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PubMed1996

Education to improve the quality of clinical care in group practices.

Intervening to improve the quality of medical care is an essential component of an effective quality improvement program. Although interventions may take many forms, most have some educational component. This article discusses different types of educational strategies that may be used in group practices and describes our experience with a continuing medical education (CME) program based on the results of clinical performance measurement. Data are presented showing the effectiveness and acceptability of the educational intervention in the DEMPAQ project.

Curriculum↗
PubMed1997

Management of nursing within a collaborative physician group practice.

Today's changing health care environment suggests the need for integration of high-quality primary medical and nursing care to address the complex psychosocial and environmental aspects of health in the elderly. This article describes a model of geriatric primary collaborative care between nurses and physicians that has been successfully implemented in a large primary care group practice setting.

Aged↗
PubMed1996

What makes quality assurance effective? Results from a randomized, controlled trial in 16 primary care group practices.

OBJECTIVES: The authors estimate separately contributions of each component intervention to overall effectiveness of quality assurance cycles used to improve practice performance. METHODS: In a randomized, controlled trial, experimental cycles of quality assurance were conducted for eight patient-care guidelines, with two experimental cycles assigned to each of 16 group practices. For three separate interventions per cycle, practitioners: (1) were notified of the name of the experimental guideline, (2) discussed criteria of conformance to the guideline, and (3) received feedback on performance. Actions taken in response to interventions were documented. Using medical records data for a baseline year and for 3 months after each intervention and an additional 9 months, the authors scored each practice for conformance to two experimental guidelines and to control guidelines. RESULTS: For all patient-care guidelines combined, and for four of five guidelines showing improvement, knowledge of guidelines and review criteria alone produced no change. After feedback, performance improved and improvement persisted for at least 9 months. The number of corrective actions implemented contributed significantly to effectiveness of quality assurance. CONCLUSIONS: Feedback to providers of data on their performance is a more powerful stimulus for quality improvement than is knowledge of guidelines or discussion of review criteria.

Ambulatory Care↗
PubMed1993

Let us now revisit prepaid group practice.

American medicine will soon enter health care reform. The Clinton Administration's Task Force on Health Care Reform is likely to introduce change that relies heavily on managed care, a field now dominated by the health insurance industry. Physicians can manage health care themselves by forming Prepaid Group Practices (PGPs). PGPs combine health insurance functions with physician managed health care. They can negotiate directly with health care purchasers, thereby abrogating the commercial health insurance industry.

Delivery of Health Care↗
PubMedDate not supplied

Increasing physician productivity using a physician extender: a study in an outpatient group practice at the Mayo Clinic.

Physician extenders (PE) can perform some tasks usually performed by a physician. Time recouped by physicians using a PE may increase physician productivity and physician professional satisfaction. A prospective study was completed using a PE in an outpatient general medical group practice setting to reduce physician indirect patient care, such as responding to patient telephone calls, refilling prescriptions, triage, and order entry. Physicians using a PE had increased productivity relative to physicians who did not use a PE. Physician satisfaction with the PE model was excellent. A physician extender may improve physician productivity by performing indirect patient care usually performed by physicians.

Efficiency↗
PubMed1976

The role of new health practitioners in a prepaid group practice: provider differences in process and outcomes of medical care.

Practice patterns and patient-reported outcomes of care are compared in detail for ten physicians and 12 new health practitioners delivering ambulatory care in two departments of a prepaid group practice, the Columbia Medical Plan (CMP). All providers completed questionnaires for a 50 per cent random sample of patients seen during a two-week period. Patients completed questionnaires prior to receiving care and were interviewed one week and one month after their clinic visits. New health practitioners deliver approximately 75 per cent of well-person care, 56 per cent of problem-oriented care in adult medicine, and 29 per cent of problem care in pediatrics. They have become increasingly involved over time in the treatment of acute conditions and injuries while physicians have retained their predominant role in treating patients with chronic conditions. Thirty-two per cent of visits with new healh providers involved a physician in one or more of the following: decision-making, direct supervision, consultation, or seeing the patient as a second provider of care. Degree of autonomy varied by type of task performed, category of problem treated, and specialty. The following outcomes of care were examined by type of provider: patient-reported change in problem status,including frequency and intensity of pain or discomfort, level of anxiety, and degree of activity limitation; the degree to which physician-specified criteria for the most commonly occurring conditions were met with respect to change in problem status; and patient satisfaction with a number of dimensions of the clinic visit. The analysis suggests that the new health practitioners at the CMP are providing care, within their areas of responsibility, of comparable quality to that delivered by physicians.

Acute Disease↗
PubMed1992

Enhancing the training of internal medicine residents at Stanford by establishing a model group practice and raising its clinical educators' status.

The education of residents is shifting to the ambulatory care setting. In addition, there is a growing trend toward managed care and increasing competition for patients to be served by "real-world" practices. The authors describe the formation and operation of a program that was established in 1981 at the Stanford University School of Medicine to respond to these changes: the Stanford Medical Group (SMG), a model group practice in internal medicine that operates within the academic medical center. Because raising the status of the clinician-educator faculty was a critical issue for the SMG, the authors also describe the Medical Center Professoriate, a separate faculty track created in 1989 to recognize and reward Stanford's clinician-educators. The authors conclude that the SMG has succeeded in its training and patient care goals and has weathered the great changes in the health care environment that have taken place since 1981. They also report that the separate faculty track is serving its purpose well. They hope that educators and program directors at other academic medical centers may find the descriptions of the SMG and the professoriate useful in solving similar problems.

California↗
PubMed1989

Competition within the firm: theory plus some evidence from medical group practice.

Recent work on the economics of the firm and other organizations has emphasized the importance of internal organization and incentives. The issue of competition within the firm has not arisen, however. In this article I construct a model of nonprice competition among members of a professional partnership and test the model with data on medical group practice. The empirical results are consistent with the hypothesis of nonprice competition among members of the firm.

Economic Competition↗
PubMedDate not supplied

My dad was not a prepaid group practice patient.

The author's father was a psychiatrist, a concerned citizen, and a Medicare patient. He died recently after a prolonged illness during which a panoply of physicians cared for him in ways that were sometimes redundant, inefficient, and poorly coordinated. He was definitively not a prepaid group practice patient. The author reviews the growing body of evidence that suggests that physician density is associated with greater costs but not improved outcomes. He reflects on his father's concerns with equity in health care and how prepaid managed care might have provided more efficient and less expensive medical coverage for his father's final sickness.

Aged↗
PubMedDate not supplied

Palliative treatment of advanced pancreatic carcinoma in community-based oncology group practices.

This study was aimed at evaluating the feasibility, effectiveness, and toxicity of palliative chemotherapy/supportive care in patients with advanced pancreatic cancer being treated on an outpatient basis. A retrospective analysis was performed on 127 consecutive, unselected patients with advanced pancreatic cancer in four community-based oncology group practices. Median age was 63 years and WHO performance status ranged from 0 to 3. Forty-three patients (34%) had locally advanced disease, and 84 patients (66%) had distant metastases; 94 patients (74%) received cytotoxic treatment during the course of their disease, and 33 (26%) received best supportive care only. First-line treatment consisted of gemcitabine (1,000 mg/m2 on days 1, 8, and 15 of a 28-day cycle) in 81 patients (86%), 5-fluorouracil (5-FU) in 8 patients (9%), radiochemotherapy in 4 patients (4%), and radiation therapy only in 1 patient (1%). A total of 1,501 gemcitabine treatments were given during the study period. Toxicity was moderate. Four patients (3%) required hospitalization for treatment-related side effects, and 111 patients (88%) died during the observation period. Symptom control, as measured by reduction of pain medication, was seen in 25% of patients receiving gemcitabine, whereas no reduction in pain medication was seen in the best supportive care group. The median survival of patients receiving cytotoxic treatment (mainly gemcitabine) was 42 weeks, and the median survival of patients receiving best supportive care was 21 weeks. The overall survival rate at 6, 12, 24, and 36 months was 65%, 32%, 14%, and 7%, respectively. Based on these outcomes, it appears that patients with locally advanced and metastatic pancreatic cancer benefit from adequate palliative treatment, including cytotoxic chemotherapy with gemcitabine, and this can be accomplished on an outpatient basis.

Adult↗
PubMed2004

Outpatient therapy in metastatic breast cancer. A retrospective study of 90 patients treated in an oncology group practice.

BACKGROUND: Whenever possible, treatment of breast cancer should be performed in an outpatient setting, but only few data about patients being treated exclusively on an outpatient basis are available. PATIENTS AND METHODS: A retrospective analysis was performed in 90 unselected patients who were treated consecutively in our oncology group practice between 6/95 and 8/99. RESULTS: Median age at detection of metastases was 55 years (30-90) and performance status ranged from 0 to 2. 83 patients (92.2%) received chemotherapy, 7 (7.8%) received endocrine therapy only. CMF was used in 27.7%, anthracyclines in 71.1% and taxanes in 43.3%. 855 chemotherapy cycles were performed and the observed toxicity was mild. Reversible grade 3 and 4 hematotoxicity was seen after 27 cycles (3.2%). Neurotoxicity or mucositis grade 3 and 4 were seen in 6 patients (6.6%). Therapy-associated hospitalization occurred in 1 patient thrice due to febrile neutropenia. Complete remissions were seen in 5 patients (5.6%) during first-line therapy. Median survival of the whole cohort until the end of the follow-up period (2/03) was 28 months (2-259). Overall survival after 1, 2, 3 and 5 years was 83, 56, 33 and 18% respectively. 50% could die at home. CONCLUSIONS: Treatment of metastatic breast cancer can be performed with minimal toxicity and a high patient acceptance in the outpatient setting. Overall survival and median survival are comparable to historical results achieved in specialized academic hospitals. Hospitalization could be avoided in the majority of patients and half of them could die at home.

Adult↗