William E. Neighbor

A comparison of self-report and chart audit in studying resident physician assessment of cardiac risk factors

OBJECTIVE: To examine the relationship between resident physicians’ perceptions of their preventive cardiology practices and a chart audit assessment of their documented services.DESIGN: A criterion standard comparison of two methods used to assess resident physicians’ practices: self-report and chart audit.SETTING: Physician ambulatory care in a residency program.PATIENTS AND OTHER PARTICIPANTS: Coronary artery disease (CAD) risk factor assessment was evaluated by self-report for 72 resident physicians and by chart audit of randomly selected records of 544 of their patients who did not have CAD or a debilitating chronic disease during a one-year period.INTERVENTION: Measurements of the residents’ perceived CAD risk factor assessment practice by self-report, and chart audit assessments of their recorded care.MAIN OUTCOME: The relationship between self-reported and chart audit assessments of CAD risk factors.RESULTS: Chart audit assessment of CAD risk factor management was highly significantly (p<0.01) lower than self-reported behaviors for evaluation of cigarette smoking, diet, physical activity, stress, plasma cholesterol, blood pressure, and body weight/obesity.CONCLUSIONS: Three different interpretations of these findings are apparent. 1) Physician self-report is a poor tool for the measurement of clinical behavior, and therefore research of physician behavior should not rely solely on self-reported data; 2) physicians’ chart recording of their clinical practice is insufficient to reflect actual care; or 3) neither is an accurate measure of actual practice.

A multifaceted intervention in support of diabetes treatment guidelines: a cont trial

OBJECTIVE in an academic family practice clinic, we performed a controlled trial of a multifaceted intervention versus usual care for managing diabetes. Providers received didactic training and computerized compliance feedback to support staged diabetes management, an evidenced-based approach to diabetes care. RESEARCH DESIGN AND METHODS one firm of the clinic practice received the intervention, the other served as the control group during a 14-month baseline period and a 14-month study period. HbA1(c) was the principal outcome measure. RESULTS there was a significant 0.71% difference in change in HbA1(c) values between the intervention and control firms (P=0.02). The subgroup with the greatest improvement in HbA1(c) was those subjects who started the intervention with a HbA1(c) above 8%. The overall improvement in glycemic control could not be explained by differences in visit frequency or the aggressiveness of drug therapy. There were no changes in healthcare utilization or costs between the two firms. CONCLUSION in an academic family practice clinic, a multifaceted intervention in support of diabetes treatment guidelines modestly improved glycemic control without incurring additional costs. The improvement was mostly due to mitigation of the natural deterioration in control usually seen. Further efforts are required to involve all patients in co-managing their diabetes.

Relative Impact of Patient and Clinic Factors on Adherence to Primary Care Preventive Service Guidelines: An Exploratory Study

Background.Preventive care service use is commonly compared across health plans, clinics, or individual providers, yet little is known about the influence of the clinic versus patient factors on utilization of these services. Objectives.To measure the relative influence of the facility (clinic) versus patient factors (demographic, behavioral and functional characteristics) on patients’ utilization of mammography, Pap smears, cholesterol screening, and retinal exams for those with diabetes. Research Design. Retrospective analysis, using administrative and patient survey data Subjects.Enrollees in 2 University-based clinics and a county hospital-based clinic serving a predominantly low-income population with limited access to health care. Eligibility for cervical cancer screening, screening mammography, cholesterol screening, or annual retinal exam (diabetes) was defined by age, sex, and diagnosis. Measures.Multivariate models, one using readily available administrative data, and another using detailed health status and behavior data gathered from a clinics-wide survey. Results.Unadjusted screening rates for three of four procedures were significantly and substantially lower at the county hospital based clinic than the two University-based clinics. After adjusting for patient characteristics, utilization of three screening services at the county hospital remained significantly below the University-based clinics (Odds Ratios [95% CI]: mammogram 0.15 [0.06–0.35]; Pap smear 0.32 [0.21–0.50]; cholesterol 0.19 [0.09–0.38]; diabetes retinal exam10.68 [0.93–3.01]). The models with detailed survey data performed only marginally better than the models using only administrative data. Conclusions.Patient characteristics were much less important than the clinic for predicting whether patients received primary care preventive services. Our results suggest that case mix adjustment is unlikely to explain away discrepancies in performance between clinics or provider groups.

Curricular influences on preventive-care attitudes

Attitudes are one of the most important outcomes of medical education, but little is known about curricular influences on specific attitudes. This study examined changes in attitudes toward 20 preventive-care services in a cohort of 175 medical students. Specifically, a cohort of medical students was followed over a 30-month interval that spanned the period from medical school entry through the first 6 months of clinical clerkships. Perceived importance, as well as student confidence in the ability of primary-care physicians to provide 20 preventive-care services, was examined. Importance ratings for preventive-care services remained stable, while levels of confidence in the ability of physicians to provide the services increased. Implications of the results are discussed in relation to the possibilities for emphasizing disease prevention content in medical education.

The Health of the Public Program at the University of Washington: A New Role for Academic Medical Centers.

Abstract The University of Washington Health of the Public Program has convened a consortium composed of the regions academic medical center, the two largest managed care plans in Washington, and representatives of the states major private and public purchasers of health care. The consortiums purpose is to test the feasibility of collaboratively collecting cross‐system data, assessing variations in practice, and implementing sitespecific interventions to improve the management of common illnesses and encourage preventive care. Changes under way in the ambulatory training environment and in the undergraduate curriculum as a result of the consortiums initial efforts are described. In todays climate of cost consciousness and concerns about quality, academic medical centers can play an important role in helping to improve community‐wide outcomes of care. Acad. Med. 66(1991):499–505.

Oral contraceptive use and coronary risk factors in women.

The relationship between oral contraceptive use and other coronary artery disease risk factors was examined in 215 nonsmoking women grouped as never, current, or previous users. Current oral contraceptive users had higher triglyceride levels (p less than or equal to 0.001) than other groups, higher systolic blood pressure, and lower plasma HDL-cholesterol levels (p less than or equal to 0.05) than previous users. The effect of oral contraceptive use on plasma triglyceride values persists on multivariate regression analysis independently of age, body mass index, dietary sodium and cholesterol intake, cigarette smoking, and level of physical activity. Oral contraceptive use also has an independent relationship to the plasma total cholesterol/HDL- cholesterol ratio. These findings indicate that oral contraceptive use is adversely associated with plasma lipid and lipoprotein values.

Measures Of Clinical Effectiveness: The Numbers Needed To Treat

Many Western biologists ... comprehend that, objectively, what they are watching is deceptively complex. . . . They know that while experiments can be designed to reveal aspects of the animal, the animal itself will always remain larger than any set of experiments. They know they can be very precise about what they do, but that does not guarantee they will be accurate. They know that the behavior of an individual animal may differ strikingly from generally recognized behavior of its species; and that the same species may behave quite differently from place to place, from year to year.