Thomas G. Rundall

Evidence-based Management: From Theory to Practice in Health Care

The rise of evidence-based clinical practice in health care has caused some people to start questioning how health care managers and policymakers make decisions, and what role evidence plays in the process. Though managers and policymakers have been quick to encourage clinicians to adopt an evidence-based approach, they have been slower to apply the same ideas to their own practice. Yet, there is evidence that the same problems (of the underuse of effective interventions and the overuse of ineffective ones) are as widespread in health care management as they are in clinical practice. Because there are important differences between the culture, research base, and decision-making processes of clinicians and managers, the ideas of evidence-based practice, while relevant, need to be translated for management rather than simply transferred. The experience of the Center for Health Management Research (CHMR) is used to explore how to bring managers and researchers together and promote the use of evidence in managerial decision-making. However, health care funders, health care organizations, research funders, and academic centers need wider and more concerted action to promote the development of evidence-based managerial practice.

As good as it gets? Chronic care management in nine leading US physician organisations.

Innovations in care management processes have improved the care of patients with chronic illnesses, but many patients still do not receive these benefits. The authors have studied the barriers and facilitators to implementing these improvements in leading US physician practices About 125 million of the 276 million people living in the United States have some type of chronic illness (table 1).1 Four chronic conditions affect nearly half of Americans with a chronic disease: asthma, depression, and diabetes each affect about 15 million,2–4 while five million have congestive heart failure.5 In 1999 these four chronic diseases were directly responsible for 140 000 deaths in the United States6 and generated at least

Rethinking Prevention in Primary Care: Applying the Chronic Care Model to Address Health Risk Behaviors

173bn (£108bn, €170bn) in medical and other costs. 5 7–9 Over the past decade the effectiveness of care for patients with these and other major chronic illnesses has been improved by innovations in care management processes such as the use of guidelines, disease management techniques, case management, and patient education to improve self management of chronic disease.10 However, many patients are not benefiting from these advances. Recent studies indicate that fewer than half of US patients with asthma, depression, and diabetes receive appropriate treatment.11–13 Organisational characteristics of physician practices associated with effective chronic disease care include the use of patient care teams, supportive information systems, and a high volume of patients.14 Hence, we expect that in the United States moderate and large sized, well organised, multispecialty practices are likely to offer chronic disease care that is as good as it gets and provide other physician organisations with benchmarks against which performance can be measured. #### Summary points

An Empirical Assessment of High-Performing Medical Groups: Results from a National Study:

This study examines the Chronic Care Model (CCM) as a framework for preventing health risk behaviors such as tobacco use, risky drinking, unhealthy dietary patterns, and physical inactivity. Data were obtained from primary care practices participating in a national health promotion initiative sponsored by the Robert Wood Johnson Foundation. Practices owned by a hospital health system and exhibiting a culture of quality improvement were more likely to offer recommended services such as health risk assessment, behavioral counseling, and referral to community-based programs. Practices that had a multispecialty physician staff and staff dieticians, decision support in the form of point-of-care reminders and clinical staff meetings, and clinical information systems such as electronic medical records were also more likely to offer recommended services. Adaptation of the CCM for preventive purposes may offer a useful framework for addressing important health risk behaviors.

Type of health care coverage and the likelihood of being screened for cancer.

The performance of medical groups is receiving increased attention. Relatively little conceptual or empirical work exists that examines the various dimensions of medical group performance. Using a national database of 693 medical groups, this article develops a scorecard approach to assessing group performance and presents a theory-driven framework for differentiating between high-performing versus low-performingmedical groups. The clinical quality of care, financial performance, and organizational learning capability of medical groups are assessed in relation to environmental forces, resource acquisition and resource deployment factors, and a quality-centered culture. Findings support the utility of the performance scorecard approach and identification of a number of key factors differentiating high-performing from low-performing groups including, in particular, the importance of a quality-centered culture and the requirement of outside reporting from third party organizations. The findings hold a number of important implications for policy and practice, and the framework presented provides a foundation for future research.

A meta-analysis and theoretical review of school based tobacco and alcohol intervention programs

OBJECTIVES This study explored whether type of outpatient health coverage affected the likelihood of men and women aged 20 to 64 years receiving recommended cancer screening procedures. METHODS Data from the 1989 and 1990 California Behavioral Risk Factor Surveillance Surveys were used to compare Pap smear, mammogram, fecal occult blood test, and proctoscopic examination rates for adults with three different types of private health care coverage (Group/staff model health maintenance organization, Independent Practice Association Model health maintenance organization, indemnity plan) and no outpatient health insurance. Logistic regression models were used to control for sociodemographic and health characteristics and whether individuals had a usual health care provider. RESULTS Individuals with Group Model health maintenance organization coverage were significantly more likely than those with indemnity plans to have had recent cervical, breast, and colorectal cancer screening, whereas screening likelihood for those with Independent Practice Association model health maintenance organization coverage did not differ substantially from those with indemnity plans. Individuals with no outpatient coverage were less likely to be screened than those with outpatient coverage. The most consistently significant predictor across cancer screening procedures for both men and women was having a usual doctor who knew their medical history. CONCLUSIONS Adults who had private outpatient insurance were more likely to undergo recommended cancer detection procedures than those who did not. Adults who belonged to a health maintenance organization, which emphasizes and pays for a broader spectrum preventive care, were more likely to receive Pap smears, mammograms, and fecal occult blood tests than those covered by indemnity plans. Receiving care primarily from one doctor significantly increased the likelihood of having screening procedures, irrespective of type of health plan.

The Impact of Hospitalists on the Cost and Quality of Inpatient Care in the United States: A Research Synthesis:

Abstract A review of outcome evaluations published after 1970 dealing with school based interventions on alcohol and tobacco reveals four major theoretical bases supporting the program intervention models employed: rational, social reinforcement, social norms and developmental. The review found this research still in need of methodological improvements prominently involving the assessment of experimental attrition and the validity of the dependent variable measure. For the projects reviewed here, program interventions based upon predominantly rational models produced fewer positive behavior and attitude effects but more positive knowledge effects than those for which the rational model was not dominant. Behavior effects for published school based smoking outcome evaluations were generally positive for both short and long term effects. Behavior effects for published alcohol evaluations were mixed, positive and negative. Knowledge effects were consistently positive over all studies reviewed here, but attitu...

What Are the Facilitators and Barriers in Physician Organizations’ Use of Care Management Processes?

There is substantial disagreement regarding the impact of hospitalists on costs, quality, and satisfaction with inpatient care. The authors reviewed 21 evaluations of the use of hospitalists in U.S. hospitals. Most evaluations found that patients managed by hospitalists had lower total costs or charges than patients in comparison groups and that these savings were achieved primarily by reducing length of stay. Most evaluations found no statistically significant differences in quality of care or satisfaction. However, lack of random assignment limits the ability to draw causal inferences from many of the evaluations. All randomized studies were conducted in teaching hospitals, raising questions as to the generalizability of findings to nonteaching hospitals. Further research is needed to better identify the mechanisms by which hospitalists reduce length of stay and to ascertain which types of hospitalist programs are most effective and which patients are most likely to benefit.

The Effect of Income on Use of Preventive Care: An Evaluation of Alternative Explanations

BACKGROUND Care management processes (CMPs) such as disease registries, reminder systems, performance feedback, case management, and self-management education can improve chronic illness care, yet 50% of physician organizations have instituted few if any CMPs. METHODS Site-visit interviews were conducted with 158 leaders at 15 physician organizations, with 3 organizations (1 large medical group, 1 small medical group, and 1 independent practice association [IPA]) chosen randomly in most cases in each of five communities. RESULTS Seven of the 15 organizations had implemented CMPs minimally or not at all. CMPs were most common for diabetes and least common for depression; no IPAs had achieved significant CMP implementation for any of the conditions. The two most commonly mentioned facilitators were strong leadership and organizational culture valuing quality. The top five barriers were poor financial situation, reimbursement that does not reward high quality, inadequate information technology, physician resistance, and physicians being too busy. DISCUSSION Strong leadership and a quality-valuing culture are important facilitators of improved chronic care, but if insurers do not reward chronic care improvement, it is unlikely that CMPs will become permanently institutionalized in physician organizations.

Effect of Primary Health Care Orientation on Chronic Care Management

Three alternative explanations for the effect of income on use of physician services for preventive care are evaluated. Path analysis is used to estimate the direct effect of income on use (the financial constraint explanation), the indirect effect of income through health beliefs (the culture of poverty explanation), and the indirect effect through the availability of a usual source of care (the system barrier explanation). Data for the analysis are from household interviews with 781 adult residents of Washtenaw County, Michigan. A general model of utilization of preventive health services is proposed that incorporates all three explanations. Path coefficients are estimated, and the direct and indirect effects of income on use are compared. The data reveal a negligible direct effect of income on preventive use, a positive indirect effect through perceived susceptibility to illness (one operationalization of the culture of poverty explanation), and a positive indirect effect through usual source of care. These findings are consistent with other recent research on the effect of income on health services utilization and contribute to a growing body of evidence which suggests that changes in the health care delivery system may be necessary if we are to achieve equity in the utilization of preventive care services.