Background:

Rural primary care providers (PCPs) are challenged to answer clinical questions and keep up-to-date with best evidence resources like the Cochrane Database of Systematic Reviews (CDSR). Personal digital assistants (PDAs) with good clinical decision support software and concise pre-validated reviews are common, but their use has not been assessed among rural PCPs.

Objectives:

Test the feasibility and effectiveness of providing the CDSR and other best evidence resources at the point of clinical decision-making with PDAs in rural primary care.

Methods:

Pre-post experimental pilot study design was completed in rural primary care clinics in Tennessee. Subjects were 11 non-academic family physicians, general internists, nurse practitioners in fulltime rural practice. Subjects were trained to use PDAs and InfoRetriever software - that contained the abstracts of all the CDSRs - in their practices for 6 consecutive months. Training focused on:

1. use of pre-validated summaries and abstracts of systematic reviews; and
2: 'clinical rules', a function of InfoRetriever that used interactive evidence-based tools with algorithms to assist the PCP with clinical decisions about individual patients.

The training highlighted three common 'tracer' conditions (sore throat/pharyngitis, sinusitis, ankle injury). Outcomes included all the clinical decisions from chart data for each of three 'tracer' conditions for the 6-months post training versus the same 6 months the prior year. These included prescribing antibiotics for sore throat/pharyngitis or sinusitis, and ordering an x-ray for acute ankle injury. Secondary outcomes were other clinical decisions (e.g., other treatments and tests) and the actual usage of InfoRetriever, automatically recorded by the software.

Results:

There were 477 InfoRetriever searches and 1016 clinical encounters for the 'tracer' conditions. There were only 14 Cochrane database searches. Antibiotic usage dropped, x-rays ordered increased, but none were statistically significantly. Prescribing for symptomatic relief (analgesics, decongestants, for sore throat/pharyngitis; antihistamine/decongestants for sinusitis) significantly decreased. Nasal inhaler prescribing for acute sinusitis significantly increased.

Conclusions:

PCP use of PDAs for clinical decision-making hardly changed the frequent overuse of antibiotics and x-rays, but did alter prescribing of substances for symptomatic relief. Cochrane database searches were rarely performed, suggesting rural PCPs need to be made more aware of their utility.