Injury Prevention
Better health while you wait: A controlled trial of a computer-based intervention for screening and health promotion in the emergency department*,**

https://doi.org/10.1067/mem.2001.110818Get rights and content

Abstract

Study Objective: We evaluate a computer-based intervention for screening and health promotion in the emergency department and determine its effect on patient recall of health advice. Methods: This controlled clinical trial, with alternating assignment of patients to a computer intervention (prevention group) or usual care, was conducted in a university hospital ED. The study group consisted of 542 adult patients with nonurgent conditions. The study intervention was a self-administered computer survey generating individualized health information. Outcome measures were (1) patient willingness to take a computerized health risk assessment, (2) disclosure of behavioral risk factors, (3) requests for health information, and (4) remembered health advice. Results: Eighty-nine percent (470/542) of eligible patients participated. Ninety percent were black. Eighty-five percent (210/248) of patients in the prevention group disclosed 1 or more major behavioral risk factors including current smoking (79/248; 32%), untreated hypertension (28/248; 13%), problem drinking (46/248; 19%), use of street drugs (33/248; 13%), major depression (87/248; 35%), unsafe sexual behavior (84/248; 33%), and several other injury-prone behaviors. Ninety-five percent of patients in the prevention group requested health information. On follow-up at 1 week, 62% (133/216) of the prevention group patients compared with 27% (48/180) of the control subjects remembered receiving advice on what they could do to improve their health (relative risk 2.3, 95% confidence interval 1.77 to 3.01). Conclusion: Using a self-administered computer-based health risk assessment, the majority of patients in our urban ED disclosed important health risks and requested information. They were more likely than a control group to remember receiving advice on what they could do to improve their health. Computer methodology may enable physicians to use patient waiting time for health promotion and to target at-risk patients for specific interventions. [Rhodes KV, Lauderdale DS, Stocking CB, Howes DS, Roizen MF, Levinson W. Better health while you wait: a controlled trial of a computer-based intervention for screening and health promotion in the emergency department. Ann Emerg Med. March 2001;37:284-291.]

Introduction

Two common problems in the emergency department are long waiting times and a failure to identify sensitive personal and public health risks. These stem from constraints on provider time. Could patient waiting time, commonly perceived as time wasted, be used as an opportunity for screening and health promotion? We hypothesized that we might be able to address these issues with the use of a self-administered computer-based program. A review of the literature indicates that patients find computer-based health risk appraisal acceptable and are more likely to answer sensitive questions truthfully on a computer.1, 2, 3, 4, 5 However, there is limited experience with integrating interactive computer systems into clinical practice.6 We developed such a system, Prevent HealthQuiz, and evaluated its utility for nonurgent patients waiting for care in an urban ED.

The ED may constitute an advantageous venue for reaching out to people with serious health risks. There are approximately 100 million ED patient visits per year in the United States. Many ED patients are without a regular source of care.7, 8, 9 Beyond the need for linkage to primary care and community-based resources, there is evidence that preventive services may be acceptable to ED patients10, 11 and cost-effective, particularly for vulnerable populations.12, 13, 14 Most ED patients have acute health care problems but are not critically ill. In the ED setting, these patients are assigned to nonurgent triage categories and often spend a significant amount of time waiting to be seen by the physician. Is this waiting time a potential “teachable moment”?

We wanted to determine whether ED patients were interested in health risk assessment and health promotion. Further, we were interested in its effect on patient recall of health advice. Finally, we sought to assess the practical utility of using patient waiting time for screening and health education in a manner that would not interfere with patient flow in a busy inner-city ED.

Section snippets

Materials and methods

We conducted a controlled clinical trial of a computer-based health risk assessment in an inner-city university teaching hospital ED with approximately 38,000 adult visits per year, 40% of which are classified as nonurgent. Health care is provided by emergency medicine and internal medicine residents who are supervised by emergency medicine faculty members. Our study focused solely on patients assigned to nonurgent triage categories. We used a quasi-randomized design based on alternating

Results

During a 6-month period, the research assistants approached 570 nonurgent patients. Twenty-eight were ineligible because of pain (n=21) or had no access to a telephone (n=7). Four hundred eighty-three (89%) of eligible patients agreed to participate, and 470 of them were enrolled into 1 of the 2 study arms. The remaining 13 patients were called for treatment before being assigned. Two hundred forty-eight patients were assigned to the prevention group and 222 patients were assigned to the

Discussion

We found it feasible to use computer survey technology for risk factor screening and health promotion in the acute care setting. ED patients were very accepting of this technology and interested in using their waiting time as an opportunity to receive health information. Of importance, patients receiving the computer intervention were more likely than the control group to remember being given health advice 1 week after the ED visit.

The US Preventive Services Task Force and Centers for Disease

Acknowledgements

We acknowledge the contributions of James Walter, MD, Linda Druelinger, MD, Jon Olsen, MD, Robert Mulliken, MD, Jack Iwashyna, Richard Kim, Lance Becker, MD, Terry VandenHoek, MD, Annette Miller, RN, Sue French, RN, David Mingay, PhD, and Dexter Voisin, PhD. In addition, John Bailar, MD, Marshall Chin, MD, and Nicholas Christakis, MD, PhD, provided valuable editorial advice.

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    *

    Supported by a grant from The Chicago Community Trust (No. 6-35467), the Robert Wood Johnson Clinical Scholars Program, and the University of Chicago Section of Emergency Medicine, Department of Medicine. Technical and computer program development support was provided by The Clinical Practice Enhancement and Anesthesia Research Foundation at the University of Chicago. The University of Chicago and 2 other universities have jointly licensed their rights in HealthQuiz to a nonprofit foundation. If this process is made financially viable, physicians at the University of Chicago Department of Anesthesia and Critical Care may benefit by support of their research. HealthQuiz is currently available free on the Internet at www.healthquiz.com. The primary investigator on the project, Karin Rhodes, MD, is an emergency physician currently supported by the Robert Wood Johnson Foundation as a first-year fellow in the Clinical Scholars Program at the University of Chicago.

    **

    Address for reprints: Karin Rhodes, MD, University of Chicago, Robert Wood Johnson Clinical Scholars Program, 5841 S Maryland Avenue, MC 2007, B234, Chicago, IL 60637; 773-834-4094, fax 773-702-1295; E-mail [email protected].

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