Improving residents' compliance with standards of ambulatory care: results from the VA Cooperative Study on Computerized Reminders.

CONTEXT: Computerized systems to remind physicians to provide appropriate care have not been widely evaluated in large numbers of patients in multiple clinical settings. OBJECTIVE: To examine whether a computerized reminder system operating in multiple Veterans Affairs (VA) ambulatory care clinics improves resident physician compliance with standards of ambulatory care. DESIGN, SETTING, AND PARTICIPANTS: A total of 275 resident physicians at 12 VA medical centers were randomly assigned in firms or half-day clinic blocks to either a reminder group (n = 132) or a control group (n = 143). During a 17-month study period (January 31, 1995-June 30, 1996), the residents cared for 12,989 unique patients for whom at least 1 of the studied standards of care (SOC) was applicable. MAIN OUTCOME MEASURES: Compliance with 13 SOC, tracked using hospital databases and encounter forms completed by residents, compared between residents in the reminder group vs those in the control group. RESULTS: Measuring compliance as the proportion of patients in compliance with all applicable SOC by their last visit during the study period, the reminder group had statistically significantly higher rates of compliance than the control group for all standards combined (58.8% vs 53.5%; odds ratio [OR], 1.24; 95% confidence interval [CI], 1.08-1.42; P =.002) and for 5 of the 13 standards examined individually. Measuring compliance as the proportion of all visits for which care was indicated in which residents provided proper care, the reminder group also had statistically significantly higher rates of compliance than the control group for all standards combined (17.9% vs 12.2%; OR, 1.57; 95% CI, 1.45-1.71; P<.001) and for 9 of the 13 standards examined individually. The benefit of reminders, however, declined throughout the course of the study, even though the reminders remained active. CONCLUSIONS: Our data indicate that reminder systems installed at multiple sites can improve residents' compliance to multiple SOC. The benefits of such systems, however, appear to deteriorate over time. Future research needs to explore methods to better sustain the benefits of reminders. JAMA. 2000;284:1411-1416.

Cost-effectiveness of universal compared with voluntary screening for human immunodeficiency virus among pregnant women in Chicago.

OBJECTIVES: To determine and compare the cost-effectiveness of implementing 3 screening strategies to detect human immunodeficiency virus (HIV) infection among pregnant women in Chicago, Illinois: no screening, voluntary screening, and universal screening. METHODS: A decision-analysis model was developed, using standard cost-effectiveness analysis from a societal perspective. Reference case estimates were derived from a surveillance project conducted by the Illinois Department of Public Health and studies were published in the medical literature. Costs included direct and indirect medical costs associated with identification of pregnant women infected with HIV and identification, prevention, and treatment of perinatally HIV-infected newborns. Specifically, for each screening option, the cost per pregnant woman screened, the resulting number of pediatric HIV infections, and the number of newborn life-years were calculated. All costs were adjusted to the 1997 dollar value and discounted at 3%. Sensitivity analyses were determined for all variables included in the decision model. RESULTS: The estimated prevalence of HIV infection among pregnant women in Chicago is .41%. For every 100,000 pregnant women, it is estimated that 104.6 children would be infected with HIV if no screening strategy were implemented and 44.8 children would be infected if voluntary HIV testing (assuming a 92.7% acceptance rate) were available. In comparison, if universal HIV testing was performed, the number of children infected with HIV would decrease to 40 cases. Sensitivity analysis across a maternal HIV prevalence rate of.01% to 2.2% found that universal screening would be cost-saving in communities where the seroprevalence is.21%. In Chicago, it would take an estimated 5. 2 months of screening pregnant women to avert 1 case of pediatric HIV. Taking into consideration the lifetime costs of treating a child with HIV infection, universal HIV testing of 100,000 pregnant women would result in a cost-savings of $3.69 million when compared with no screening, and $269,445 when compared with voluntary screening. We estimated that it would cost $11.1 million to screen 100,000 pregnant women in Chicago. The cost-savings produced with increased screening are the direct result of reduced cases of newborns infected with HIV. A 2-way sensitivity analysis was performed to examine how costs vary as a function of the voluntary rates for HIV-positive and HIV-negative women. When screening falls below 50% for HIV-positive mothers, universal screening becomes cheaper than voluntary screening even if no HIV-negative mothers were screened. CONCLUSION: Reference case analyses showed that universal HIV screening of pregnant women in Chicago would both decrease the number of HIV-infected newborns and save money in comparison to voluntary or no testing strategies. Sensitivity analysis was robust across all variables for the conclusion that universal screening was more effective than voluntary screening. For many communities that have HIV prevalence rates for mothers of >.21%, universal screening would also save money in comparison to voluntary screening. For communities with prevalence rates <.21%, the benefits of universal screening may outweigh the costs for screening as we found that desirable incremental cost-effectiveness ratios were found for prevalence rates as low as.0075%.

Providing pediatric subspecialty care: A workforce analysis. AAP Committee on Pediatric Workforce Subcommittee on Subspecialty Workforce.

OBJECTIVE: To provide a snapshot of pediatric subspecialty practice, examine issues pertaining to the subspecialty workforce, and analyze subspecialists' perspective on the health care market. BACKGROUND: Before the effort of the Future of Pediatric Education II (FOPE II) Project, very little information existed regarding the characteristics of the pediatric subspecialty workforce. This need was addressed through a comprehensive initiative involving cooperation between subspecialty sections of the American Academy of Pediatrics and other specialty societies. METHODS: Questionnaires were sent to all individuals, identified through exhaustive searches, who practiced in 17 pediatric medical and surgical subspecialty areas in 1997 and 1998. The survey elicited information about education and practice issues, including main practice setting, major professional activity, referrals, perceived competition, and local workforce requirements. The number of respondents used in the analyses ranged from 120 (plastic surgery) to 2034 (neonatology). In total, responses from 10 010 pediatric subspecialists were analyzed. RESULTS: For 13 of the subspecialties, a medical school setting was specified by the largest number of respondents within each subspecialty as their main employment site. Direct patient care was the major professional activity of the majority of respondents in all the subspecialties, with the exception of infectious diseases. Large numbers of subspecialists reported increases in the complexity of referral cases, ranging between 20% (cardiology) and 44% (critical care), with an average of 33% across the entire sample. In all subspecialties, a majority of respondents indicated that they faced competition for services in their area (range: 55%-90%; 71% across the entire sample); yet in none of the subspecialties did a majority report that they had modified their practice as a result of competition. In 15 of the 17 subspecialties, a majority stated that there would be no need in their community over the next 3 to 5 years for additional pediatric subspecialists in their discipline. Across the entire sample, 42% of respondents indicated that they or their employer would not be hiring additional, nonreplacement pediatric subspecialists in their field in the next 3 to 5 years (range: 20%-63%). CONCLUSION: This survey provides the first comprehensive analysis to date on how market forces are perceived to be affecting physicians in the pediatric subspecialty workforce. The data indicate that pediatric subspecialists in most areas are facing strong competitive pressures in the market, and that the market's ability to support additional subspecialists in many areas may be diminishing.

The learning ability paradox in adult metamemory research: where are the metamemory differences between good and poor learners?

College students' ability to judge whether a studied item had been learned well enough to be recalled on a later test was examined in three experiments with self-paced learning procedures. Generally, these learners compensated for item difficulty when allocating study time, studying hard items longer than easy items, but they still recalled more easy items than hard items and tended to drop items out too soon. When provided with test opportunities during study or a delay between study and judgment, learners compensated significantly more for item difficulty and recalled substantially more. Paradoxically, good and poor learners compensated similarly for item difficulty and benefited similarly from testing during study and from delayed decision making. Thus, although the ability to make metamemory decisions was shown to be important for effective learning, these decisions were made equally well by good and poor associative learners. An analysis of tasks used to investigate metamemory-memory relationships in adult learning may provide an account for this apparent learning ability paradox.