J. Eaton et al. Visit length and abdominal aortic aneurysm screening Potential interventions to improve compliance These tools include developing a physician-directed protocol that would enable nursing staff to identify eligible patients and order a screening ultrasound during the rooming process. Most providers surveyed in this study believed that such a protocol would improve screening ordering rates. A similar model for cancer screening has been found to be superior to the traditional physician-directed model [14]. In addition, surveillance systems for AAA with nurse- practitioner oversight have achieved compliance with screening guidelines as high as 98.5% over a 7-year period [15]. We did not identify any differences in screening rates according to provider gender or role. Staff physicians did not screen at greater rates than other providers, suggesting that interventions to improve screening should not be limited to speciﬁc provider groups. From National Ambulatory Medical Care Survey data [16], we know that men have fewer ofﬁce visits than women in the screen- ing age group. For men, who may not visit a clinic for years, mailed reminders such as those successfully used to increase screening mammography rates could be employed [17]. In addi- tion, advances in HIT can be used to boost patients’ completion rates of preventive screenings. For example, with the advent of electronic patient health records, patients can track and manage their own relevant preventive or screening services [18]. Mayo Clinic recently launched such an online patient-managed personal health record system, Mayo Clinic Health Manager, that patients can use to receive reminders and recommendations tailored to their lifestyle and health status [19]. However, rather than relying on methods that place the burden on the patient to initiate scheduling of important screening for services in which the test poses no (or minimal) risk to the patient (e.g. AAA, osteoporosis, breast cancer), allied health staff can be trained to schedule screenings when the patient is due. In our study of breast cancer screening, a part-time trained appointment secre- tary managed the breast cancer screenings for thousands of patients [17]. In the future, HIT systems may allow patients to directly schedule these types of preventive screenings when they become eligible or due for those services, and primary care pro- viders would need to interact with the patient only if the test results were abnormal. The importance of delivery rates of preventive services and electronic connectivity with patients is reﬂected in the inclusion of multiple metrics for these two health care components in the newly announced ‘meaningful use’ measures for HIT [20]. Impact on other clinical practices New infrastructures are needed to improve preventive services such as AAA screening. The patient-centred medical home calls for a personal physician to lead a team of individuals to provide compre- hensive care for patients, including preventive services, through multiple modalities. [21,22] Examining the quality of preventive care as we have done in this study and the use of electronic systems such as our automated reminder system are important features of this model. This study further reinforces the concept of the medical home in that multiple modalities, in addition to electronic systems, are needed for providing preventive services, particularly when the visit time is a limiting factor. Additional resources discussed previously are needed to improve compliance. Similar strategies presented in this study can be employed in other clinics to identify © 2011 Blackwell Publishing Ltd areas of suboptimal performance and to improve the quality of care delivered to patients in primary care practices. Study limitations This study had several limitations. First, it was performed over a 4-month period, so the results only approximate actual AAA screening ordering rates over longer periods. Second, ordering practices at only the initial visit during the study period were examined, and it is plausible that some patients had an ultrasound ordered on a subsequent visit. However, we found that, even if all visits during the study interval were included, only 15.5% of eligible patients had AAA screening ordered by their provider. Aside from patient refusal, other patient factors (e.g. insurance status, ethnicity, language barriers, medical comorbidities) were not assessed. Consequently, it is unknown if any of these factors contributed to the low rate of AAA screening ordering. Finally, because this study involved only a single practice site, it may not represent screening ordering rates in the rest of country. Conclusions This study demonstrated low rates of AAA screening ordering for patients who met the eligibility criteria. It also showed that rates were independent of provider type or gender but were related to visit length. Because providing preventative services is often time- consuming, electronic reminder systems have often been employed in clinical practices like ours around the country. Such systems may not act as a magic bullet to this problem. A more comprehensive and multidisciplinary approach is required, as illustrated by the concept of the medical home, to improve pre- ventive screening rates. 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