Visit length and abdominal aortic aneurysm screening Table 2 Primary care internal medicine clinic providers’ perceptions and knowledge regarding abdominal aortic aneurysm (AAA) screening guidelines and practices* J. Eaton et al. % response 19.3 46.8 33.9 65.1 86.7 74.3 79.0 58.1 34.6 22.4 23.4 5.6 14.0 49.1 38.2 12.7 0.0 64.2 45.3 48.1 41.5 70.6 20.2 9.2 Question 1. Familiarity with US Preventive Services Task Force AAA screening guidelines 2. Identify correct frequency of AAA screening 3. Identify correct speciﬁc AAA screening criteria 4. Estimate what percentage of your eligible patients have undergone the recommended AAA screening 5. Estimate what percentage of eligible patients in the primary care internal medicine clinic have undergone the recommended AAA screening 6. Identify factors that may contribute to poor AAA screening ordering practices in the primary care internal medicine clinic 7. Do you believe a nurse-driven ordering protocol would improve AAA screening ordering rates? Possible response Very Somewhat Not Once in a lifetime Men Current smokers Former smokers Age 65 to 75 years <25 25 to 49 50 to 75 >75 Not applicable <25 25 to 49 50 to 75 >75 Lack of provider knowledge Lack of patient knowledge Forgot to order Physician-dependent ordering system Yes Unsure No *A total of 109 respondents: residents, 42.2%; nurses, 30.3%; staff, 22.0%; midlevel providers, 2.8%; not applicable, 2.7%. forgetting to order the test and a physician-dependent ordering system were important factors in low screening rates. Physician reminders to order screening The primary care clinic examined in this study uses health infor- mation technology (HIT), speciﬁcally real-time clinical decision support, to identify patients who are due for the screening, remind- ing providers to order age- and gender-speciﬁc screening tests and tests for chronic condition management. This protocol accurately identiﬁes patients in need of screening tests, including AAA screening, at each ofﬁce visit. Paper copies of the clinical decision support tool summary screen of tests needed for each patient are placed outside the examination room door as well as in the patient’s hands once the patient is taken to the room. However, the provider must still review the recommen- dation during the visit, order the test and explain it to the patient. Prior to implementation of this system, our AAA screening rates were only 3%. In general, our ﬁndings support other studies that have shown that provider-reminder systems have only a modest impact on screening practices. In a systemic review of the various types of physician prompts, including combined paper and com- puter reminders, paper-only reminders and computer-only remind- ers, the delivery of preventive care was improved by an average of only 12% to 14% [13]. As such, practice redesign is also needed so that all members of the care team, including the physician, work together to improve compliance. 596 Provider-related reasons for failure to order screening We identiﬁed some provider-related reasons for low rates of AAA screening ordering. First, our survey showed that providers have not yet internalized the recent guidelines. In fact, only a minority felt that they were very familiar with USPSTF guidelines for AAA screening, and their ability to identify the speciﬁc components of the guidelines varied greatly. Second, a large proportion of pro- viders reported that they forgot to address the screening during the visit. Considering the once-a-lifetime recommended screening for AAA and the other competing screening tests that need completion at more frequent intervals (e.g. cholesterol levels, mammography, colonoscopy), it is understandable that AAA screening may not be foremost in the minds of providers – even during medical exami- nations in which prevention is stressed. Provider perceptions about their personal screening ordering practices versus the clinic’s practices as a whole were similar in that many felt that fewer than 25% of their own eligible patients and those of other providers had undergone AAA screening. These ﬁndings were consistent with the actual screening rate observed in this study. Third, our study showed that providers thought that lack of patient knowledge was also a barrier to appropriate ordering practices. Indeed, in our experience, public awareness of AAA screening is lower than that of other preventive screening mea- sures; because it is a recent recommendation, it has not been publicized to the extent that breast and colon cancer screening have. © 2011 Blackwell Publishing Ltd