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PubMed1995

Impact of physician awareness on hospital charges for radical retropubic prostatectomy.

PURPOSE: We determine if physician awareness of hospital costs for radical retropubic prostatectomy affects physician practice patterns. MATERIALS AND METHODS: We reviewed 256 consecutive radical retropubic prostatectomies performed by 14 urologists during 4 years at a community hospital. After 2 years the physicians were provided information on factors that may decrease charges. RESULTS: Charges decreased significantly following intervention, from +f417,134 within the initial 2 years to +f413,826 within the last 2 years (p < 0.005). Significant decreases were noted for length of stay, need for intensive care, operating time and blood loss. CONCLUSIONS: Traditional methods of physician education can impact practice patterns to decrease hospital charges for radical retropubic prostatectomy.

Adult↗
PubMed2001

Hypertensive patients and their general practitioners.

This study examined the relative contribution of hypertensive patients and their physicians in selecting total annual physician visit frequencies and made regional comparisons between two Canadian cities. We found that the frequency of physician visits was primarily influenced by physician referrals and physician practice patterns, which accounted for about 80 percent of the total explainable variance in physician visits. The relative contribution of other available patient and physician characteristics in determining visit frequency was rather small.

Adult↗
PubMed1990

Physicians' reactions to uncertainty in patient care. A new measure and new insights.

Although variations in physicians' practice patterns and use of resources are well documented, the reasons for these variations are less well understood. The uncertainty inherent in patient care may be one explanation. Existing measures of intolerance to uncertainty, developed in contexts outside of patient care, fail to explain these variations. To address this limitation, the Physicians' Reactions to Uncertainty scale was developed. A questionnaire containing an initial pool of 61 items was mailed to a random sample of 700 physicians in North Carolina and Oregon, stratified by specialty. The items covered nine areas of physicians' reactions to uncertainty derived from interviews with physicians and a definition of the concept affective reactions to uncertainity in patient care. Factor analysis of the 428 responses received yielded two primary factors that accounted for 58% of the common variance among the 61 items. Items with unambiguous loadings on these factors defined two reliable and readily interpretable subscales: Stress from Uncertainty (Cronbach's alpha = 0.90, 13 items) and Reluctance to Disclose Uncertainty to Others (alpha = 0.75, 9 items). By virtue of its clarity and good psychometric properties, this new measure promises insights into the role that uncertainty plays in physicians' resource utilization and practice patterns.

Adaptation, Psychological↗
PubMedDate not supplied

Physician knowledge and practice patterns relating to diabetic nephropathy.

OBJECTIVE: To assess the knowledge and practice patterns of primary care physicians relating to the detection and treatment of diabetic nephropathy and to compare these findings with current standards of care. DESIGN: National survey. PARTICIPANTS: 1,000 randomly selected physicians. SETTING: Primary care. INTERVENTION: Mailed questionnaire consisting of a six-page "Diabetes Survey." RESULTS: Among the 1,000 primary care physicians, 950 were considered eligible for the survey. Sufficiently completed surveys were returned by 216 physicians, yielding an adjusted response rate of 22%. In general, patients with type 1 diabetes were monitored more intensively than those with type 2 diabetes. Primary care physicians were more likely to monitor patients for overt proteinuria (86%) than microalbuminuria (58%). Of the physicians who claimed to monitor patients for microalbuminuria, 39% chose inappropriate methods for detection, which lowers the percentage of physicians who correctly monitored for microalbuminuria to 37%. More than 95% of the respondents were aware of the benefits of angiotensin-converting enzyme inhibitors (ACEIs) in delaying the progression of diabetic nephropathy. Patients with proteinuria (86%) were more likely to be treated with an ACEI than were patients with microalbuminuria (79%). If a patient presented with proteinuria but without hypertension, the use of ACEIs fell to 75%. Rates of referral to a nephrologist were low at early stages of the disease (3% to 11%) and remained relatively low (28%) at later stages, even when serum creatinine was greater than 3 mg/dL. CONCLUSION: Further efforts directed toward education of primary care physicians about diabetic nephropathy have the potential to improve the care of patients with this disorder. These findings demonstrate a unique opportunity for pharmacists to become educators to physicians in their community.

Diabetic Nephropathies↗
PubMed1999

The use of physician financial incentives and feedback to improve pediatric preventive care in Medicaid managed care.

OBJECTIVE: Immunizations and other cost-effective preventive services remain underused by many children, especially those living in poverty. Given the effectiveness of provider-based tracking systems and the widespread use by managed care organizations of financial incentives to influence physician practice patterns, we designed and tested an intervention combining these strategies. We studied whether a system of semiannual assessment and feedback, coupled with financial incentives, could improve pediatric preventive care in a Medicaid health maintenance organization (HMO). METHODOLOGY: We randomly assigned primary care sites serving children in a Medicaid HMO to one of three groups: a feedback group (where physicians received written feedback about compliance scores), a feedback and incentive group (where physicians received feedback and a financial bonus when compliance criteria were met), and a control group. We evaluated compliance with pediatric preventive care guidelines through semiannual chart audits during the years 1993 to 1995. RESULTS: Compliance with pediatric preventive care improved dramatically in the study period. Repeated measures ANOVA demonstrated a significant increase in all three study groups throughout the time in total compliance scores (from 56%-73%), as well as scores for immunizations (from 62%-79%) and other preventive care (from 54%-71%). However, no significant differences were observed between either intervention group and the control group, nor were there any interaction (group-by-time) effects. CONCLUSIONS: Feedback to physicians, with or without financial incentives, did not improve pediatric preventive care in this Medicaid HMO during a time of rapid, secular improvements in care. Possible explanations include the context and timing of the intervention, the magnitude of the financial incentives, and lack of physician awareness of the intervention.

Analysis of Variance↗
PubMed2002

Family history and colorectal cancer screening: a survey of physician knowledge and practice patterns.

OBJECTIVES: Risk stratification is essential to effective implementation of colorectal cancer (CRC) screening strategies. The objectives of this study were to assess and compare the current knowledge and practice patterns of gastroenterologists and primary care physicians regarding familial risk of CRC. METHODS: We conducted a survey of regional gastroenterologists and a sample of university- and community-based primary care physicians. The survey instrument assessed physician knowledge of screening recommendations and current practices for individuals with family histories of CRC, adenomatous polyps (APs), familial adenomatous polyposis (FAP), and hereditary nonpolyposis cancer (HNPCC). The instrument also elicited data about familial risk assessment, documentation, and notification of at-risk family members. RESULTS: Thirty-five gastroenterologists (65%) and 58 primary care physicians (92%) completed the survey. Most gastroenterologists and primary care physicians (85% vs 72%) chose age 40 as the appropriate age to begin screening for a family history of CRC, but relatively few (37% vs 36%) recommended screening at age 40 for a family history of APs. Gastroenterologists were significantly more likely to recommend screening for FAP at puberty (80% vs 27%, p < 0.001) and for HNPCC at age 25 (73% vs 50%, p = 0.04). Colonoscopy was the preferred screening strategy by both groups for family histories of CRC (97%), HNPCC (97%), and APs (77%); primary care physicians also preferred colonoscopy for family histories of CRC (72%) and HNPCC (76%) but flexible sigmoidoscopy plus fecal occult blood testing for a family history of APs (38%). Gastroenterologists were more likely to recommend genetic testing for persons at risk of FAP (91% vs 71%, p = 0.03) and HNPCC (72% vs 57%, p = 0.18), routinely inquire about a family history of CRC or APs (93% vs 63%, p < 0.001), and recommend notification of at-risk first-degree relatives with family histories of CRC (94% vs 55%, p < 0.001) or AP (53% v.s 6%, p < 0.001). CONCLUSION: Although gastroenterologists are more likely than primary care physicians to elicit a family history of colorectal neoplasia and implement appropriate screening strategies, overall compliance with recommended guidelines and notification of at-risk relatives are suboptimal. Novel approaches for improving awareness of the available screening guidelines are needed.

Adult↗
PubMed1999

Reducing cesarean birth rates with data-driven quality improvement activities.

Reduction of cesarean section rates has been a difficult process that has not been easily accomplished by the institution of guidelines. It is more a process of changing physician behavior rather than of medical education. This article analyzed the role of intensive feedback of outcomes to bring about such changes. Two large private obstetric services in San Francisco, CA, were studied. Intensive outcomes feedback using a computerized information system, The Perinatal Data Center, regarding cesarean birth rates and a variety of obstetric outcomes was provided to the medical and nursing staff at one hospital. The other center served as a control. After the first observation period, the outcomes system was introduced to the second hospital. Finally, "open label" feedback, intradepartmental release of everyone's key statistics with names attached, was performed. Active management of labor was not practiced at either hospital. Results. Cesarean birth rates were stable in the baseline period from 1980 through 1988 at 24% to 25%. Introduction of the Perinatal Data Center outcomes system was associated with a reduction to 21% at the first hospital with no change in the control hospital. Subsequent introduction of the system 3 years later in the control hospital resulted in a decline from 25% to 20.5%. After merger of the two obstetric units and the institution of "open label" feedback, an additional decline to 18.5% was observed. Conclusion. Physician practice patterns and cesarean birth rates can be altered with the intensive use of comparative outcome data and strong physician leadership. Nonblinded, intradepartmental distribution of outcomes is an even more effective tool.

Algorithms↗
PubMed1996

The gatekeeper effect on managing acute medical conditions.

This study was designed to analyze whether the gatekeeper approach, by itself, is effective in changing physicians' practice patterns. The effect of the gatekeeper could be isolated, because a 95% overlap existed between contracted physicians in the PPO plan and the POS plan used in the study. In treating low-to-moderately resource-intensive conditions, the results of this episode-of-care study showed that the POS system of care (gate-keeper in place) was no more efficient than the PPO system of care (no gatekeeper mechanism) in terms of overall medical costs.

Acute Disease↗
PubMed2002

Increased physician-reported sleep apnea: the National Ambulatory Medical Care Survey.

BACKGROUND: Despite increased recognition of sleep apnea as a major health problem, little is known about physician practice patterns regarding this condition. METHODS: We used the National Ambulatory Medical Care Survey (NAMCS) data between the years of 1990 to 1998, a weighted estimate of the frequency of physicians' diagnoses nationwide in their outpatient practices, to address the following questions: (1) has there been an increase in physician reporting of sleep apnea, (2) which physicians reported diagnoses of sleep apnea, and (3) what are the demographic characteristics of patients with diagnoses of sleep apnea? RESULTS: During this 9-year period, there was a 12-fold increase in the diagnosis of sleep apnea in outpatients, from 108,121 to 1,305,624 diagnoses (p < 0.001). Among other primary sleep disorders, only insomnia had an increase in reporting (fourfold, p < 0.001). Report of sleep apnea was greatest among primary care providers (37%), pulmonologists (24%), and otolaryngologists (18%). Sleep apnea was reported more often in men than in women (3:1, respectively), and 80% of diagnoses occurred in the following age groups: 30 to 39 years (12%), 40 to 49 years (33%), 50 to 59 years (27%), and 60 to 69 years (12%). Conditions associated with sleep apnea included hypertension (10%), obesity (6%), and COPD (7%). Increased reporting of sleep apnea by NAMCS physicians was associated with increases in the number of accredited sleep laboratories and the number of sleep publications in the medical literature during the period of review (p < 0.001). CONCLUSION: Sleep apnea is recognized increasingly by physicians. Further investigation is necessary to define those factors that influence physician recognition and reporting of sleep apnea, and approaches associated with optimum patient outcomes.

Female↗
PubMed1989

Cost containment and physician payment methods in The Netherlands.

Cost containment in the Netherlands has been partly achieved by negotiated agreements between insurers and physician associations. The negotiating system in the Netherlands involves the determination of capitation and fee-for-service rates, based on negotiated norms for personal remuneration, practice costs, and practice size. Physician practice patterns are monitored in an effort to control volume. Selected aspects of the negotiating structure could be adopted by Medicare and HMOs to clarify issues in negotiations with physicians and to reimburse physicians more equitably. However, establishment of standardized fees and volume monitoring may not be as effective as global expenditure controls.

Cost Control↗
PubMed1997

Can information on cost improve clinicians' behavior? Lessons from health care trials and management theory.

Facing intense price competition and societal pressures, health care provider organizations have focused increasingly on the cost-effectiveness of medical services. In instances when there is insufficient evidence that a more expensive treatment course generates improved outcomes, the lower cost option is often encouraged. Yet, with resource utilization still determined principally by individual physicians, large practice variations often persist. This paper reviews the literature and explores the impact of sharing cost information on physicians' practice patterns utilizing management theory concepts. More research should be conducted to determine long-term benefits of educational interventions, physicians' fundamental views on the relationship between cost and quality and its effect on their responsiveness to cost information, and the role of leadership in changing clinical behavior.

Cost Control↗
PubMedDate not supplied

Furthering cost-effective medical practice.

Increased competition among hospitals and new incentives for efficiency in hospital medical practice are promoting hospital managers to become more aggressive and innovative in supervising the clinical processes involved in the delivery of patient care. One of the areas that has recently come under increased scrutiny is that of physician practice patterns. In the hospital, there may be variances in resource use and cost among physicians treating the same disease. Often, these variances appear unnecessary. Managers are looking for ways to encourage physicians to modify their practice patterns to be more efficient and cost effective. This goal creates new issues for hospital managers who are developing approaches to assess and change physician behavior. What these new issues involve and how managers can deal with them is the subject of this article.

Cost-Benefit Analysis↗
PubMed1987

Severity of illness, quality of care, and physician practice as determinants of hospital resource consumption.

Health care providers continue the debate over why it costs more to care for patients than the DRG reimbursement rate allows. This study examines severity of illness (measured by the AS-SCORE rating), quality of care (measured by the Adverse Patient Occurrences Inventory), and physician practice patterns as sources of variability in hospital resource use by patients in two DRGs. Both instruments independently account for some of the intra-DRG variability in length of stay and total charges. The study indicates that there is a positive relationship between severity of illness and decreased quality of care and that physician practice does not affect variation in resource use when cardiovascular complications, severity of illness, and quality of care are controlled.

Adult↗
PubMed1995

Primary care physician productivity: the physician factor.

OBJECTIVES: To model physician productivity as a function of clinic (support system) characteristics and physician characteristics and to model the time a physician spends with the patient as a function of patient characteristics. DESIGN: Observational study. SETTING: A general medicine clinic of a university-affiliated Veterans Affairs medical center. PATIENTS: A cohort of 2,520 patients having 2,721 consecutive outpatient visits to 56 physicians. MAIN OUTCOME MEASURES: Physician productivity defined as patients seen/physician/hour and time (minutes) spent with the patient. RESULTS: Physicians saw a mean (+/- SD) of 1.62 +/- 0.68 patients/hour. Clinic characteristics explained 8.2% of the variability of session-specific physician productivity. Controlling for clinic characteristics, a factor representing the physician explained an additional 55.4%. A model for overall physician productivity, using physician characteristics, explained 84.9% of the variance, and time spent with the patient was an important predictor. Modeling physician time with patients, patient characteristics accounted for only 7% of the variability. Controlling for patient characteristics, the individual physician again provided the greatest explanatory power, an additional 22.8% of the variability. CONCLUSIONS: Physicians' practice patterns, rather than clinic or patient characteristics, may account for most of the variation in physician productivity. Given the magnitude of the influence of individual practice patterns, interventions to increase productivity need to consider methods to affect physician behavior.

Appointments and Schedules↗
PubMed2005

Racial and ethnic disparities in care: the perspectives of cardiologists.

BACKGROUND: Despite extensive documentation of racial and ethnic disparities in care, provider awareness of disparities has been thought to be low. To be effective, educational efforts for physicians must consider providers' knowledge and beliefs about what causes disparities and what can be done about them. METHODS AND RESULTS: We conducted a Web-based survey of 344 cardiologists to determine their level of awareness of disparities and views of underlying causes. Responses were assessed by means of 5-point Likert scales. Thirty-four percent of cardiologists agreed that disparities existed in care overall in the US healthcare system, and 33% agreed that disparities existed in cardiovascular care. Only 12% felt disparities existed in their own hospital setting, and even fewer, 5%, thought disparities existed in the care of their own patients. Despite this, most respondents rated the strength of the evidence about disparities as "very strong" or "strong." Respondents identified many potential causes for disparities in care but were more likely to endorse patient and system level factors (eg, insurance status or adherence) rather than provider level factors. CONCLUSIONS: Cardiologists' awareness of disparities in care remains low, and awareness is inversely proportional to proximity to their own practice setting.

Adult↗
PubMedDate not supplied

Using compensation to improve primary care.

Progressive primary care networks are now placing significant portions of physician salaries at risk by linking compensation to quantifiable measures such as net medical revenue (collections), reduced practice expenses, cost and utilization, quality of care and patient satisfaction. For most networks, a combination of productivity increases and expense reductions are critical to ensure financial survival. This case study illustrates how one network's unique incentive compensation program targeted higher productivity levels by incentivizing desirable behaviors.

Efficiency, Organizational↗