Redesigning primary care processes to improve the offering of mammography. The use of clinic protocols by nonphysicians.

OBJECTIVE: To develop, within the framework of continuous quality improvement, new processes for offering mammography and determine whether protocols executed completely by nonphysicians would increase mammography utilization. DESIGN: A prospective follow-up study with patients from an intervention clinic and two control clinics. SETTING: Three general internal medicine clinics in a large, urban teaching hospital in Detroit, Michigan. PATIENTS/PARTICIPANTS: A total of 5,934 women, aged 40 through 75 years, making 16,546 visits to one of the clinics during the study period (September 1, 1992, through November 31, 1993). INTERVENTION: Medical assistants and licensed practical nurses in the intervention clinic were trained to identify women due for screening mammography, and to directly offer and order a mammogram if patients agreed. MEASUREMENTS AND MAIN RESULTS: Patients were considered up-to-date with screening if they had a mammogram within 1 year (if age 50-75) or 2 years (if age 40-49) prior to the visit or a mammogram within 60 days after the visit. The proportion of visits each month in which a woman was up-to-date with mammography was calculated using computerized billing records. Prior to the intervention, the proportion of visits in which women were up-to-date was 68% (95% confidence interval [CI] 63%, 73%) in the intervention clinic and 66% (95% CI 61%, 71%) in each of the control clinics. At the end of the evaluation, there was an absolute increase of 9% (95% CI 2%, 16%) in the intervention clinic, and a difference of 1% (95% CI -5%, 7%) in one of the control clinics and -2% (95% CI -3%, 5%) in the other. In the intervention clinic, the proportion of visits in which women were up-to-date with mammography increased over time and was consistent with a linear trend (p = .004). CONCLUSIONS: Redesigning clinic processes to make offering of mammography by medical assistants and licensed practical nurses a routine part of the clinic encounter can lead to mammography rates that are superior to those seen in physicians' usual practice, even when screening levels are already fairly high. Physicians need not be considered the sole, or even the primary, member of the health care team who can effectively deliver some preventive health measures.

Health outcomes among African American and Caucasian adults following a randomized trial of an asthma education program.

OBJECTIVES: Re-analysis of a randomized trial of an asthma education program designed to assess the effects of the intervention on emergency department visits, limited days of activity and asthma knowledge and beliefs separately for African American and Caucasian adults with asthma. DESIGN: Two hundred and forty-one respondents between the ages of 18 and 70 were evaluated in two emergency departments (one inner city and one suburban location) of a large, midwestern health care system and were randomized to an intervention or control group. RESULTS: Regardless of race, members of the intervention group showed a decrease in the number of post-intervention emergency department visits (ANOVA interaction between race and group effect p value = 0.93). The greatest decrease occurred during the first four post-intervention months. No differential effect of the asthma education intervention by race was found on the change in asthma knowledge and beliefs over the study period (ANCOVA interaction between race and group effect p value = 0.60). CONCLUSION: This study demonstrates that post-intervention, both African American and Caucasian study participants showed a decrease in emergency department visits and an increase in asthma self-management. This finding is especially important for African Americans, who face increasing asthma mortality and morbidity.

The cost and effectiveness of an education program for adults who have asthma.

STUDY OBJECTIVE: To determine whether a self-management training program decreases emergency department visits and reduces costs for patients with asthma. DESIGN: Randomized controlled trial of an educational program. SETTING: Two sites--an urban emergency room and a suburban emergency room. PATIENTS: 241 asthma patients between the ages of 18 and 70 years. Of the 119 patients in the intervention group and the 122 in the control group, 185 (76%) were available for follow-up. INTERVENTION: All patients seen in the emergency departments were given usual medical care and follow-up. Patients in the intervention group were asked to attend three educational sessions on asthma conducted by a specially trained RN. The program stressed importance of medication compliance, methods to control and prevent attacks, effects of drugs and rationale for their use, relaxation exercises, and smoking cessation. MEASUREMENT AND MAIN RESULTS: All patients received telephone interviews four, eight, and 12 months after entry into the study. Reports based on hospital admissions and emergency room utilization were verified by billing records. Three patients died during the study, none from asthma-related problems. The intervention group had significantly fewer asthma-related emergency visits (16 visits per 100 persons) than did the control group (39 per 100 persons); p = 0.0005 for the 12 months of follow-up. The effect of the intervention on asthma-related emergency department visits was strongest during the initial four months postintervention (68 per 100 persons versus 220 per 100 persons, p = 0.003). The financial analysis showed that the $85/person cost for the educational sessions was offset by the $628/person reduction in emergency room charges. CONCLUSION: Education enables patients with asthma to decrease utilization of emergency services.

The on-call experience of interns in internal medicine. Medical Education Task Force of Henry Ford Hospital.

As part of an effort to examine the structure and content of our residency program in internal medicine, we assessed interns' activities on call to identify problems with workload scheduling, supervision, or learning. Eleven interns were observed continuously during a 34-hour on-call period. Interns averaged 5.6 hours at the bedside, with 57 minutes of that time under direct supervision of a resident or attending physician. Nearly half of new patient examinations continued after midnight despite a special night admission team that evaluated all patients admitted after 11 pm. The interns averaged 21 beeps per 30 hours. They slept an average of 2.5 hours with two interruptions. They read about their patients an average of 4 minutes during the 34-hour period. Most supervision was away from the bedside (82/139 minutes). Bedside supervision occurred predominantly during rounds (45/57 minutes). Attending physicians averaged only 12 minutes of bedside interaction with the intern. Many of these findings were unanticipated. Structural defects in the training program were defined and are being addressed. Other training programs should consider similar analyses before making fundamental changes.