Do standing orders help with chronic disease care and health maintenance in ambulatory practice?
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 disease3-5 | Pneumococcal vaccine | Baseline range: 5%-15%; Follow-up range: 25%-28.3% | 3.7-10 |
| Influenza6-8 | 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. | |||
