ACGME competencies in neurology: web-based objective simulated computerized clinical encounters.

OBJECTIVE: The American Headache Society developed an innovative Web-based neurology resident educational program to 1) meet the objectives of the Accreditation Council for Graduate Medical Education Outcomes Project; 2) provide measurable improvement of a neurology resident's understanding of headache and the performance within each core competency; 3) assist residents and program directors in identifying knowledge gaps; and, ultimately, 4) improve the quality of patient care through enhanced educational initiatives. METHODS: Quantitative analysis focused on pretest and post-test results, level attainment on case-based simulations, competency achievement, and interactions between cases. One of four validated global scores was related to each resident response on all competency learning opportunities and was measured, from one case to another, to determine improvement and understanding. The pretest and post-test each consisted of 50 randomized questions that tested baseline and improvement on specific core competencies and understanding of headache. RESULTS: The pretest mean score was 30.08, and the post-test mean score was 34.79. A paired sample t test analysis showed a significant difference from pretest to post-test scores (M = -4.72, SD = 4.88, t[91] = -9.269, p < 0.001). There was significant improvement in the competencies as the residents moved through the cases as well as in each of the competencies from the pretest to the post-test. Results showed that residents increased their knowledge and performance by synthesizing the content. CONCLUSIONS: This outcomes analysis demonstrates the effectiveness of the American Headache Society Neurology Resident's Program in improving the resident's knowledge of headache medicine and Accreditation Council for Graduate Medical Education core competencies.

Cost-effectiveness and cost-benefit of sumatriptan in patients with migraine.

OBJECTIVE: To investigate the cost-effectiveness and cost-benefit of initiating sumatriptan therapy in patients with acute migraine who were previously taking nontriptan drugs. PATIENTS AND METHODS: This is an economic analysis of a prospective, pretest-posttest, observational 6-month outcomes study of 178 patients with a physician diagnosis of migraine who received their first prescription for sumatriptan between October 1994 and August 1996 and were members of a mixed-model managed care organization in western Pennsylvania. Migraine-related resource use data were obtained from the managed care organization's medical and pharmacy claims databases. The primary outcome measure for this economic analysis was the total disability time that patients experienced because of migraine. Patients reported time missed from work and usual nonwork activities because of migraine on self-administered questionnaires at baseline and at 3 and 6 months after initiation of sumatriptan. RESULTS: Initiation of sumatriptan resulted in a decrease of 662 migraine-disability-days for work and 1236 migraine-disability-days for nonwork activities during the 6 months of the study (decrease from 27.8 to 17.2 days per person), totaling 1898 migraine-disability-days averted with sumatriptan therapy. Migraine-related medical costs were lower after sumatriptan was initiated ($18,351 vs $26,192), whereas migraine-related pharmacy costs were lower with prior nontriptan drug therapy ($22,209 vs $74,861). The overall net cost savings after sumatriptan was initiated in these patients was $222,332 ($1249 per patient) with a benefit-to-cost ratio of $5.67 gained for each health care dollar spent from a societal perspective. The incremental cost-effectiveness ratio was $25 for each additional migraine-disability-day averted by using sumatriptan vs nontriptan drug therapy. Sensitivity analysis showed that changes in medical costs had little effect on the ratios and that sumatriptan remained cost-beneficial across a wide range of patient wages. CONCLUSION: This study showed that initiation of sumatriptan in patients previously receiving nontriptan therapy was cost-effective and had an economic benefit for patients, employers, and society. Sumatriptan also helped patients and physicians achieve goals recommended by the US Headache Consortium by reducing patients' disability and thus improving their ability to function at work and nonwork activities.

Certificate of need and the quality of cardiac surgery.

Historically, states have used Certificate of Need (CON) programs to review proposals for new construction and expanded services in an effort to control costs and to improve the quality of and promote access to health care services. Congressional funding for CON ended in 1987. However, today, 26 states use CON to regulate cardiac surgery. There has been little evidence of the impact of CON on the quality of services. Pennsylvania is in a unique position to study the impact of CON on the quality and outcomes of care because the state terminated CON in 1996 and has publicly reported quality and outcomes data on coronary bypass graft (CABG) surgeries since 1992. Using a statewide inpatient data-reporting system, the volumes and outcomes of CABG surgeries at all Pennsylvania hospitals were examined in the 3 years prior to and the 3 years after the termination of CON. In the 3 years following the elimination of CON, the number of open-heart surgery programs increased 25%, yet there was no significant increase in the number of CABG surgeries performed. Quality, as measured by mortality rate, was not impacted by the real-location of the relatively stable CABG volume in the short term; this may be due, in part, to itinerant surgeons and statewide public performance monitoring. The long-term implications of deregulation are unclear and deserve future study.

Pharmacoeconomic fellowships: the need for outcome measures.

Pharmacoeconomic fellowship programmes have been in existence for more than 10 years, but their effectiveness has not been evaluated. The aim of this project was to construct a framework to examine the potential outcome measures for pharmacoeconomic fellowships so that the effectiveness of these programmes may be determined. Using the Donabedian model, the structures, processes, and outcomes of pharmacoeconomic fellowship programmes were investigated. The structures of these programmes include the facilities, qualifications of the teaching staff and organisation, and operations of the institution. Most pharmacoeconomic fellowships are based in academic institutions and the pharmaceutical industry. Credentials of the preceptors and teaching staff consist of an advanced degree and relevant expertise in pharmacoeconomics and outcomes research. The processes of pharmacoeconomic fellowships include the duration of the programme as well as the research skills and the educational components taught. However, current guidelines do not define outcome measures for these pharmacoeconomic fellowships. Potential outcomes may include whether or not a degree was obtained, the management and research skills acquired, as well as the type of experiential training received. Further research is required to develop these outcome measures, so the effectiveness of pharmacoeconomic fellowship programmes may be assessed.

Physician executives report high job satisfaction. Summary of findings from a survey of senior physician executives.

The role of the senior physician executive is well established in American hospitals and health systems. There is little research, however, on overall physician executive job satisfaction, their perceptions of their organizational role and job performance, or their views of the medical staffs with which they work. A recent survey of physician executives examined these and other areas. It found physician executives to be quite satisfied with their jobs. What follows is a summary of the findings. An article based on the survey will be featured in a future issue of The Physician Executive.

Cost-effective treatment of depression with selective serotonin reuptake inhibitors.

OBJECTIVE: To compare factors that influence cost of antidepressant therapy between older tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) and among drugs in the SSRI class. STUDY DESIGN: Literature review. RESULTS: Pharmacoeconomic data from the primary care and managed care settings demonstrate that the higher acquisition cost of the SSRIs is offset by reduced medical utilization because of a lower incidence of treatment-related adverse events, drug switching, and dosage adjustments than among patients taking TCAs. Analysis of pharmacy claims data suggests that drug acquisition costs, use of concomitant medications, incidence of dose titration, frequency of multitablet therapy (dose stratification), and duration of therapy are the key factors in determining the cost of SSRI therapy. Among the established SSRIs, drug acquisition costs are lowest for paroxetine and sertraline. Costs for concomitant medications may vary by healthcare plan. Recent reports indicate that paroxetine is associated with a low incidence of dose titration. Paroxetine and sertraline are available in extended dosage forms to reduce the need for multitablet therapy. Duration of therapy with all SSRIs is typically shorter than recommended. CONCLUSION: Antidepressant therapy with SSRIs has been shown to be more cost effective than treatment with TCAs when overall healthcare utilization and expenses are considered.

The timing of neonatal discharge: An example of unwarranted variation?

UNLABELLED: Discharge from an intensive care nursery should be dependent on the infant's clinical and social condition and independent of the day of the week. OBJECTIVE: To evaluate admission and discharge dates of 5272 neonates cared for in 5 major metropolitan regions in the United States and managed by a national disease management company for the distribution of the day of the week. STUDY DESIGN: All infants discharged to home between July 1, 1996 and September 30, 1998 are included. Data are represented as a percentage of total discharges or admissions for each weekday assignment. Using the normal approximation to the multinomial distribution, we tested for proportional differences on each weekday. RESULTS: The data demonstrate that the timing of nursery discharge has an uneven distribution across the days of the week, with weekend (Saturday and Sunday) discharge rates that are significantly lower than weekday discharge rates. This uneven distribution exists in both the term and preterm subgroups as well. There is also an uneven distribution of births among the days of the week, with a pattern that reveals fewer weekend births than weekday births in the entire population studied, as well as in both the term and preterm subgroups. Normalizing these weekend discharges to the previous weekday could generate potential saving of $1 569 405 in charges for the total population and 627 days of hospitalization. The average length of stay of infants discharged on Mondays is longer than for those infants discharged on Saturday or Sunday. CONCLUSIONS: We speculate that changes in discharge planning could decrease the variation in day of discharge, shorten length of hospitalization, and potentially reduce cost.

Palivizumab for respiratory syncytial virus prophylaxis in high-risk infants: a cost-effectiveness analysis.

BACKGROUND: Prophylactic therapy with palivizumab, a humanized monoclonal antibody, has been shown to reduce the number of respiratory syncytial virus (RSV)-related hospitalizations in preterm infants. The cost-effectiveness of this therapy has not been evaluated from the provider's perspective using cost data. OBJECTIVES: The objectives of this study were to determine the cost per RSV infection episode avoided by using prophylactic palivizumab therapy in a high-risk infant population and to determine whether certain subgroups of infants derived greater benefit from prophylactic therapy. METHODS: A decision-analytic model simulating an RSV infection episode was developed to evaluate the cost-effectiveness of palivizumab prophylaxis from the perspective of the health care system (provider). Data to populate the model were gathered from the medical literature (identified through a MEDLINE search of studies on the incidence of RSV infection) and the IMpact-RSV clinical trial. Data included incidence of RSV infection and the associated health care resource use and costs. Costs to the provider were determined using a university-affiliated hospital cost-accounting system. Cost-effectiveness ratios were calculated over a range of RSV infection incidence rates in a control population. Sensitivity analyses were performed for the cost of palivizumab therapy, the cost of RSV-related hospitalization, and the number of emergency department, physician office, and home health care visits. For the subgroup analysis, infants were classified by gestational age (<32 and > or = 32 weeks) and stratified by severity of chronic lung disease. RESULTS: The cost per additional RSV infection episode avoided ranged from dollars 0 (cost savings) to dollars 39,591 for palivizumab prophylaxis costs of dollars 2500 and from dollars 2702 to dollars 79,706 for palivizumab prophylaxis costs of dollars 4500. The model was insensitive to changes in the number of emergency department, physician office, and home health care visits. The difference in RSV incidence between the treatment and control groups was greater among infants > or = 32 weeks' gestational age than among infants <32 weeks' gestational age. onclusions: The incremental cost-effectiveness of palivizumab compared with no prophylactic therapy was sensitive to changes in the incidence of RSV infection in control infants, the average cost of RSV hospitalization, and the cost of palivizumab. Clinicians may use this information along with additional factors to determine whether palivizumab is cost-effective in their clinical setting and geographic area.

Quality in health care: what are the problems and what are the solutions?

The health care industry must define quality as achieving "desired health outcomes" that are "consistent with current professional knowledge." Once a single definition is established, health care professionals can begin to measure quality and improve the process of health care in this country. Clinical variation and an increasing number of medical mistakes have contributed to rising health care costs and poor quality. Once the industry establishes what is wrong, it can begin to devise some solutions to improve the quality of health care. A six-step strategy to improve quality is suggested: increasing accountability at all levels of the industry, continuous quality improvement, standardization of medicine using guidelines, patient empowerment, improved access to health information through a centralized database, and the need for incentives for patients and medical professionals. Although many physicians are skeptical of such changes, the health care industry clearly must work together to address the issue of quality appropriately.

Optimizing quality of care and cost effectiveness in treating allergic rhinitis in a managed care setting.

Allergic rhinitis is a common condition in managed care populations. The direct medical cost of rhinitis exceeded $3 billion in 1996, and an additional cost of $4 billion resulted from the exacerbation of other concomitant conditions, such as asthma or otitis media. Costs continued to increase in 1999; sales of prescription antihistamines and nasal steroids exceeded $3 billion and $1 billion, respectively. The indirect costs of allergic rhinitis include lost work productivity, reduced performance and learning, and increased workplace and traffic accidents. Rhinitis treatments include allergen avoidance, over-the-counter (OTC) sedating antihistamines, nonsedating antihistamines, nasal steroids, and immunotherapy. Allergen avoidance strategies for patients with asthma and rhinitis are ineffective or are of very limited benefit. Allergists criticize the use of OTC sedating antihistamines, which are associated with reduced learning and performance even when sedation does not occur. Evidence-based literature reviews of clinical trials have shown that nasal steroids are more effective than nonsedating antihistamines in the treatment of rhinitis. The most commonly prescribed nasal steroid, fluticasone, has been shown to be effective in treating rhinitis and in improving patients' quality of life. It is also more cost effective than the most commonly prescribed antihistamine, loratadine. Clinical trials have indicated that immunotherapy is expensive and of limited benefit. As these evidence-based findings are used to develop managed care treatment guidelines, nasal steroids are likely to be recommended as the first-line treatment for rhinitis, which should result in lower treatment costs and improved outcomes for patients with rhinitis.

Development and validation of a questionnaire to evaluate patient satisfaction with diabetes disease management.

OBJECTIVE: To develop a reliable and valid questionnaire to measure patient satisfaction with diabetes disease management programs. RESEARCH DESIGN AND METHODS: Questions related to structure, process, and outcomes were categorized into 14 domains defining the essential elements of diabetes disease management. Health professionals confirmed the content validity. Face validity was established by a patient focus group. The questionnaire was mailed to 711 patients with diabetes who participated in a disease management program. To reduce the number of questionnaire items, a principal components analysis was performed using a varimax rotation. The Scree test was used to select significant components. To further assess reliability and validity; Cronbach's alpha and product-moment correlations were calculated for components having > or =3 items with loadings >0.50. RESULTS: The validated 73-item mailed satisfaction survey had a 34.1% response rate. Principal components analysis yielded 13 components with eigenvalues > 1.0. The Scree test proposed a 6-component solution (39 items), which explained 59% of the total variation. Internal consistency reliabilities computed for the first 6 components (alpha = 0.79-0.95) were acceptable. CONCLUSIONS: The final questionnaire, the Diabetes Management Evaluation Tool (DMET), was designed to assess patient satisfaction with diabetes disease management programs. Although more extensive testing of the questionnaire is appropriate, preliminary reliability and validity of the DMET has been demonstrated.

Quality and outcome determination in health care and orthopaedics: evolution and current structure.

Quality health care has many definitions. Among those definitions is "care that consistently contributes to the improvement or maintenance of the quality and/or duration of life." The current evolution in health care has been fueled by three necessities frequently demanded by payers and employers: improvement in access, lowering of cost, and definition and quantification of the quality of care. This evolution has been facilitated by the so-called industrialization of medicine. This concept includes the adoption of industrial economic principles and techniques that facilitate the measurement of processes and outcomes. Quality health care is currently recognized as health care that is characterized by three elements: the use of practice guidelines or standards, the implementation of continuous quality improvement techniques, and the use of outcome determination and management. Practice guidelines demand the adoption of evidence-based principles in evaluation and care, as well as minimization of variations in evaluation and care. Continuous quality improvement seeks to determine why variations in processes of care occur and then to minimize those variations. Outcomes may be measured in terms of both very objective and very subjective variables and also on the basis of cost-efficiency. Most tools currently used to quantify outcomes, especially in orthopaedics, involve measurements of general health and of specific body part or organ system function. This evolution in health care is producing significant alterations in methods of traditional health-care delivery. The accumulating evidence indicates that these changes, although frequently unpopular, are improving the quality of health care.

A cost-effective method to characterize variation in clinical practice.

This study's objective was to measure variation in physicians' practice styles and policies. Family physicians and general internists were surveyed about evidence-based medicine in the areas of asthma, congestive heart failure, and diabetes mellitus. They were asked about clinical recommendations where standards of practice were uncertain, controversial, or changing in response to published guidelines. Also included were items dealing with managed care. Although there was wide variation in responses to 20 of 36 items, some responses were consistent with practice guidelines. Responses to several items indicated a tendency to overuse expensive tests. Overall, the results indicate that a brief, open-ended survey can assess practice variation quickly and economically, as contrasted with more expensive analyses of medical records or claims data. With proper validation such assessments can be used as baselines to guide interventions, as well as measures of the outcomes of these interventions to change practice styles.

Changes in resource use and outcomes for patients with migraine treated with sumatriptan: a managed care perspective.

BACKGROUND: Migraine headaches result in significant patient suffering and high costs to managed care organizations and employers. Studies that evaluate patient outcomes and the financial consequences of migraine treatment are important from a clinical and an economic perspective. METHODS: This prospective, observational study assessed the outcomes of migraineurs in a mixed model staff/ independent practice association managed care organization for patients previously diagnosed as having migraine who received their first prescription for sumatriptan. Data collected included medical as well as pharmacy claims and patient surveys to measure changes in satisfaction, health-related quality of life, workplace productivity, and nonworkplace activity after sumatriptan therapy was initiated. RESULTS: A total of 178 patients completed the study. Results showed significant decreases in the mean number of migraine-related physician office visits, emergency department visits, and medical procedures in the 6 months after sumatriptan therapy compared with the 6 months before sumatriptan was used (P<.05). Four of the health-related quality-of-life dimensions and the physical component summary score measured by the SF-36 (which is a valid, reliable general health status instrument) showed significant improvements at 6 months compared with patients' scores before use of sumatriptan (P<.05). Health-related quality of life measured by the disease-specific instrument MSQ (Migraine-Specific Quality of Life Questionnaire-Version 1.0, 1992 Glaxo Wellcome Inc, Research Triangle Park, NC) showed significant improvement at 3 and at 6 months compared with baseline scores (P<.05). There were also improvements in patient satisfaction and significant reductions in time lost from workplace productivity and nonworkplace activity. CONCLUSION: In the 6 months after sumatriptan therapy was initiated, health care resource use and time lost from workplace productivity and nonworkplace activity were reduced, while health-related quality of life and patient satisfaction scores improved for the managed care migraineurs enrolled in this study.