Lisa E. Harris

Effects of computerized guidelines for managing heart disease in primary care.

BACKGROUND: Electronic information systems have been proposed as one means to reduce medical errors of commission (doing the wrong thing) and omission (not providing indicated care).OBJECTIVE: To assess the effects of computer-based cardiac care suggestions.DESIGN: A randomized, controlled trial targeting primary care physicians and pharmacists.SUBJECTS: A total of 706 outpatients with heart failure and/or ischemic heart disease.INTERVENTIONS: Evidence-based cardiac care suggestions, approved by a panel of local cardiologists and general internists, were displayed to physicians and pharmacists as they cared for enrolled patients.MEASUREMENTS: Adherence with the care suggestions, generic and condition-specific quality of life, acute exacerbations of their cardiac disease, medication compliance, health care costs, satisfaction with care, and physicians’ attitudes toward guidelines.RESULTS: Subjects were followed for 1 year during which they made 3,419 primary care visits and were eligible for 2,609 separate cardiac care suggestions. The intervention had no effect on physicians’ adherence to the care suggestions (23% for intervention patients vs 22% for controls). There were no intervention-control differences in quality of life, medication compliance, health care utilization, costs, or satisfaction with care. Physicians viewed guidelines as providing helpful information but constraining their practice and not helpful in making decisions for individual patients.CONCLUSIONS: Care suggestions generated by a sophisticated electronic medical record system failed to improve adherence to accepted practice guidelines or outcomes for patients with heart disease. Future studies must weigh the benefits and costs of different (and perhaps more Draconian) methods of affecting clinician behavior.

Clinical Correlates of Functional Status in Patients With Chronic Renal Insufficiency

Patients with end-stage renal disease (ESRD) are known to have significantly reduced functional abilities, as measured by the Sickness Impact Profile (SIP). We investigated the clinical correlates with SIP scores in a cohort of patients with lesser degrees of renal dysfunction recruited from an academic general medicine practice (mean calculated creatinine clearance, 25 mL/min). Of 603 eligible patients with chronic renal insufficiency (CRI) defined as a serum creatinine greater than 1.5 mg/dL and a calculated creatinine clearance less than 50 mL/min on two occasions more than 6 months apart, 360 (60%) agreed to participate. These patients were primarily elderly (mean age, 69 years) black (83%), women (69.2%), with an average of 6 years of education and a household income of

Measuring patient satisfaction for quality improvement.

400 to

Effects of multidisciplinary case management in patients with chronic renal insufficiency

800 per month; 92% had hypertension and 57% had diabetes. The SIP was administered in-home by trained interviewers. Independent variables included demographic data, education, income, and medications (via interviewers), vital signs taken by a renal nurse, and diagnostic test results and diagnoses from patients computerized records. The total SIP score was the dependent variable, and its physical and psychosocial subscales were also investigated. Variables with univariate correlations with total SIP (P < 0.05) were included in a multiple regression analysis. All variables with a multivariable P value less than 0.10 were included in the final model. The mean SIP score was 24.5 +/- 15.6, higher than that found in patients on dialysis. Significant (P < 0.05) independent correlates with higher SIP scores (greater disability) were lower educational level and income, prior diagnoses of coronary artery disease and stroke, and lower serum albumin.(ABSTRACT TRUNCATED AT 250 WORDS)

Dimensions and Correlates of Physician Work Satisfaction in a Midwestern City

BACKGROUND Surveys used for health plan quality reporting are generally administered annually to health plan enrollees to assess satisfaction with both the health plan and health care services. Therefore, surveys may lack sensitivity to measure the effects of patient-focused, quality improvement initiatives that could demonstrate results in a shorter time period. OBJECTIVES We describe the development and testing of a multidimensional, visit-specific measure of satisfaction with primary care that may be used in quality improvement. METHODS Conducted in five adult and pediatric primary care sites serving a commercial, largely managed-care population, the survey includes the Medical Outcomes Study Visit-Specific Questionnaire, the American Board of Internal Medicine Patient Satisfaction Questionnaire, and locally developed items. We assessed the instruments reliability, validity, and utility for quality improvement. RESULTS For both adult and pediatric samples, three factors emerged: satisfaction with the provider, satisfaction with access, and satisfaction with the office. Satisfaction with the provider and with the office were independently correlated with overall satisfaction in both samples; satisfaction with access was significantly correlated with overall satisfaction only for adults. For adults, patients who disenrolled from the health plan were less satisfied with the office compared with patients who remained with the health plan. Finally, for adults, we detected significant differences across practice sites in terms of satisfaction with office and access; for children, there were intersite differences in terms of satisfaction with provider, office, and access. CONCLUSIONS We have support for the reliability and validity of this instrument that has identified differences in satisfaction between practice sites that may be used for quality improvement.

Different integration processes of patient satisfaction among four groups.

PURPOSE Though case management has been recommended to improve the outcomes of patients with costly or morbid conditions, it has seldom been studied in controlled trials. We performed a randomized, controlled clinical trial of an intensive, multidisciplinary case management program for patients with chronic renal insufficiency and followed patients for 5 years. PATIENTS AND METHODS We enrolled 437 primary-care patients (73% of those eligible) with chronic renal insufficiency (estimated creatinine clearance consistently < 50 mL/min with the last serum creatinine level > 1.4 mg/dL) who were attending an urban academic general internal medicine practice. The intensive case management, administered during the first 2 years after enrollment, consisted of mandatory repeated consultations in a nephrology case management clinic staffed by two nephrologists, a renal nurse, a renal dietitian, and a social worker. Control patients received usual care. Primary outcome measurements included serum creatinine level, estimated creatinine clearance, health services use, and mortality in the 5 years after enrollment. Secondary measures included use of renal sparing and potentially nephrotoxic drugs. RESULTS There were no differences in renal function, health services use, or mortality in the first, second, or third through fifth years after enrollment. There were significantly more outpatient visits among intervention patients, mainly because of the added visits to the nephrology case management clinic. There were also no significant differences in the use of renal sparing or selected potentially nephrotoxic drugs. The annual direct costs of the intervention were

Restricting Medicaid Payments for Transportation: Effects on Inner-City Patients’ Health Care

89,355 (

Can mental health treatment be effectively delivered in primary care? A primer for employee benefit design, decision makers, and an outcome research example

484 per intervention patient). CONCLUSION This intensive, multidisciplinary case-management intervention had no effect on the outcomes of care among primary-care patients with established chronic renal insufficiency. Such expensive and intrusive interventions, despite representing state-of-the-art care, should be tested prospectively before being widely introduced into practice.

An Assessment of SBIRT Prescreening and Screening Outcomes by Medical Setting and Administration Methodology

OBJECTIVES The purpose of this study was to examine the dimensions of physician work satisfaction across a variety of medical specialties and practice settings. METHODS A modified version of the Scheckler et al survey instrument was mailed to all physicians in Marion County, Indiana. Forty-two percent (777) of the eligible physicians responded. Exploratory factor analysis and internal consistency measures were used to assess the instruments validity and reliability. Multivariable linear regression was used to predict global and summary scale scores. RESULTS Four dimensions of physician work satisfaction were identified: relationships with patients (k = 6, alpha = 0.81), autonomy in clinical decision-making (k = 8, alpha = 0.81), office resources (k = 7, alpha = 0.87), and professional relationships (k = 5, alpha = 0.82). Most (73%) of the physicians were satisfied with their overall practice, and the majority were also satisfied with their income. Significant differences were observed in the sources and magnitude of physician work satisfaction across medical specialty, practice setting, and financial arrangement. Physicians in private practice were most satisfied with their overall practice and office resources, whereas physicians in health maintenance organizations (HMOs) were most satisfied with their autonomy in clinical decision-making. Physicians not working in HMOs but having a large percentage of patients with capitated reimbursement were not enthusiastic about the effect of managed care on their medical practice. Among primary care physicians, family practitioners and general internists were generally less satisfied, and general pediatricians were generally more satisfied with most aspects of their medical practices. CONCLUSIONS The modified version of the Scheckler et al instrument is a reliable and valid measure of physician work satisfaction. Increases in the market share of managed care have differentially affected the work satisfaction of physicians based on their medical specialty, practice setting, and financial arrangements.

Development of a Stroke-Specific Quality of Life Scale

Abstract: We examined integration processes of patient satisfaction among four groups of patients and found that these groups of patients combined their health care attribute reactions differently to form their overall satisfaction. For the study, we used an emerging noncompensatory model in health care and considered an interaction effect in the analysis. We discuss the implication of the different integration processes of patient satisfaction for health care managers and make practical suggestions for more effective and efficient means of increasing patient satisfaction.