Do standing orders help with chronic disease care and health maintenance in ambulatory practice?

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Clinical Inquiries

Do standing orders help with chronic disease care and health maintenance in ambulatory practice?

J Fam Pract. 2010 April;59(4):226-227

By

Katrina Donahue, MD, MPH

Marcus Plescia, MD, MPH

Karen Stafford, MLS

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References

1. Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002;136:641-651.

2. Nichol KL, Zimmerman R. Generalist and subspecialist physicians’ knowledge, attitudes, and practices regarding influenza and pneumococcal vaccinations for elderly and other high-risk patients: a nationwide survey. Arch Intern Med. 2001;161:2702-2708.

3. Mold JW, Aspy CA, Nagykaldi Z. Implementation of evidence-based preventive services delivery processes in primary care: an Oklahoma Physicians Resource/Research Network (OKPRN) study. J Am Board Fam Med. 2008;21:334-344.

4. Rhew DC, Glassman PA, Goetz MB. Improving pneumococcal vaccine rates. Nurse protocols versus clinical reminders. J Gen Intern Med. 1999;14:351-356.

5. Herman CJ, Speroff T, Cebul RD. Improving compliance with immunization in the older adult: results of a randomized cohort study. J Am Geriatr Soc. 1994;42:1154-1159.

6. Margolis KL, Nichol KL, Wuorenma J, et al. Exporting a successful influenza vaccination program from a teaching hospital to a community outpatient setting. J Am Geriatr Soc. 1992;40:1021-1023.

7. Nichol KL, Korn JE, Margolis KL, et al. Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program. Am J Med. 1990;89:156-160.

8. Goebel LJ, Neitch SM, Mufson MA. Standing orders in an ambulatory setting increases influenza vaccine usage in older people. J Am Geriatr Soc. 2005;53:1008-1010.

9. Christy C, McConnochie KM, Zernik N, et al. Impact of an algorithm-guided nurse intervention on the use of immunization opportunities. Arch Pediatr Adolesc Med. 1997;151:384-391.

10. Kharbanda EO, Maehr J, Middleman AB, et al. Influenza vaccine: a position statement of The Society for Adolescent Medicine. J Adolesc Health. 2007;41:216-217.

11. Vaccine-preventable diseases: improving vaccination coverage in children adolescents and adults. A report on recommendations from the Task Force on Community Preventive Services. MMWR Recomm Rep. 1999;48(RR-8):1-15.

12. Harper SA, Fukuda K, Uyeki TM, et al. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2004;53 (RR-6):1-40.

EVIDENCE-BASED ANSWER

RESULTS ARE MIXED. Studies of standing orders tend to examine their effect on compliance with preventive interventions for chronic disease rather than disease outcomes. In the ambulatory setting, they improve rates of influenza vaccination (strength of recommendation [SOR]: C, consistent cohort studies measuring vaccination rates), pneumococcal vaccination (SOR: C, consistent randomized controlled trials [RCTs] measuring vaccination rates), childhood immunizations (SOR: C, inconsistent RCTs measuring vaccination rates), and mammograms (SOR: C, RCT measuring screening rate).

Standing orders don’t improve screening rates for colorectal cancer (SOR: C, RCT measuring screening rate).

Evidence summary

Organizational changes in physician offices can improve delivery of services for preventing and controlling disease.¹ Standing orders—typically defined as physician-approved protocols that authorize nurses or other staff members to perform procedures, such as immunizations without direct physician involvement¹—are readily applicable in ambulatory settings. However, only 30% of physicians use standing orders in their practices.²

Research on standing orders in ambulatory care has focused on immunizations and cancer screening (TABLE). Interventions implementing standing orders typically have multiple components and include staff education, chart flow sheets, and recall-reminders for patients.

TABLE
Effect of standing orders in ambulatory practice

Disease	Standing order	Improvement in vaccination or screening rate	NNT*
Pneumococcal disease^3-5	Pneumococcal vaccine	Baseline range: 5%-15%; Follow-up range: 25%-28.3%	3.7-10
Influenza^6-8	Influenza vaccine	Baseline range: 32%-51.4%; Follow-up range: 58%-74.6%	3.8-4.3
Cancer screening³	Mammogram	Baseline: 33%; Follow-up: 60%	3.7
Childhood illnesses⁹	Immunizations, ages 2-5 yr	Baseline: 14%; Follow-up: 29%	6.7
*Number needed to treat (NNT) is based on the number of additional patients who receive an intervention based on the number who may be exposed to the standing order.

Evidence-based answers from the Family Physicians Inquiries Network

Do standing orders help with chronic disease care and health maintenance in ambulatory practice?

References

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