Competition on quality in managed care.

There is intense competition between managed care organizations (MCOs) in the USA based on cost and benefit coverage, but scant attention to differences in quality. Consumer preference for 'choice' has stimulated the growth of overlapping networks of providers across competing MCOs. These networks have tended to perform less well on the quality indicators in report cards than staff model MCOs. Ideally one would measure individual provider performance; but the overlapping networks, and the fact that each MCO represents a small fraction of each provider's practice, make that difficult to do. MCOs could potentially collaborate to measure individual provider performance. Financial incentives and risk-adjusted premiums might stimulate competition on quality within MCOs. It seems more likely that true competition on quality will occur between groups of providers, organized or integrated delivery systems, than between MCOs. Nevertheless, MCOs are likely to offer some quality-improving programs directly to their members, and can stimulate the competition between providers by collaborating to obtain provider-specific measurements.

Clinical quality measurement. Comparing chart review and automated methodologies.

OBJECTIVES: This study investigates the use of data from automated systems within a large managed care plan to create indicators of clinical quality. METHODS: Measures from the first year of Health Plan Employer Data and Information Set, HEDIS 2.0, are used to compare chart review and automated analysis methodologies. The contributions of various data systems in creating clinical quality measures are evaluated. RESULTS: Chart review data usually are better for creating clinical quality indicators, although the level of agreement between the two methodologies often is quite high. Computerized patient record systems are found to be the most reliable automated data source, and automated claims are found to be the least reliable. This study's findings suggest that automated encounter systems may provide relatively reliable data. CONCLUSIONS: Managed care plans may not want to rely on automated data alone for clinical quality measurement. The results reported here support the use of combined methodologies such as the "hybrid" method, which utilizes both automated and chart-review data.

Information technology applications in quality assurance and quality improvement, Part II.

Many information technologies have been or could be applied to efforts to measure and improve health care quality. This article reviews the recent literature in medical informatics, quality assurance, and quality improvement to identify these and current, emerging, and potential technologies.

Information technology applications in quality assurance and quality improvement, Part I.

Many information technologies have been or could be applied to efforts to measure and improve health care quality. This article reviews the recent literature in medical informatics, quality assurance, and quality improvement to identify these and current, emerging, and potential technologies.

Serum sickness in children after antibiotic exposure: estimates of occurrence and morbidity in a health maintenance organization population.

The computerized outpatient records of the Harvard Community Health Plan, a 230,000-member health maintenance organization, were used to determine the frequency with which serum sickness is recognized in the practice setting after exposure to antibiotics. The medical records of 3,487 children who had been prescribed cefaclor or amoxicillin were searched in December 1986 for coded diagnoses of serum sickness and related conditions. Diagnoses were validated by blinded review of dictated and written office notes. There were 12 cases of serum sickness in 11,523 child-years. During this time, these children were prescribed 13,487 courses of amoxicillin, 5,597 courses of trimethoprim-sulfamethoxazole (TMP-SMZ), 3,553 courses of cefaclor, and 2,325 courses of penicillin V. Serum sickness was considered to be antibiotic-related if it occurred within 20 days of initiation of antibiotic therapy. Five cases were temporally associated with cefaclor, one with both amoxicillin and TMP-SMZ, four with TMP-SMZ alone, and one with penicillin V alone. One case was not associated with any antibiotic exposure. All antibiotic-related cases occurred in children under age 6 years who were treated for otitis media or streptococcal pharyngitis, and most cases began 7-11 days after initiation of antibiotic. All but one of the antibiotic-related cases occurred in children who had relatively heavy lifetime antibiotic exposure. The risk of serum sickness was significantly elevated after cefaclor compared with amoxicillin, even among the most heavily exposed children (relative risk = 14.8, p = 0.01, 95% confidence interval 2.0-352.0). Most cases prompted several physician visits, but none required hospitalization.

Assessing a methodology for physician requirement forecasting. Replication of GMENAC's need-based model for the pediatric specialty.

Methodologies for determining levels of U.S. physician requirement are as complex as they are controversial. One long-standing controversy surrounds the advantages of an epidemiologic need-based forecasting model over an economic demand-based model. This paper examines the need-based requirement approach as recently developed by the Graduate Medical Education National Advisory Committee (GMENAC). This approach is assessed for the pediatric specialty by replicating the original model using data derived from three large HMOs. These data were empirically obtained from the computerized visit records of more than 10,000 children at each of the three plans and normatively from Delphi panels consisting of pediatric practitioners at those same sites. Results indicate that if U.S. pediatrician requirement was estimated on the basis of HMO practice data, rather than GMENAC's national ideals, fewer physicians would be needed. The pediatric requirement based on local Delphi panel judgments was lower still, due in great part to the suggestion of increased delegation rates to nonphysician providers. Implications of this comparative analysis for the GMENAC need-based methodology and future physician requirement modeling efforts are discussed.

Feedback reduces test use in a health maintenance organization.

In a cross-over design, three interventions were tested for their impact on the rate of use of 12 commonly ordered blood tests and roentgenograms among internists in a health maintenance organization. Overall use fell by 14.2% in a 16-week period during which physicians received confidential feedback on their individual rates of use compared with peers (cost feedback). Eleven of 12 tests showed some decrease. Similar feedback on rates of abnormal test results (yield feedback) and a program of test-specific education failed to show a consistent effect. Variability in rates of test use among physicians, as measured by the coefficient of variation, fell by 8.3% with cost feedback, by 1.3% with yield feedback, and by 2.3% with education, but these changes were inconsistent across tests.

Semiautomated reminder system for improving syphilis management.

This project utilized an automated record system, COSTAR, to assess and improve the quality of care in managing syphilis in a health maintenance organization. A scoring tool was developed to assess care. There were four experimental periods, each lasting one year. The periods were Baseline (no intervention), Education (publication of guidelines and an educational session), Reminder (deficiencies in care brought to the attention of providers in time to permit correction), and Post-reminder (no intervention). Scores for overall management of syphilis rose from 70.4 to 90.5% during the Reminder period and did not deteriorate significantly in the Post-reminder period. Scores in the Education period were not significantly higher than baseline. The cost of the system was $195 per year. An inexpensive reminder system was effective in bringing about a significant improvement in quality of care for syphilis, and the effect persisted for at least a year after the system was discontinued.

Improving physician performance through peer comparison feedback.

A project to improve physician performance in colorectal cancer screening was evaluated as part of an ambulatory quality assurance program. A minimum standard was adopted requiring a digital examination and stool test for occult blood at annual check-ups of patients aged 40 years and older. During a 31/2-year period, three different intervention strategies for improved compliance with the standard were sequentially implemented and assessed: educational meeting, retrospective feedback of group compliance rate, and retrospective feedback of individual compliance rate compared with that of peers. A pretest/posttest design was employed in evaluating the first two intervention strategies. Neither strategy resulted in significant improvement in compliance. Monthly feedback of individual performance ranked with that of peers was then implemented in a randomized clinical trial utilizing a crossover design. During the first 6-month period, the physicians receiving feedback (group 1) improved from 66.0% to 79.9% (P less than 0.001), while the control group (group 2) also improved, from 67.5% to 76.6% (P less than 0.001), suggesting a spillover effect. During the second 6-month period, group 2 received feedback and group 1 did not. Group 1 stabilized at approximately 80% while group 2 continued to improve from 76.6% to 84.0% (P less than 0.001). Behavior changes persisted at 6 and 12 months after intervention.

The role of patient interventions in ambulatory quality assurance programs.

This paper highlights several studies conducted by a quality assurance research program in a health maintenance organization which provide tangible support for the need to integrate patient interventions with quality assurance activities. A model for quality assurance is described which proposes to include identification of the role of patient behavior in affecting health outcomes, and to develop intervention mechanisms directed towards patients. The experiences from this investigation suggest the need to add patient interventions to the traditional quality assurance efforts of affecting system and provider behaviors. Four of the ten projects conducted are described to illustrate these issues. Topics reviewed are maternity care, hypertension, management of breast disease, and pap smears for high-risk women. These recommendations are particularly appropriate for health maintenance organizations since both quality assurance and health education programs are mandated in the 1973 HMO Act. However, these findings are of relevance to other ambulatory care settings as well.