participants as having a high positive impact on decision-making, versus 14.9% of answers to questions in the control group that practitioners sought out themselves. Seventeen percent of the answers were rated as having a moderate positive impact in the intervention group, versus 5.9% in the control group. Only 7.8% of answers in the intervention group were rated as having no impact, versus 24.8% of answers in the control group. A negative impact (where practitioners found too much or too little information or information that they disagreed with or felt was harmful) was found for 7.7% of librarian-provided answers, compared with 44.9% of practitioner-sought answers.
Satisfaction was very high, according to the exit satisfaction survey, with 86% agreeing that the service had a positive impact on decision-making, and 83% stating that relevant answers were provided in an appropriate time frame. Most participants (72%) would consider using such a service, and 33% indicated they would be willing to pay for this type of service.
Conclusion – A point-of-care reference service, in which librarians answer primary care practitioners’ questions within minutes, has a very positive impact on clinical decision making and a high rate of client satisfaction. This system saves PCPs time, which may allow them to spend more time with patients. In supporting good clinical decision making, the service may also decrease the need for referrals and further tests. The service is cost-effective, as librarians find better quality information than practitioners, and they do it faster, on a lower per-hour salary.
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