Charles O. Hershey

Influence of Simple Computerized Feedback on Prescription Charges in an Ambulatory Clinic: A Randomized Clinical Trial

Pharmaceuticals account for a significant portion of health care costs and are an important target for attempts at cost reductions. While many techniques have been shown effective, most are resource-intensive, have demonstrated fatigue after the intervention is ceased, and have been directed at specific items rather than total charges. The authors designed a computerized program to feed back prescription charges. The intervention is easy to execute, inexpensive, and can be maintained indefinitely. The intervention was performed in a randomized, prospective, controlled trial with the medical residents of a large county hospital. The goal was to reduce total prescribing charges and produce a meaningful financial result. The intervention reduced the mean charge for a prescription by 6.7% (P < 0.025), but with a long latent period and minimal impact on resident knowledge of drug charges. Significant differences were seen only at the end of the study. The program was viewed positively by the residents. The low cost of the intervention yielded a benefit-to-cost ratio in excess of 50:1. Because of computerization and ongoing patient and resident randomization at the study hospital, added costs of this randomized trial in terms of computer time and research assistance were less than

A Measure of Physician Mental Work Load in Internal Medicine Ambulatory Care Clinics

1,000.

The cost implications of academic group practice. A randomized controlled trial.

Physician mental work load is an important variable intervening between work demands imposed on physicians and physician performance. A brief instrument was developed to measure the mental work load experienced during a clinic session in internal medicine ambulatory care hospital clinics. The instrument covered six dimensions of mental work load: performance, time load, mental effort, physical effort, psychologic stress, and difficulty. Cronbachs alpha reliability coefficient for the instrument was 0.83. The instrument exhibited construct validity. As hypothesized, mental work load was found to be positively associated with number of patients seen and with fatigue, and mental work load was inversely associated with physician satisfaction with the patient care they provided and with their self–rating of the quality of care they provided. The importance of measuring physician mental work load is discussed.

Update on screening for type 2 diabetes. The why, who, how, and what of testing and diagnosing.

We evaluated the reorganization of a general medical clinic into several group practices, using equivalent groups of patients and physicians in a randomized controlled trial. The group practice, unlike the traditional clinic, provided decentralized registration, clinic coverage five days a week, and telephone coverage at night and on weekends. Residents worked in small groups with an attending physician, nurse practitioner, and receptionist. All financial activity involving a sample of 2299 patients was followed during the 11-month intervention. The total hospital charges per patient were 26 percent lower for the patients seen in the group practice than for those seen in the traditional clinic (P = 0.003). This difference was primarily attributable to inpatient charges, which were 27 percent lower per patient hospitalized (P = 0.004). The mean length of stay was 8.3 days among group-practice patients and 10.5 days among traditional-clinic patients (P = 0.011). We conclude that organizational changes to improve outpatient access and to integrate inpatient and outpatient services can decrease medical charges.

Academic group practice. The physicians' view.

PREVIEW Diabetes mellitus, a leading cause of death in the United States, remains undiagnosed in more than 5 million people. While screening for this disease is key to reducing its complications, morbidity and mortality, the recommendations for identifying and testing at-risk populations are debatable. This article summarizes the competing guidelines for screening for type 2 diabetes and offers insight on the different diagnostic methods and tools available.

Assessment of Delivery of Preventive Health Services

In order to evaluate physician response to the reorganization of a traditional medical clinic into a group practice model, a randomized controlled trial was conducted using equivalent groups of patients and physicians. The group practice model, unlike the traditional clinic, provided decentralized registration, 5 days/week clinic coverage, and night/weekend phone coverage. Residents worked in small groups with an attending physician, nurse practitioner, staff nurse, and receptionist. A panel of 50 medical residents was interviewed prior to the reorganization and 1 year later. Residents in the experimental groups perceived improvements in the ancillary staff, placed a higher value on informal discussion of patient management problems, and were more satisfied with the outpatient experience. Moreover, residents in the group practices were more likely to voluntarily schedule additional clinic sessions to accommodate their patients. No change was noted in their career choices. We conclude that reorganization of a traditional medical clinic into a group practice model can result in increased physician satisfaction although it may not have a major impact on long-term career goals.

Postmortem management of patient affairs: The resident's perspective

Our objective was to design and evaluate an instru ment to assess the performance of a clinic in the deliv ery of preventive health services to a general medical clinic population. The patients were identified prospec tively ; data were obtained retrospectively with review of the charts. The study was conducted in a primary care clinic staffed primarily by internal medicine residents in an urban academic medical center. Patients who were receiving continuity care in the clinic and who were scheduled for an appointment during the 4-week study period were eligible for inclusion. Patients were iden tified by the appointment schedule. Charts were re viewed for the delivery of preventive health services. Data were abstracted utilizing a standard instrument. We found that the rate at which services were provided varied considerably by service and over time. The tech niques used provided some insight into methods for the evaluation of the delivery of preventive services. It should be possible to assess a clinics performance over a range of services over its entire population over time. An understanding of this more global performance may provide a better tool for managers and researchers ad dressing these issues. There may be legitimate reasons for services not being provided. These issues are com plex and require sensitive, detailed investigation.

Experience with community academic practice: Strategies for the ambulatory education of residents

The role of residents continues to evolve, and they are finding themselves increasingly being asked to request an autopsy from a grieving family. Although much has been written previously concerning the need for residents to be more aggressive in obtaining autopsy, this article suggests that structural problems must be addressed if the current low autopsy rate is to be improved.

The elderly psychiatric patient with positive syphilis serology: the problem of neurosyphilis.

The expectation that training programs will place more of their physician graduates into primary care has caused internal medicine programs to explore different educational experiences for their residents. One proposal is to transfer the ambulatory training site for residents from the hospital clinic to a community academic practice (CAP) site. We discuss the theoretical aspects, the practical considerations, and our experience with one CAP site, including the problems that have been solved and the problems remaining.

Reduction of anti-inflammatory drug costs with newer aspirin formulations.

Objective: Older patients have a high prevalence of neurological and psychiatric disorders. They also have a baseline prevalence of late latent syphilis or positive syphilis serology. Thus the clinical question arises as to whether a neuropsychiatric disorder in a geriatric patient is neurosyphilis or if the positive serology is incidental. Method: An illustrative case example is used to illustrate this dilemma. The relevant literature is reviewed. Results: The cerebrospinal fluid (CSF) protein is an important indicator of inflammatory activity in the central nervous system and is used as a clinical guide in the diagnosis. Elderly patients have higher values of normal CSF protein than younger patients. Conclusions: Given the importance of CSF protein in the diagnosis of neurosyphilis, physicians must include this knowledge, that elderly patients have higher CSF protein values, in their clinical decision making in the differentiation between neurosyphilis and late latent syphilis in the elderly patient.