David I. Cohen

Improving physician compliance with preventive medicine guidelines.

Similar general medical outpatient clinics with randomly assigned patients were used to evaluate the effectiveness of a program that was to increase house staff compliance with preventive medicine guidelines. Two clinics were designated experimental and two served as controls. In the experimental clinics, age-specific checklists of all recommended preventive procedures (drawn from the Canadian Task Force report on The Periodic Health Examination and American Cancer Society guidelines) were appended to each patients chart. In addition, house officers were presented with a series of weekly seminars dealing with issues in screening, as well as the specific recommendations included in the checklist. House officers in all four clinics were tested for their knowledge and attitudes toward the preventive program before and after the intervention. Counts of immunizations and mammograms performed and the total populations eligible for these procedures were determined for all four clinics. As predicted, test scores as well as mammography and immunization rates increased significantly (from 2-40 per cent) in the intervention clinics as compared with controls. We conclude that this intervention was clearly effective in the short run. However, follow-up studies will be necessary to determine whether the desired long-term effect has been achieved.

Does cost information availability reduce physician test usage? A randomized clinical trial with unexpected findings.

Four similar teams of physicians associated with similar inpatient units and randomly assigned patients were used to study the effect of providing physicians with cost information about their use of lab tests and x-rays. Two teams received information about lab test costs, and two teams received x-ray test costs. Test usage fell during the experimental conditions and continued to fall after the experimental period ended in teams in which there was an interested leader.

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

Effect of an academic group practice on patient show rates: A randomized controlled trial

1,000.

Academic group practice. The patient's perspective.

Ambulatory medical clinics at academic centers are reputed to be expensive, inefficient, and poorly regarded by the medical residents who staff them. In an effort to address these problems, some centers have reorganized their traditional clinics into group practices. These group practices are thought to be more effective for teaching and providing services than are the traditional clinics. This is a report on the results of a study in which the authors reorganized two of four firm clinics into group practices in order to test the influence of the organizational changes on the various aspects of ambulatory care. During this controlled prospective trial of the group practice model, higher show rates were observed for patients in the group practices than in the traditional clinics (70% vs 65%, P < 0.0005). The possible reasons for the higher rates are discussed.

Academic group practice. The physicians' view.

The effect upon patient satisfaction of a reorganization of a traditional medical clinic into a group practice model was examined in a controlled trial in which both patients and physicians were randomized. 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, a nurse practitioner, and a receptionist. This reorganization resulted in a substantial decrease in charges and utilization for patients in the experimental group. A panel of 302 patients was interviewed prior to the reorganization and 1 year later. Patients in the experimental groups perceived improvements in access to their physicians as well as decreases in clinic waiting time and decreases in the lag time between requesting and obtaining an appointment. General health perceptions and other satisfaction measures were unchanged. The authors conclude that a group practice organization can result in decreased patient charges without substantially altering patient satisfaction.

Resident Knowledge of Charges: Are We Asking the Right Questions?

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.

Improving the knowledge base for health systems management: the strategy at Case Western Reserve University

ABSTRACT: Physician knowledge of costs and charges for medical services is thought to have substantial relevance for cost containment. Unfortunately, numerous studies have demonstrated the difficulties in using educational techniques to improve knowledge and reduce charges. Furthermore, reductions in charges, when achieved, have not correlated with improved physician knowledge. The authors examined several methods of ascertaining physician knowledge of charges and they suggest that previous methods may have been too insensitive. Previous reports may have underestimated physician knowledge of costs and charges.

The Use of Prenatal Cytogenetic Diagnosis: A Comparison of Rates in Prepaid Group Practices and the General Population

The Health Systems Management Center at Case Western Reserve University is a unique program that involves both the School of Medicine and the School of Management. It was created to improve the knowledge base for managing medical care through education, research and practice.

Intravenous Therapy Team and Peripheral Venous Catheter—Associated Complications: A Prospective Controlled Study

To determine whether the reduction in services associated with prepaid group practice is indiscriminate or limited to medically “discretionary” services, the author compared the utilization rates for prenatal cytogenetic diagnosis (a medically indicated service for women aged 35 and older) in prepaid group practices and the geographically corresponding populations-at-large in four settings. The utilization rates by members of the prepaid group practices were equal to rates calculated for the geographically corresponding populations-at-large in two settings, and 2.3 times greater in the other settings. Whatever factors which may be responsible for the reduction of discretionary services delivered to members of prepaid group practices do not appear to interfere with the delivery of a strongly indicated service, prenatal cytogenetic diagnosis, in the population at risk.