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At least 19 recordsLinked to original sources
PubMedDate not supplied

The modification of physician practice patterns.

While physicians are directly responsible for only a small proportion of healthcare expenditures, their decisions influence the majority of medical costs. Because practice variations among physicians have been demonstrated abundantly, strategies to modify practice patterns have evolved. This article addresses the different factors that influence variations in patterns of practice, including physician characteristics, knowledge, beliefs, and attitudes. In designing programs to modify practice patterns, educational efforts, along with practice guidelines and feedback, all have been used. Although there are mixed results for each, the use of opinion leaders and the timing of interventions proximal to practice decisions are important. The costs and benefits of interventions are discussed as a method for assessing the utility of different programs to modify practice patterns.

Behavior Therapy↗
PubMed1995

Management of parapneumonic effusions. An analysis of physician practice patterns.

OBJECTIVE: To evaluate physician practices in managing patients with parapneumonic effusions and the impact of practice patterns on clinical outcome. DESIGN: Case series. SETTING: Private, tertiary care medical center. PATIENTS: Thirty-nine hospitalized patients with complicated parapneumonic effusions and a separate group of 191 patients admitted with community-acquired pneumonia. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Evaluation of physician practice patterns in managing complicated parapneumonic effusion and the impact of delaying thoracentesis (> or = 2 days after pleural fluid detection) or pleural drainage (> or = 2 days after pleural fluid criteria for drainage fulfilled) on duration of hospitalization, cost of hospitalization, and need for thoracotomy. RESULTS: Thirty-eight of the 39 patients with complicated parapneumonic effusions underwent thoracentesis that was "delayed" (5.7 +/- 3.1 days) in 16 patients. Delays in thoracentesis were associated with longer hospitalizations (P = .02). Laboratory tests ordered on nonpurulent pleural fluid were incomplete for 16 of 38 patients. Chest tube or surgical pleural drainage was delayed (4.2 +/- 3.5 days) in 10 of 38 patients who underwent thoracentesis. Delays in initiating drainage were associated with prolonged hospitalization (P = .04). Delaying interventions accounted for a mean cost increment per patient of $8462 for delayed thoracentesis and $9332 for delayed drainage. Of the 191 patients with community-acquired pneumonia, 99 (52%) had pleural effusions but only 15 (15%) underwent thoracentesis. CONCLUSIONS: Physicians commonly delay thoracentesis and chest tube drainage to observe parapneumonic effusions for improvement. This practice pattern is associated with longer and more costly hospitalizations.

Adult↗
PubMed2005

Explaining variation in physician practice patterns and their propensities to recommend services.

Variations in physician practice patterns have important implications for quality and cost. The purpose of this article is to explain variation in physicians' practice patterns in terms of physician personal characteristics, practice setting, patient population, and managed care involvement. Data on 2,455 primary care physicians were derived from the Community Tracking Study Physician Survey (1996-1997). Factor scores were determined based on responses to three clinical scenarios that represent discretionary medical decisions. These scenarios include a specialist referral for benign prostatic hyperplasia, prescription drugs for elevated cholesterol, and an office visit for vaginal discharge. Physician age, being a foreign medical school graduate, being a solo practitioner, and having a larger proportion of Medicaid patients were all associated with higher factor scores, a greater likelihood of ordering a service. Being board certified was associated with lower factor scores. Managed care involvement was not a significant predictor of factor scores.

Adult↗
PubMed2001

Evidence to action: a tailored multifaceted approach to changing family physician practice patterns and improving preventive care.

BACKGROUND: Although there is much room for improvement in the performance of recommended preventive manoeuvres, many inappropriate preventive interventions are being done. We evaluated a multifaceted intervention, delivered by nurses trained in prevention facilitation, to improve prevention in primary care. METHODS: Forty-six health service organizations (HSOs) were recruited from 100 sites in Ontario. After baseline data were collected, we randomly assigned the practices to either an 18-month (July 1997 to December 1998) multifaceted intervention delivered by 1 of 3 nurse facilitators (23 practices) or no intervention (23 practices). The unit of intervention and analysis was the medical practice. The outcome measure was an overall index of preventive performance, which was calculated as the proportion of eligible patients who received 8 recommended preventive manoeuvres less the proportion of eligible patients who received 5 inappropriate preventive manoeuvres. RESULTS: One HSO, in the intervention group, was lost to follow-up. Before the intervention, the index of preventive performance was similar for the intervention and control groups (31.9% [95% confidence interval (CI) 27.3%-36.5%] and 32.1% [95% CI 27.2%-37.0%] respectively). At follow-up the corresponding values were 43.2% (95% CI 38.4%-48.0%) and 31.9% (95% CI 26.8%-37.0%), for an absolute improvement in the intervention group of 11.5% (p < 0.001). The mean proportion of eligible patients who received the recommended manoeuvres was 62.3% (95% CI 58.2%-66.4%) in the intervention group, as compared with 57.4% (95% CI 54.1%-60.7%) in the control group, for an absolute improvement of 7.2% (p = 0.008). The corresponding values for the inappropriate manoeuvres were 19.1% (95% CI 15.6%-22.6%) and 25.5% (95% CI 20.0%-31.0%), for an absolute improvement of 4.4% (p = 0.019). INTERPRETATION: The tailored multifaceted intervention delivered by nurse facilitators was effective in modifying physician practice patterns and significantly improved preventive care performance.

Family Practice↗
PubMed1989

Methods of analyzing physician practice patterns in hypertension.

A principal method of studying physician practice patterns has been to examine physicians' responses to brief written cases. We have compared this method with practice patterns of the same physicians derived from chart audit. Subjects were 98 family practice residents for whom data were available in actual patient encounters for the workup of asymptomatic hypertension. Short, carefully structured case reports using four cues were designed and a checklist similar to the one used for test ordering in practice was employed. Chart reviews and billing encounter forms were used for comparison. Results indicated residents ordered fewer tests in clinical practice, due, in part, to practice constraints not represented in the written cases. Physicians tend to make the diagnosis of hypertension incrementally in practice, with no one visit adequately representing the point of diagnosis. Studies based on data bases using a patient encounter as the unit of analysis in chronic disease such as hypertension may spuriously underestimate the actual number of tests ordered for the workup. Judgment cases may better reflect the patterns of use of information in a well-defined problem. Prediction of number of tests ordered in the clinical setting has not been established in this case.

Adult↗
PubMed2000

[Practice patterns, physicians' characteristics and patient-evaluated quality of general practice in Norway].

BACKGROUND: Norwegian general practice is a conglomerate of organisational forms. Studies of quality differences between types of practice have not been published. There is scant knowledge of how physician characteristics may influence patients' experience of the quality of care. MATERIALS AND METHODS: In this study of patient experiences with quality in primary care, we received answers to a questionnaire from more than 1,600 patients who had made office visits to 61 GPs working in 44 different practices. The patients expressed their opinion of the quality of medical-technical performance, doctor-patient relationship, information and support, accessibility and the organisation of general practice. Using multilevel analysis we compared solo-practices with group practices, and conventional types of practices with list-patient practices. RESULTS: No significant differences in patient experienced quality were found for different practices with traditional organisation. List-patient practices scored lower on quality than conventional practices, especially on accessibility and organisation. There were no significant differences in patient evaluation related to the doctor's gender. GPs with more than ten years in a practice were rated lower on quality than GPs with ten or fewer years of experience. INTERPRETATION: The way general practice is organised and the number of years the GP has worked in the same practice appear to influence how patients experience the quality of primary health care.

Family Practice↗
PubMed1994

Focus on quality: profiling physicians' practice patterns.

This article presents a physician practice profiling system developed using Medicare data to evaluate the quality of care provided by primary care physicians. We discuss four attributes to physicians' practice profiles that make them useful for quality improvement: flexibility, user involvement in developing profiles, explicit plans for evaluation, and fairness to groups of providers. This system serves as a model for physician profiling with a focus on quality of care measurement.

Aged↗
PubMed2004

Lung cancer: a cost and outcome study based on physician practice patterns.

Chemotherapy is now an acceptable treatment for selected patients with non-small-cell lung cancer. With the wide assortment of cytotoxic and supportive-care drugs, there are opportunities for assessing the value of various treatment approaches. This study was undertaken to assess variations in treatment patterns in a large oncology group with emphasis on costs incurred and survival. A total of 1215 patients seen in 1996 by Medical Oncologists (a community-based private practice) were identified as new lung cancer patients by review of billing data. Of these, 858 received chemotherapy and were evaluated for charges. Three hundred were evaluated for charges, hospice care, and survival. Differences in practice patterns for physicians and the causes of those differences were assessed. Differences in survival, charges, and hospice care for those patients who were seen by high-charge and low-charge physicians were measured. Clear differences emerged in practice patterns for these Medical Oncologists. Higher charges were associated with higher average number of chemotherapy cycles given, greater use of second- and third-line chemotherapy and greater use of support drugs, particularly G-CSF and erythropoietin. For stage IV non-small-cell lung cancer, there was no difference in survival or in hospice utilization for the two groups. For all patients combined, there was no significant survival difference. There may be as much as 100% difference in costs incurred for lung cancer chemotherapy based on variations in practice patterns alone without a measurable survival difference. These results suggest approaches for cost-minimization and disease management. These suggestions have been reinforced by recent clinical data and guideline development.

Aged↗
PubMed1999

Small clinical cost studies can improve physician practice patterns.

The Exempla Lutheran Medical Center uses the analysis of individual physician practice patterns to improve physician performance. Studies of initial breast biopsies, inguinal herniorrhaphy, laparoscopic cholecystectomy, and anterior cruciate ligament repair provided quantitative clinical information for analyzing individual practice patterns. The breast biopsy study indicated a positive correlation between practice patterns and patient satisfaction. Results from the inguinal herniorrhaphy study led to cost reductions due to increased information on supply cost. Despite the documented similarity in practice patterns for laparoscopic cholecystectomy, cost data analysis revealed differences of more than $1,000 per case for one physician. Further investigation showed that variance in profit margins was due to differing reimbursements from insurance contracts. All three studies demonstrated that cost data can stimulate discussion among providers and influence individual practice patterns.

Benchmarking↗
PubMed1995

Profiling physician practice patterns using diagnostic episode clusters.

Health plans and providers need to profile current practice patterns to understand better the resources used in managing medical conditions. A profiling system is presented that groups International Classification of Diseases (ICD-9-CM) codes into 125 diagnostic clusters based on clinical homogeneity with respect to physician treatment response. For each diagnostic cluster, diagnostic episode clusters (DECs) are formulated. A DEC links all services incurred in treating a patient's medical condition within a specific period of time. Each DEC is marked with a severity-of-illness, comorbidity, and age indicator. To test the validity of the diagnostic cluster methodology, claims were analyzed from a preferred provider organization (PPO) and an independent practice association (IPA). PPO and IPA DEC charges and utilization were compared with t-tests. Physician practice patterns differed based on patient severity of illness, comorbidities, and age. Both PPO and IPA physicians delivered significantly more resources to patients in higher severity-of-illness categories. PPO physicians generally treated older patients with more resources than younger patients. Patient age did not have the same impact on IPA physicians' practice patterns. IPA physicians' average treatment pattern was about 22% less expensive than that of PPO physicians. IPA physicians decreased average expenses by reducing hospital days by about 73% (P < 0.01) and hospital outpatient visits by about 89% (P < 0.01) compared to the rates of PPO physicians. Ambulatory services among IPA physicians were not significantly higher than rates for PPO physicians. The DEC methodology is a valid approach for profiling patterns of treatment. The style of medicine in the IPA was less hospital intensive and, consequently, less expensive than that practiced by PPO physicians. PPO physicians also had greater practice pattern variations than IPA physicians.

Cluster Analysis↗
PubMed2002

Validating an instrument for selecting interventions to change physician practice patterns: a Michigan Consortium for Family Practice Research study.

OBJECTIVES: The goal of this study was to develop a psychometric instrument that classified physiciansamprsquo response styles to new information as seekers, receptives, traditionalists, or pragmatists. This classification was based on specific combinations of 3 scales: (a) belief in evidence vs experience as the basis of knowledge, (b) willingness to diverge from common or previous practice, and (c) sensitivity to pragmatic concerns of practice. The instrument will help focus efforts to change practice more accurately. STUDY DESIGN: This was a cross-sectional study of physician responses to a psychometric instrument. Paper-and-pencil survey forms were distributed to 3 waves of physicians, with revision for improved internal consistency at each iteration. POPULATION: Participants were 1393 primary care physicians at continuing education events in the Midwest or at primary care clinic sites in the Veteransamprsquo Health Administration system. OUTCOMES MEASURED: Internal consistency was measured by factor analysis with orthogonal rotation and Cronbachamprsquos alpha. RESULTS: A total of 1287 usable instruments were returned (106, 1120, and 61 in the 3 iterations, respectively), representing approximately three fourths of distributed forms. Final scale internal consistencies were a = 0.79, b = 0.74, and c = 0.68. The patterns of scores on the 3 scales were consistent with the predictions of the theoretical scheme of physician types. The "seeker" type was the rarest, at fewer than 3%. CONCLUSIONS: It is possible to reliably classify physicians into categories that a theoretical framework predicts will respond differently to different interventions for implementing guidelines and translating research findings into practice. The next step is to demonstrate that the classification predicts physician practice behavior.

Adult↗
PubMedDate not supplied

The ambulatory care of HIV-infected persons: a survey of physician practice patterns.

OBJECTIVE: To describe the use of various counseling practices, examinations, and laboratory tests used by general internists in the primary care of HIV-infected persons. DESIGN: Mailed questionnaire survey. SUBJECTS: Random sampling of members of the Society of General Internal Medicine. RESULTS: Based on a 64% response rate (131/205), there are many areas of physician agreement in the ambulatory care of HIV-infected persons. Greatest physician consensus was seen in the use of viral serologic testing, vaccinations, and Pap tests. Most (70-80%) primary care physicians do not use surrogate markers such as beta 2-microglobulin and p24 antigen to follow disease progression; instead, they rely mostly on CD4 lymphocyte counts. Sixty percent of physicians continue to order CD4 lymphocyte counts when a baseline count is under 200 cells/mm3. All studies are ordered more frequently for patients with more advanced disease. As a group, those physicians following the largest number of patients do not manage patients significantly differently from the less HIV-experienced physicians. CONCLUSIONS: Despite some variation, there is substantial consensus on the "routine" management of HIV-infected persons. Clinical guidelines would be one mechanism for defining appropriate care of HIV-infected patients. The majority judgments of the practitioners studied here could be one component among various sources of information used by expert panels to define guidelines except where studies clearly indicate a different and more effective approach. Such incorporation might increase guideline acceptance by practicing clinicians.

Adult↗
PubMed2001

Process evaluation of a tailored multifaceted approach to changing family physician practice patterns improving preventive care.

BACKGROUND: We conducted a process evaluation of a multifaceted outreach facilitation intervention to document the extent to which the intervention was implemented with fidelity. We also hoped to gain insight into how facilitation worked to improve preventive performance. METHODS: We used 5 data collection tools to evaluate the implementation of the intervention, and a combination of descriptive, quantitative, and qualitative analyses. Triangulation was used to attain a complete understanding of the quality of implementation. Twenty-two intervention practices with a total of 54 physicians participated in a randomized controlled trial that took place in Southwestern Ontario, Canada. The key measures of process were the frequency and time involved to deliver intervention components, the scope of the delivery and the utility of the components, and physician satisfaction with the intervention. RESULTS: Of the 7 components in the intervention model, prevention facilitators (PFs) visited the practice most often to deliver the audit and feedback, consensus building, and reminder system components. All the study practices received preventive performance audit and feedback, achieved consensus on a plan for improvement, and implemented a reminder system. Ninety percent of the practices implemented a customized flow sheet, and 10% used a computerized reminder system. Ninety-five percent of the intervention practices wanted critically appraised evidence for prevention, 82% participated in a workshop with opinion leaders in preventive care, and 100% received patient education materials in a binder. Content analysis of the physician interviews and bivariate analysis of physician self-reported changes between intervention and control group physicians revealed that the audit and feedback, consensus building, and development of reminder systems were the key intervention components. Ninety-five percent of the physicians were either satisfied or very satisfied with the intervention, and 90% would have been willing to have the PF continue working with their practice. CONCLUSIONS: Primary care practices in Ontario can implement significant changes in their practice environments that will improve preventive care activity with the assistance of a facilitator. The main components for creating change are audit and feedback of preventive performance, achieving consensus on a plan for improvement, and implementing a reminder system.

Family Practice↗
PubMed1987

Effects of patient management guidelines on physician practice patterns: the Community Hospital Oncology Program experience.

The Community Hospital Oncology Program (CHOP), funded under contracts by the National Cancer Institute (NCI) from 1981 to 1984, was designed to be a model for delivery of the most up-to-date cancer care in the community setting. Site specific patient management guidelines (PMGs) were developed by physicians who saw a majority of cancer patients in each community and represent a consensus of the most current information on pretreatment evaluation and management for each cancer site. There was the potential for PMGs to have a strong effect on physician practice patterns. A patterns of care study (POC) was conducted in the 17 CHOPs to determine the influence of guidelines on practice patterns. The practice elements examined in this report are clinical staging for breast and small-cell lung cancer, medical oncology consultation for breast cancer patients with positive lymph nodes, and radiation therapy consultation for rectal and small-cell lung cancer. These elements were in all CHOP guidelines. Except for physicians most active in the CHOP, the data provide no evidence of diffusion of guideline principles to the majority of practicing physicians. Although all guidelines contained discussion of the importance of staging before definitive treatment for breast cancer, only 33% of the 1,922 charts examined had a stage recorded. In small-cell lung cancer, 67% of the 388 charts examined had stage recorded. The years in practice of the primary physician had an inverse relationship to practice patterns as defined by the guidelines. Physician specialty was also a determinant of practice patterns for small-cell lung cancer. However, participation in guideline development and their dissemination did not significantly influence the patterns of care elements examined in this study.

Breast Neoplasms↗
PubMedDate not supplied

Physician practice patterns: chest x-ray ordering for the evaluation of acute cough illness in adults.

OBJECTIVES: The authors examine which clinical factors contribute to the clinician suspicion of pneumonia, as well as the relationship between clinical factors, clinician suspicion of pneumonia, and ordering chest X-rays (CXR). METHODS: Three hundred consecutive adults presenting to the clinic with acute cough in the winter of 2003 were studied. Using standardized encounter forms, data were collected on sociodemographics, illness impact, symptoms, tobacco use, past medical history, vital signs, physical examination findings, chest X-ray result, and clinician diagnoses. Clinicians rated their suspicion of pneumonia on a 5-point Likert scale. Multivariable logistic regression analysis was used to determine independent predictors of clinician suspicion of pneumonia and of ordering of CXRs. RESULTS: Clinician suspicion of pneumonia was low in the majority of patients presenting for evaluation of cough (63%). Higher clinician suspicion of pneumonia was predicted by advanced patient age (odds ratio [OR]: 4.6; 95% confidence interval [CI] [1.2-18.1]), shortness of breath (2.4; [1.0-6.0]), fever (5.5; [1.8-17.5]), tachycardia (3.8; [1.1-13.1]), rales (23.8; [5.7-98.7]), and rhonchi (14.6; [5.2-40.5]). CXRs were ordered in 19% of patients presenting with acute cough. Intermediate clinician suspicion of pneumonia (OR: 7.9; 95% CI: [2.8, 22.5]) (v. low suspicion), advanced patient age ([.greaterequal] 65 years) (9.2; [2.7, 31.6]) (v. ages 18-44 years), and decreased breath sounds on examination (5.1; [1.8, 14.3]) are independent predictors of ordering a CXR. Among patients with a clinical diagnosis of pneumonia (n = 31), CXRs were ordered in only 61%. CONCLUSIONS: Advanced patient age and physical findings on chest examination influence clinician practice in obtaining CXRs, beyond their contribution to clinician suspicion of pneumonia. Physicians do not appear to endorse recommendations that the diagnosis of community-acquired pneumonia be based on or confirmed by CXR.

Acute Disease↗
PubMed2000

1999 American Urological Association Gallup Survey: changes in physician practice patterns, treatment of incontinence and bladder cancer, and impact of managed care.

PURPOSE: The Health Policy Survey and Research Committee of the American Urological Association and the Gallup Organization have performed a yearly survey of American urologists since 1992 to assess practice patterns. The results of the 1999 survey are presented. MATERIALS AND METHODS: A random sample of 503 urologists was interviewed in February and March 1999. Major content areas were physician practice patterns, the impact of managed care, and the treatment of pediatric patients, prostate cancer and benign prostatic hyperplasia, female incontinence and bladder cancer. RESULTS: The average urologist is 46.8 years old, certified by the American Board of Urology, sees 78 patients and performs 3.1 major surgical procedures weekly, refers moderate and complex pediatric procedures to specialists, and receives 40.6% of practice income from managed care. CONCLUSIONS: In an era when large group practices seem to be the norm remarkably 32% of urologists remain in solo practice. There has been a shift in where urologists spend their time, that is more in the office and less in the operating room. Minor and major open surgical procedures increased from 12.4 weekly to 16.4 and 2.9 to 3.1 in 1995 and 1999, respectively. Most urologists are comfortable treating straightforward pediatric problems such as cryptorchidism but refer more complex problems to pediatric urologists. Managed care represents an ever increasing proportion of urologist practice income, while office expenses continue to increase.

Adult↗
PubMed1991

Carotid endarterectomy in a community hospital: a change in physicians' practice patterns.

A total of 243 consecutive carotid endarterectomies (CEA) performed at Providence Medical Center in Portland, Oregon, were retrospectively reviewed over a 22-month period. Of these, 137 patients (56%) underwent CEA for asymptomatic disease, 52 (37%) of whom had stenotic lesions of 79% or less. There were 6 deaths (3%) and 12 strokes (5%). Four strokes were in asymptomatic patients. These data prompted development of criteria for CEA: (1) hemisphere-specific transient ischemic attacks, reversible ischemic neurologic deficits, or amaurosis fugax with an appropriate carotid lesion; (2) completed stroke with major recovery and significant carotid stenosis; (3) asymptomatic lesion with greater than 80% stenosis (D+) either by carotid arteriogram or non-invasive lab evaluation; and (4) other indications only with a supporting second opinion from a disinterested vascular surgeon, neurosurgeon or neurologist. A prospective review followed institution of the guidelines. In 21 months, 148 operations were performed, a 36% reduction over the initial study period. Of these, 46 (31%) were for asymptomatic lesions. Two patients (4%) did not fulfill the guideline criteria. There were six strokes (4%) and no deaths. The reduction of CEAs appears to be related to a significant decrease in "inappropriate" operations being performed. Surgeons' familiarity with the data rather than external pressures seems to be the major factor in changing practice patterns. The decrease in stroke/death rate is not statistically significant.

Aged↗
PubMed1999

1998 American Urological Association Gallup Survey: changes in physician practice patterns, treatment of ureteral stones and impact of managed care.

PURPOSE: The American Urological Association first commissioned the Gallup Organization to conduct a study to assess urologist practice patterns in 1992. We present the results of the seventh consecutive Gallup Survey performed for the Association. MATERIALS AND METHODS: A random sample of 537 American urologists who completed urological residency and practiced at least 20 hours weekly in 1997 were interviewed by telephone in March 1998. Major topic areas included general demographics, practice patterns, treatment of ureteral stones and experience with managed care. RESULTS: Demographic trends indicated a significant decrease in average urologist age from 49.4 years in 1992 to 46.8 in 1998. Of the urologists 99% reported that they treat ureteral stones. Managed care had an increasingly larger role in most practices, particularly in the western United States, where 73% of urologists reported that they contract with a Medicare health maintenance organization. CONCLUSIONS: The average age of practicing urologists significantly decreased, which may be due to an increasing number of urologists retiring at an earlier age, although this finding is not clear. Nearly all urologists treated ureteral stones with considerable consistency. Finally, managed care appeared to have a major impact on most urologists throughout the United States.

Adult↗