Clinical practice guidelines: quality improvement tools versus legal norms.

The role of clinical guidelines in malpractice litigation has been controversial. The primary purpose of guidelines as a quality improvement tool must be sustained, and applications of guidelines beyond this purpose must be done carefully, with full recognition of inherent limitations.

Potential effects of managed care on specialty practice at a university medical center.

BACKGROUND: The growth of managed care presents a challenge to academic medical centers, because the demand for the services of specialists is likely to continue decreasing. We estimated the number of enrollees the University of Michigan Medical Center would need in its health maintenance organization (HMO) system in order to provide revenue equivalent to the total revenue it received for professional specialty care in 1992. METHODS: Rates of utilization and payment were based on the medical center's experience with managed care in 1992 in its independent practice association HMO, in which 25,000 members had capitated coverage and received primary and all specialty care from university physicians, and 15,000 members received primary care and most specialty care from physicians outside the university. We assumed that persons not enrolled in Medicare were all enrolled in managed-care plans. Primary care activity was excluded from the calculations of expense, revenue, and numbers of faculty members. RESULTS: If all specialty services were provided by the university to HMO members, all the 21 specialties examined except obstetrics and gynecology and emergency services would require an enrollment of more than 250,000 to support the 1992 level of professional revenue and maintain the number of faculty members. If university services were provided only for referrals from a loosely affiliated network of community physicians in the HMO system, all the 19 specialties examined except plastic surgery would require an HMO enrollment of more than 1 million. In a combined model in which all specialty services were provided to 100,000 HMO members and network referrals were provided to 500,000 members, substantial changes in faculty composition would be needed in all the departments studied. CONCLUSIONS: Because of the large number of HMO members required, unless other changes occur, it is unrealistic to expect that the University of Michigan Medical Center could create an HMO or network large enough to support the specialty practice of the current number of faculty members at the 1992 level of financing.

A model for practice guideline adaptation and implementation: empowerment of the physician.

The Medical Center model of practice guideline adaptation and implementation uses local clinical leaders to evaluate nationally endorsed guidelines, adapt those guidelines for use in the local setting, work with support staff to develop and apply methods for guideline implementation, and assist the evaluation of clinical practice and outcomes data. The model described here combines the guideline dissemination techniques of clinical leadership, implementation, and data support and feedback. This model overcomes the failures of previous models by incorporating local physician involvement during every step of practice guideline selection, adaptation, implementation, and evaluation, and by supporting the physician leaders with quality data, resources to support guideline implementation, and outcomes assessment and feedback.

Comparison of adrenergic agonists for the treatment of ventricular fibrillation and pulseless electrical activity.

The primary role of epinephrine for the treatment of ventricular fibrillation (VF) and pulseless electrical activity (PEA) is to increase blood flow to the myocardium and central nervous system and ultimately improve survival. However, despite the administration of epinephrine, survival following VF or PEA is low. In an attempt to improve outcome from VF and PEA, alternative adrenergic agonists (methoxamine, phenylephrine, norepinephrine) which have different pharmacological properties than epinephrine have been evaluated. In order to determine the role of alternative adrenergic agonists for the treatment of VF and PEA this paper will compare the pharmacological properties and pharmacodynamic effects of these drugs to epinephrine. Specifically, receptor physiology along with the effects of adrenergic agonists on coronary perfusion pressure, survival, myocardial oxygen demand, and cerebral blood flow will be discussed.

The development and evaluation of new versions of the written examination for the American Heart Association Advanced Cardiac Life Support provider course.

STUDY OBJECTIVE: To create new versions of the written, multiple-choice examination used in the American Heart Association (AHA) Advanced Cardiac Life Support course, evaluate their reliability and difficulty, and then design revised versions with improved reliability and of standardized difficulty. DESIGN: Psychometric evaluation of new versions of the AHA Advanced Cardiac Life Support test and revisions. SETTING: AHA Advanced Cardiac Life Support courses. PARTICIPANTS: Candidates for completion of AHA Advanced Cardiac Life Support provider courses in five states. INTERVENTION: The course content was divided into 11 content areas that were weighted for importance and appropriateness for testing in a multiple-choice format. The weights were used to construct a blueprint for a 50-question, multiple-choice examination. Five versions of the examination were then constructed based on the content blueprint, drawing from new questions and expert revision of previously written questions. Reliability and difficulty were assessed using 915 administrations at five different sites nationwide. The initial test versions differed in their degree of difficulty, which was not explained by demographic factors. The results were used to revise three of the versions to improve reliability and equalize difficulty of the versions. MEASUREMENTS AND MAIN RESULTS: The final five versions have estimated reliability ranging from Cronbach's alpha of .62 to .86. Mean scores ranged from 87.4% to 89.1%. CONCLUSION: After field testing and revision, five examinations with acceptable reliability and roughly equal difficulty were constructed. The new examinations test the participants' knowledge of important aspects of resuscitation science and practice based on a blueprint of the course content.

The integrated inpatient management model's clinical management information system.

The rising cost of health care has increased the call for cost control. The pressing need to control cost, coupled with the increase in managed care and prospective payment, has placed new urgency on administrators and clinicians to work collaboratively in providing efficient and effective care. We have developed the Integrated Inpatient Management Model (IIMM) to assist in this collaborative effort. We describe the IIMM's clinical information system that provides decision support to both administrators and clinicians. This clinical information system is the information backbone for the development and monitoring of practice guidelines or critical pathways. An integrated information system of this type is essential if hospitals are to prosper during the next decade.

Drug therapy during cardiac arrest in two hospitals.

The results of a study evaluating the appropriateness of drug and defibrillation therapy given during cardiac arrest at two hospitals are reported. A retrospective study was performed to evaluate and compare the appropriateness of therapy given during adult cardiac arrest at a large teaching hospital (hospital 1) and at a smaller nonteaching hospital (hospital 2) as measured by conformance to advanced cardiac life support (ACLS) guidelines and by less stringent alternative criteria based on published data and clinical judgment. Patients included in the study were older than 18 years and had experienced at least one of five types of cardiac arrest: ventricular fibrillation, asystole, ventricular tachycardia, electromechanical dissociation, or bradycardia. The type of drug administered, the drug dosage, and the timing of dosages were evaluated, as were the timing of defibrillation attempts and the energy used for such attempts. Treatment decisions were considered inappropriate if they did not conform to standard (ACLS) or alternative criteria. In hospital 1, there were 1137 assessable decisions recorded for 75 cardiac arrests; of these, 205 (18%) were inappropriate according to standard criteria, and 96 (8.4%) were inappropriate according to alternative criteria. In hospital 2, there were 827 assessable decisions recorded for 57 cardiac arrests; of these, 173 (21%) were inappropriate according to standard criteria, and 98 (11.2%) were inappropriate according to alternative criteria. Inappropriate therapy during cardiac arrest occurred with a similar frequency in a large teaching hospital and in a smaller, nonteaching hospital. The number of inappropriate treatments was smaller when more liberal standards of therapy were used.

Selection in a preferred provider organization enrollment.

OBJECTIVE: The study was conducted to determine whether favorable or adverse selection occurred in a preferred provider organization (PPO) enrollment. DATA SOURCES AND STUDY SETTING: Secondary data sources were used to conduct a retrospective study of the utilization of health services and the demographic characteristics of the population involved in the first open enrollment in a new university-based PPO. The PPO under study, sponsored by the University of Michigan (UM) Medical Center, was offered to all 43,005 UM employees, dependents, and retirees. STUDY DESIGN: We analyzed insurance company payments during the one-year period prior to the enrollment to compare the utilization patterns of those who enrolled in the PPO with those who did not. DATA COLLECTION: Prior health care utilization data were obtained from Blue Cross-Blue Shield of Michigan on the entire university population for one year prior to the start of the PPO. Demographic data were obtained from the personnel office of the university. PRINCIPAL FINDINGS: The PPO group had a younger median age than the non-PPO group; the sex distribution was roughly similar for the two groups. In the PPO group 57 percent of all contracts were family contracts compared with only 30 percent in the non-PPO group. The PPO group experienced 20.6 percent lower inpatient payments per member, and 9.4 percent lower outpatient payments per member in the year prior to the enrollment. These differences resulted in an overall 18.7 percent lower payment per member for the PPO group in the year prior to their enrollment. CONCLUSIONS: The results show, based on prior insurance payments, that this PPO received favorable selection during the open enrollment, a finding consistent with favorable selection found in early HMO enrollment.

Financial impact of the Medicare Fee Schedule on a department of anesthesiology in an academic medical center: two scenarios.

The purpose of this study was to model the financial impact of the Medicare Fee Schedule (MFS) on an anesthesiology department in a large academic medical center under two different scenarios. Scenario 1 assumes continued use of actual-time units throughout the five-year transition period. Scenario 2 assumes a change to the use of average-time units by the time the MFS is fully implemented in 1996. Twelve months of actual payments and frequencies for services billed to Medicare in 1991 were used as baseline data. It was assumed there would be no change in volume of services, billing practices, or staffing patterns. It was estimated that upon full implementation of the MFS, the anesthesiology department that was studied would lose $244,000 (13%) under Scenario 1 and $945,000 (51%) under Scenario 2. There is a full transition to final fee schedule rates in Year 1 of the MFS transition under Scenario 1, whereas there are additional incremental losses in each successive year under Scenario 2. This study shows that HCFA's future policy decisions with regard to anesthesiology reimbursement will have substantial financial consequences for many practicing anesthesiologists.

Financial impact of the Medicare Fee Schedule on a large multispecialty faculty practice in an academic medical center.

Although there have been preliminary studies of the financial impact of the Medicare Fee Schedule (MFS) on specialty-specific groups of practicing physicians in an academic setting, there has been no published report of the financial impact of the MFS on an entire multispecialty academic faculty practice. This 1992 study reports the estimated financial impact of the MFS on the faculty practice at the University of Michigan Medical School (UMMS). The authors calculated the difference between the Medicare payments to be received when the MFS is completely implemented in 1996 and the payments received in 1991, and then repeated this process for each year of the transition period, 1992-1996. The UMMS will experience a $1.2 million (-4.7%) loss under the fully implemented MFS. The medical departments project an 8% gain, while substantial losses are projected for the surgical departments (-10%) and hospital-based departments (-15%). Projections indicate that obstetrics-gynecology and ophthalmology will lose nearly 20% and that surgery will lose 9%. But large percentage gains are projected for neurology (+43%), physical medicine (+25%), and family practice (+17%). Analysis of the MFS transition's effects shows an abrupt and unpredictable financial impact in the first year. Faculty practice plans may be more disadvantaged under the MFS than other physician groups, yet the uncertain impact of the MFS in the first year (1992) may inhibit accurate financial planning for all physician groups.

Education in adult basic life support training programs.

The Panel on Educational Issues in Adult Basic Life Support Training Programs reviewed the characteristics of adult learners, aspects of educational theory, issues concerning barriers to learning and performing CPR, and issues concerning testing and evaluation. The panel made the following recommendations: a comprehensive evaluation of the basic life support program with the goal of improving the program design and educational tools must be initiated; adult programs must be designed to motivate laypersons to become trained in CPR, as well as to target relatives and friends of high-risk individuals; and emotional and attitudinal issues, including the student's reluctance to act in an emergency, must be addressed. Programs must incorporate information on the willingness of an individual to perform CPR; CPR programs must be simplified and focus on critical success factors; flexible educational approaches in programs are encouraged; flexible programming that addresses the needs of the allied health professional is encouraged; formal testing should be eliminated for layperson programs; and formal testing for health care providers and instructors should be continued.

Education in adult advanced cardiac life support training programs: changing the paradigm. Members of the Advanced Cardiac Life Support Education Panel.

To develop a consensus for change in the educational aspects of the Advanced Cardiac Life Support (ACLS) Training Program, the American Heart Association appointed panel members to engage in a consensus process. At a preconference meeting held in the fall of 1991, panel members received broad input from experts in adult education, experienced ACLS educators, and resuscitation scientists. The panel then developed a statement based on the preconference discussions and presented it at the National Conference on CPR and Emergency Cardiac Care held in February 1992. The conference's recommendations and the process that led to them are described in this paper. The key conclusions of the consensus process are as follows. The purpose of ACLS programs is the education of health professionals whose jobs include the management of patients in arrest or near-arrest. The goal of each ACLS course is to have each participant succeed in acquiring the skills and knowledge required for resuscitation. Aspects of the course which threaten failure or raise anxiety should be minimized or eliminated. ACLS course directors are strongly encouraged to design courses whose content and presentation are best suited to the training, experience, and needs of the course participants. Flexibility is strongly encouraged. Evaluation (testing) should be used primarily for its educational value, to help both learners and instructors identify areas needing improvement. The problem learner should be identified as early as possible and should receive intensive remediation to achieve the goal of every participant acquiring the targeted skills and knowledge. Because skill retention is variable, rescuers should practice skills frequently in regular refresher sessions. At a minimum, retraining every two years is strongly recommended.

The effects of a low-cost intervention program on hospital costs.

OBJECTIVE: To assess the impact of a low-cost education and feedback intervention designed to change physicians' utilization behavior on general medicine services. DESIGN: Prospective, nonequivalent control group study of 1,432 admissions on four general medicine services over 12 months. Two services were randomly selected to receive the intervention. The other two served as controls. Admissions alternated between control and intervention services each day. Results were casemix-adjusted using diagnosis-related groups (DRGs). Three internists blinded to patient study group assignment assessed quality of care using a structured implicit instrument. SETTING: Four general medicine services at a university hospital. INTERVENTIONS: A brief orientation, a pamphlet of cost strategies and common charges, detailed interim bills, and information about projected length of stay and usual hospital reimbursement for each patient. PATIENTS/PARTICIPANTS: Each service was staffed by a full-time internal medicine faculty member, one third-year and two first-year internal medicine houseofficers, three medical students, and a clinical pharmacist. Physicians were assigned to services for one-month periods by a physician unaware of the study design. To prevent crossover, houseofficers assigned to a service returned to the same service for all subsequent general medical inpatient assignments. MEASUREMENTS AND MAIN RESULTS: Geometric mean length of stay was 0.44 days (7.8%) shorter for the intervention services than for the control services (p less than 0.01), and geometric mean charges were $341 (7.1%) less (p less than 0.01). Effects persisted despite using a more precise cost estimate or casemix adjustment. Intervention houseofficers demonstrated superior cost-related attitudes but no difference in knowledge of charges. Audits of quality of care detected no significant difference between groups. CONCLUSION: This low-intensity intervention reduced length of stay and charges, even under the cost-constrained context of the prospective payment system.

Information gathering and integration as sources of error in diagnostic decision making.

This research examined the relative importance of information gathering versus information utilization in accounting for errors in diagnostic decision making. Two experiments compared physicians' performances under two conditions: one in which they gathered a limited amount of diagnostic information and then integrated it before making a decision, and the other in which they were given all the diagnostic information and needed only to integrate it. The physicians: 1) frequently failed to select normatively optimal information in both experimental conditions; 2) were more confident about the correctness of their information selection when their task was limited to information integration than when it also included information gathering; and 3) made diagnoses in substantial agreement with those indicated by applying normative procedures to the same data. Physicians appear to have difficulties recognizing the diagnosticity of information, which often results in decisions that are pseudodiagnostic or based on diagnostically worthless information.