Diagnostic Accuracy of the Primary Care Screener for Affective Disorder (PC-SAD) in Primary Care.

BACKGROUND: Depression goes often unrecognised and untreated in non-psychiatric medical settings. Screening has recently gained acceptance as a first step towards improving depression recognition and management. The Primary Care Screener for Affective Disorders (PC-SAD) is a self-administered questionnaire to screen for Major Depressive Disorder (MDD) and Dysthymic Disorder (Dys) which has a sophisticated scoring algorithm that confers several advantages. This study tested its performance against a 'gold standard' diagnostic interview in primary care. METHODS: A total of 416 adults attending 13 urban general internal medicine primary care practices completed the PC-SAD. Of 409 who returned a valid PC-SAD, all those scoring positive (N=151) and a random sample (N=106) of those scoring negative were selected for a 3-month telephone follow-up assessment including the administration of the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I) by a psychiatrist who was masked to PC-SAD results. RESULTS: Most selected patients (N=212) took part in the follow-up assessment. After adjustment for partial verification bias the sensitivity, specificity, positive and negative predictive value for MDD were 90%, 83%, 51%, and 98%. For Dys, the corresponding figures were 78%, 79%, 8%, and 88%. CONCLUSIONS: While some study limitations suggest caution in interpreting our results, this study corroborated the diagnostic validity of the PC-SAD, although the low PPV may limit its usefulness with regard to Dys. Given its good psychometric properties and the short average administration time, the PC-SAD might be the screening instrument of choice in settings where the technology for computer automated scoring is available.

Development and preliminary validation of the PC-SAD5, a screener-derived short depression severity measure.

BACKGROUND: The prevalence of depressive disorders is high among patients with skin disease. The PC-SAD is a 37-item self-administered depression screening questionnaire that has been validated in dermatological patients. OBJECTIVE: The aim of this study was to develop and validate a brief depression severity instrument derived from the PC-SAD that can be used to assess severity and monitor ongoing clinical course. METHODS: Two patient samples participated in the study: 72 adult dermatological inpatients and 73 adults attending six primary care practices. Psychiatric assessment included the Structured Clinical Interview for DSM-IV and an 18-item version of the PC-SAD; moreover, dermatological patients completed the Patient Health Questionnaire depression scale (PHQ-9), while primary care patients were administered the Montgomery-Asberg Depression Rating Scale (MADRS). A subset of five PC-SAD items showing the best psychometric properties were selected, and the reliability and validity of the resulting instrument (PC-SAD5) were examined. RESULTS: The PC-SAD5 showed satisfactory internal consistency in both samples. There was a high correlation between PC-SAD5 and PHQ-9 and MADRS scores. Multiple regression analysis revealed a gradient of PC-SAD5 scores from patients with no mental disorder, those with milder forms of depression, to those with Major Depressive Disorder. Similar results were observed for the 18-item version of the PC-SAD. CONCLUSION: The availability of valid and reliable continuous measures of depression severity derived from the PC-SAD extends its field of application from depression screening to use as a follow-up measure of depression severity in routine clinical practice. A validated very short instrument such as the PC-SAD5 may have substantial clinical value.

Doctor discontent. A comparison of physician satisfaction in different delivery system settings, 1986 and 1997.

OBJECTIVE: To examine the differences in physician satisfaction associated with open- versus closed-model practice settings and to evaluate changes in physician satisfaction between 1986 and 1997. Open-model practices refer to those in which physicians accept patients from multiple health plans and insurers (i.e., do not have an exclusive arrangement with any single health plan). Closed-model practices refer to those wherein physicians have an exclusive relationship with a single health plan (i.e., staff- or group-model HMO). DESIGN: Two cross-sectional surveys of physicians; one conducted in 1986 (Medical Outcomes Study) and one conducted in 1997 (Study of Primary Care Performance in Massachusetts). SETTING: Primary care practices in Massachusetts. PARTICIPANTS: General internists and family practitioners in Massachusetts. MEASUREMENTS: Seven measures of physician satisfaction, including satisfaction with quality of care, the potential to achieve professional goals, time spent with individual patients, total earnings from practice, degree of personal autonomy, leisure time, and incentives for high quality. RESULTS: Physicians in open- versus closed-model practices differed significantly in several aspects of their professional satisfaction. In 1997, open-model physicians were less satisfied than closed-model physicians with their total earnings, leisure time, and incentives for high quality. Open-model physicians reported significantly more difficulty with authorization procedures and reported more denials for care. Overall, physicians in 1997 were less satisfied in every aspect of their professional life than 1986 physicians. Differences were significant in three areas: time spent with individual patients, autonomy, and leisure time (P < or =.05). Among open-model physicians, satisfaction with autonomy and time with individual patients were significantly lower in 1997 than 1986 (P < or =.01). Among closed-model physicians, satisfaction with total earnings and with potential to achieve professional goals were significantly lower in 1997 than in 1986 (P < or =.01). CONCLUSIONS: This study finds that the state of physician satisfaction in Massachusetts is extremely low, with the majority of physicians dissatisfied with the amount of time they have with individual patients, their leisure time, and their incentives for high quality. Satisfaction with most areas of practice declined significantly between 1986 and 1997. Open-model physicians were less satisfied than closed-model physicians in most aspects of practices.

The Work Limitations Questionnaire.

OBJECTIVE: The objective of this work was to develop a psychometrically sound questionnaire for measuring the on-the-job impact of chronic health problems and/or treatment ("work limitations"). RESEARCH DESIGN: Three pilot studies (focus groups, cognitive interviews, and an alternate forms test) generated candidate items, dimensions, and response scales. Two field trials tested the psychometric performance of the questionnaire (studies 1 and 2). To test recall error, study 1 subjects were randomly assigned to 2 different questionnaire groups, a questionnaire with a 4-week reporting period completed once or a 2-week version completed twice. Responses were compared with data from concurrent work limitation diaries (the gold standard). To test construct validity, we compared questionnaire scores of patients with those of healthy job-matched control subjects. Study 2 was a cross-sectional mail survey testing scale reliability and construct validity. SUBJECTS: The study subjects were employed individuals (18-64 years of age) from several chronic condition groups (study 1, n = 48; study 2, n = 121) and, in study 1, 17 healthy matched control subjects. MEASURES: Study 1 included the assigned questionnaires and weekly diaries. Study 2 included the new questionnaire, SF-36, and work productivity loss items. RESULTS: In study 1, questionnaire responses were consistent with diary data but were most highly correlated with the most recent week. Patients had significantly higher (worse) limitation scores than control subjects. In study 2, 4 scales from a 25-item questionnaire achieved Cronbach alphas of > or = 0.90 and correlated with health status and self-reported work productivity in the hypothesized manner (P < or = 0.05). CONCLUSIONS: With 25 items, 4 dimensions (limitations handling time, physical, mental-interpersonal, and output demands), and a 2-week reporting period, the Work Limitations Questionnaire demonstrated high reliability and validity.

The quality of physician-patient relationships. Patients' experiences 1996-1999.

BACKGROUND: Our objective was to examine how patients of primary care physicians are responding to a changing health care environment. The quality of their relationship with their primary care physicians and their experience with organizational features of care were monitored over a 3-year period. METHODS: This was a longitudinal observational study (1996-1999). Participants completed a self-administered questionnaire at baseline and at follow-up. The questionnaires included measures of primary care quality from the Primary Care Assessment Survey (PCAS). We included insured adults employed by the Commonwealth of Massachusetts who remained with one primary care physician throughout the study period (n=2383). The outcomes were unadjusted mean scale score changes in each of the 8 PCAS over the 3 years and associated standardized difference scores (effect sizes). The 8 PCAS scales measured relationship quality (4 scales: communication, interpersonal treatment, physician's knowledge of the patient, patient trust) and organizational features of care (4 scales: financial access, organizational access, visit-based continuity, integration of care). RESULTS: There were significant declines in 3 of the 4 relationship scales: communication (effect size [ES] = -0.095), interpersonal treatment (ES = -0.115), and trust (ES = -0.046). Improvement was observed in physician's knowledge of the patient (ES = 0.051). There was a significant decline in organizational access (ES = -0.165) and an increase in visit-based continuity (ES = 0.060). There were no significant changes in financial access and integration of care indexes. CONCLUSIONS: The declines in access and 3 of the 4 indexes of physician-patient relationship quality are of concern, especially if they signify a trend.

Switching doctors: predictors of voluntary disenrollment from a primary physician's practice.

BACKGROUND: Our objective was to evaluate 8 interpersonal and structural features of care as predictors of patients' voluntary disenrollment from their primary care physician's practice. METHODS: We performed a longitudinal observational study in which participants completed a validated questionnaire at baseline (1996) and follow-up (1999). The questionnaire measured 4 elements of the quality of physician-patient relations (communication, interpersonal treatment, physician's knowledge of the patient, and patient trust) and 4 structural features of care (access, visit-based continuity, relationship duration, and integration of care). Study participants were insured adults who reported having a regular personal physician at baseline and who completed both baseline and follow-up questionnaires (n=4108). The outcome measured was voluntary disenrollment from the primary physician's practice between baseline and follow-up. RESULTS: One fifth of the patients voluntarily left their primary physician's practice during the study period. When tested independently, all 8 scales significantly predicted voluntary disenrollment (P <.001), with somewhat larger effects associated with the 4 relationship quality measures. In multivariable models, a composite relationship quality factor most strongly predicted voluntary disenrollment (odds ratio [OR]=1.6; P<.001), and the 2 continuity scales also significantly predicted disenrollment (OR=1.1; P<.05). Access and integration did not significantly predict disenrollment in the presence of these variables. CONCLUSIONS: These findings highlight the importance of relationship quality in determining patients' loyalty to a physician's practice. They suggest that in the race to the bottom line medical practices and health plans cannot afford to ignore that the essence of medical care involves the interaction of one human being with another.

Do patient assessments of primary care differ by patient ethnicity?

OBJECTIVE: To determine if patient assessments (reports and ratings) of primary care differ by patient ethnicity. DATA SOURCES/STUDY DESIGN: A self-administered patient survey of 6,092 Massachusetts employees measured seven defining characteristics of primary care: (1) access (financial, organizational); (2) continuity (longitudinal, visit based); (3) comprehensiveness (knowledge of patient, preventive counseling); (4) integration; (5) clinical interaction (communication, thoroughness of physical examinations); (6) interpersonal treatment; and (7) trust. The study employed a cross-sectional observational design. PRINCIPAL FINDINGS: Asians had the lowest primary care performance assessments of any ethnic group after adjustment for socioeconomic and other factors. For example, compared to whites, Asians had lower scores for communication (69 vs. 79, p = .001) and comprehensive knowledge of patient (56 vs. 48, p = .002), African Americans and Latinos had less access to care, and African Americans had less longitudinal continuity than whites. CONCLUSIONS: We do not know what accounts for the observed differences in patient assessments of primary care. The fact that patient reports as well as the more subjective ratings of care differed by ethnicity suggests that quality differences might exist that need to be addressed.

Adolescents' understanding of social class: a comparison of white upper middle class and working class youth.

PURPOSE: Social class is increasingly being recognized as an important factor in the development of population-based variation in health among teens. However, little consensus exists regarding its measurement or conceptualization. METHODS: This study examined beliefs about social class of 48 working class and 50 upper middle class 16-year-old, white teens. RESULTS: Working class teens were more likely to misclassify themselves with regard to social class position. Significant class differences were present in beliefs regarding social mobility, parents' equity, equality of opportunity within society, and financial status as adults. How this conceptualization of social class translates into population-based variation in health remains an important area for further inquiry.

A national survey of health-related work limitations among employed persons in the United States.

PURPOSE: To estimate the total prevalence of health-related work limitations among working people in the United States (US) as well as their condition-specific prevalence. METHODS: A new questionnaire measuring limitations in ability to perform specific work demands was administered to 940 employed people in a national household survey. The prevalence of specific work limitations is reported as are condition-specific risk estimates (odds ratios) based on logistic regression. RESULTS: In the US, 19.3% of working people (CI = 14.0, 24.6) were limited in their abilities to perform physical work demands; 24.1% (CI = 18.9, 29.2) were limited in performing psychosocial work demands; and 13.8% (CI = 8.3, 19.3) were limited in their abilities to function without difficulty within the ambient work environment. With successive increments in the number of conditions, the odds of having a limitation increased significantly. CONCLUSIONS: This study contributes new information concerning the implications of chronic health problems for working people and the significant risks for workers with multiple chronic conditions.

Part-time physicians. Physician workload and patient-based assessments of primary care performance.

OBJECTIVE: To examine the relationship between the number of hours physicians work and patients' assessment of the physician. DESIGN: Cross-sectional study with physician and patient surveys. SETTING: Primary care practices in Massachusetts. PARTICIPANTS: A random sample of 6810 Massachusetts state employees in 15 different health plans. MAIN OUTCOME MEASURES: Eleven summary scales measuring 7 essential elements of primary care. Information was derived from the Primary Care Assessment Survey, a validated patient-completed questionnaire. RESULTS: Physicians were classified into 3 groups according to their reported hours of work: "overtime" (> 65 h/wk), "full time" (40-65 h/wk), and "part time" (< 40 h/wk). There was no statistically significant difference between the 3 groups of physicians in 10 of the 11 measures of primary care performance. Physicians who worked more than 65 hours per week were found to score significantly higher in the visit-based continuity of care category than physicians working fewer hours. Physicians working more than 65 hours per week were also found to be significantly less satisfied with the amount of time they had for family and personal life than the other 2 groups. CONCLUSIONS: Part-time physicians perform as well as full-time physicians in most aspects of primary care, including all interpersonal aspects of care, as reported by patients. Patients of physicians working more than 65 hours per week experienced higher levels of visit-based continuity of care than patients of physicians working fewer hours, but this appears to carry a cost to those physicians in the area of personal and professional satisfaction. Subsequent research should examine the relationship between physician workload and technical aspects of care.

Organizational and financial characteristics of health plans: are they related to primary care performance?

BACKGROUND: Primary care performance has been shown to differ under different models of health care delivery, even among various models of managed care. Pervasive changes in our nation's health care delivery systems, including the emergence of new forms of managed care, compel more current data. OBJECTIVE: To compare the primary care received by patients in each of 5 models of managed care (managed indemnity, point of service, network-model health maintenance organization [HMO], group-model HMO, and staff-model HMO) and identify specific characteristics of health plans associated with performance differences. METHODS: Cross-sectional observational study of Massachusetts adults who reported having a regular personal physician and for whom plan-type was known (n = 6018). Participants completed a validated questionnaire measuring 7 defining characteristics of primary care. Senior health plan executives provided information about financial and nonfinancial features of the plan's contractual arrangements with physicians. RESULTS: The managed indemnity system performed most favorably, with the highest adjusted mean scores for 8 of 10 measures (P<.05). Point of service and network-model HMO performance equaled the indemnity system on many measures. Staff-model HMOs performed least favorably, with adjusted mean scores that were lowest or statistically equivalent to the lowest score on all 10 scales. Among network-model HMOs, several features of the plan's contractual arrangement with physicians (ie, capitated physician payment, extensive use of clinical practice guidelines, financial incentives concerning patient satisfaction) were significantly associated with performance (P<.05). CONCLUSIONS: With US employers and purchasers having largely rejected traditional indemnity insurance as unaffordable, the results suggest that the current momentum toward open-model managed care plans is consistent with goals for high-quality primary care, but that the effects of specific financial and nonfinancial incentives used by plans must continue to be examined.

Assessing individual outcomes during outpatient multidisciplinary chronic pain treatment by means of an augmented SF-36.

OBJECTIVE: To meet the growing demand for objective outcomes measurement during treatment of chronic pain, we developed an instrument to track outcomes of individual patients. METHOD: In a 2-phase study, existing and novel outcomes instruments were applied in an interdisciplinary pain management program. In the initial phase, 408 patients were administered the Short Form 36-item questionnaire and during phase 2, 437 patients (87 of whom were followed) were given an expanded (191-item) questionnaire. RESULTS: When applied to individual patients, the Short Form 26-item questionnaire lacked measurement reliability for assessment of treatment outcomes and sensitivity to upper extremity or facial pathology, and failed to separate limitations of work versus everyday activity. A novel group of scales derived from responses to 61 questions, including the Short Form 36-item questionnaire, proved sufficiently reliable for routine follow-up of individual chronic pain patients. CONCLUSIONS: This new Treatment Outcomes in Pain Survey allows assessment of individual patient outcomes, and aggregate or individual clinician performance, during interdisciplinary treatment of chronic pain.

Using the "TOPS," an outcomes instrument for multidisciplinary outpatient pain treatment.

OBJECTIVE: To assess the reliability of an augmented SF-36 instrument, the Treatment Outcomes in Pain Survey ("TOPS"), in patients treated in two pain management programs, and present norms for initial values and treatment-related improvements. DESIGN: Prospective case series at two sites with longitudinal follow-up. SETTING: Multidisciplinary, comprehensive outpatient pain treatment centers in university hospitals in Salt Lake City and Boston. PATIENTS: Nine hundred and forty seven adult outpatients with a range of socioeconomic, demographic, and ethnic characteristics, all referred for evaluation and treatment of chronic pain. INTERVENTIONS: Usual practice multidisciplinary pain treatment. OUTCOMES MEASURES: TOPS prior to pain treatment and 5-week nominal follow-up. Means and standard deviations of baseline and follow-up results. Psychometric results for reliability (Cronbach alpha), validity (item discriminant validity, validity coefficients), and related statistical precision measures for group and individual designs. RESULTS: Several measures were precise enough to permit following individual patients in standard clinic treatment, of which the Total Pain Experience dimension was the most powerful. Similar psychometrics were observed in the Boston and Salt Lake City sites. The Pain Symptom, Objective Family/Social Disability, Objective Work Disability, and Upper Body Functional Limitations scales were validated. DISCUSSION: The TOPS was designed to satisfy several models of clinical pain treatment. It successfully monitored treatment based on those models. Not all patients improve with treatment, but most do. The TOPS can be administered in a variety of ways, but we found paper and pencil administration with computer scanning of results quick and efficient for making the data available to clinicians as part of treatment. CONCLUSIONS: The accuracy of the TOPS is sufficient to monitor the response of individual patients during multidisciplinary treatment of chronic pain. The TOPS provides needed documentation (e.g., to third-party payors) of the aggregate value of multidisciplinary outpatient treatment of chronic pain as well as its benefit for individual patients.

The migraine work and productivity loss questionnaire: concepts and design.

Our objectives were to: (1) develop a self-report questionnaire for measuring the impact of migraine headache on work; and (2) qualitatively assess aspects of its performance. Two samples of migraine sufferers provided the data. Sample 1 (n = 18) participated in a structured discussion group designed to elicit examples of migraine's on-the-job impact. Sample 2 (n = 11) completed a mail survey and participated in in-depth phone interviews. Interviews addressed item comprehensibility, consistency of interpretation, the cognitive processes by which certain answers were generated and response burden. The participants were currently employed men and women, at least 18 years of age, who met the International Headache Society (IHS) criteria for migraine headache [1]. Discussion group participants indicated that migraine attacks substantially diminished their job performance. Pain, photophobia, phonophobia, mental impairment and fatigue were perceived as interfering with even routine or relatively simple job tasks. The Migraine Work and Productivity Loss Questionnaire, Version 1.0 (MWPLQ) was written. Next, it was assessed in the context of the in-depth interviews. Result indicated that the MWPLQ was comprehended without difficulty, interpreted consistently and easy to complete. Thus, qualitative results provide initial support for the new questionnaire.

Linking primary care performance to outcomes of care.

BACKGROUND: Substantial research links many of the defining characteristics of primary care to important outcomes; yet little is known about the relative importance of each characteristic, and several characteristics have not been examined. These analyses evaluate the relationship between seven defining elements of primary care (accessibility, continuity, comprehensiveness, integration, clinical interaction, interpersonal treatment, and trust) and three outcomes (adherence to physician's advice, patient satisfaction, and improved health status). METHODS: Data were derived from a cross-sectional observational study of adults employed by the Commonwealth of Massachusetts (N = 7204). All patients completed a validated questionnaire, the Primary Care Assessment Survey. Regression methods were used to examine the association between each primary care characteristic (11 summary scales measuring 7 elements of care) and each outcome. RESULTS: Physicians' comprehensive ("whole person") knowledge of patients and patients' trust in their physician were the variables most strongly associated with adherence, and trust was the variable most strongly associated with patients' satisfaction with their physician. With other factors equal, adherence rates were 2.6 times higher among patients with whole-person knowledge scores in the 95th percentile compared with the 5th percentile (44.0% adherence vs 16.8% adherence, P < .001). The likelihood of complete satisfaction was 87.5% for those with 95th percentile trust scores compared with 0.4% for patients with 5th percentile trust scores (P < .001). The leading correlates of self-reported health improvements were integration of care, thoroughness of physical examinations, communication, comprehensive knowledge of patients, and trust (P < .001). CONCLUSIONS: Patients' trust in their physician and physicians' knowledge of patients are leading correlates of three important outcomes of care. The results are noteworthy in the context of pervasive changes in our nation's health care system that are widely viewed as threatening to the quality of physician-patient relationships.

The Primary Care Assessment Survey: tests of data quality and measurement performance.

OBJECTIVES: The authors examine the data quality and measurement performance of the Primary Care Assessment Survey (PCAS), a patient-completed questionnaire that operationalizes formal definitions of primary care, including the definition recently proposed by the Institute of Medicine Committee on the Future of Primary Care. METHODS: The PCAS measures seven domains of care through 11 summary scales: accessibility (organizational, financial), continuity (longitudinal, visit-based), comprehensiveness (contextual knowledge of patient, preventive counseling), integration, clinical interaction (clinician-patient communication, thoroughness of physical examinations), interpersonal treatment, and trust. Data from a study of Massachusetts state employees (n = 6094) were used to evaluate key measurement properties of the 11 PCAS scales. Analyses were performed on the combined population and for each of the 16 subgroups defined according to sociodemographic and health characteristics. RESULTS: The 11 PCAS scales demonstrated consistently strong measurement characteristics across all subgroups of this adult population. Tests of scaling assumptions for summated rating scales were well satisfied by all Likert-scaled measures. Assessment of data completeness, scale score dispersion characteristics, and inter-scale correlations provide strong evidence for the soundness of all scales, and for the value of separately measuring and interpreting these concepts. CONCLUSIONS: With public and private sector policies increasingly emphasizing the importance of primary care, the need for tools to evaluate and improve primary care performance is clear. The PCAS has excellent measurement properties, and performs consistently well across varied segments of the adult population. Widespread application of an assessment methodology, such as the PCAS, will afford an empiric basis through which to measure, monitor, and continuously improve primary care.

The Angina-related Limitations at Work Questionnaire.

This report describes initial experience with a new self-report questionnaire, the 17 item Angina-related Limitations at Work Questionnaire. Forty employed individuals with chronic stable angina pectoris completed the questionnaire which retrospectively examined the subjects' difficulty in performing specific work activities during the preceding 4 week period. The questionnaire performed well in this study and there was initial evidence of its validity and reliability. More than one-half of the respondents (52.5%) indicated at least some difficulty in performing one or more of the 17 work items due to angina during the preceding 4 weeks, with the greatest difficulty experienced in physically exerting tasks, handling stressful situations and feeling a sense of accomplishment. In contrast, only one-quarter of the sample missed any work time. In tests of convergent validity, the degree of work limitation correlated significantly with SF-36 physical and mental health component scores and with self-reports of angina symptoms. The questionnaire had internal reliability, with item to total score correlations of 0.75 or higher for 14 of the 17 items. In summary, the Angina-related Limitations at Work Questionnaire offers promise for quantifying work limitations among individuals with chronic stable angina.

A longitudinal study of hospitalization rates for patients with chronic disease: results from the Medical Outcomes Study.

OBJECTIVE: To prospectively compare inpatient and outpatient utilization rates between prepaid (PPD) and fee-for-service (FFS) insurance coverage for patients with chronic disease. DATA SOURCE/STUDY SETTING: Data from the Medical Outcomes Study, a longitudinal observational study of chronic disease patients conducted in Boston, Chicago, and Los Angeles. STUDY DESIGN: A four-year prospective study of resource utilization among 1,681 patients under treatment for hypertension, diabetes, myocardial infarction, or congestive heart failure in the practices of 367 clinicians. DATA COLLECTION/EXTRACTION METHODS: Insurance payment system (PPD or FFS), hospitalizations, and office visits were obtained from patient reports. Disease and severity indicators, sociodemographics, and self-reported functional status were used to adjust for patient mix and to compute expected utilization rates. PRINCIPAL FINDINGS: Compared to FFS, PPD patients had 31 percent fewer observed hospitalizations before adjustment for patient differences (p = .005) and 15 percent fewer hospitalizations than expected after adjustment (p = .078). The observed rate of FFS hospitalizations exceeded the expected rate by 9 percent. These results are not explained by system differences in patient mix or trends in hospital use over four years. Half of the PPD/FFS difference in hospitalization rate is due to intrinsic characteristics of the payment system itself. CONCLUSIONS: PPD patients with chronic medical conditions followed prospectively over four years, after extensive patient-mix adjustment, had 15 percent fewer hospitalizations than their FFS counterparts owing to differences intrinsic to the insurance reimbursement system.

Implementation of clinical guidelines using a computer charting system. Effect on the initial care of health care workers exposed to body fluids.

CONTEXT: While clinical guidelines are considered an important mechanism to improve the quality of medical care, problems with implementation may limit their effectiveness. Few empirical data exist about the effect of computer-based systems for application of clinical guidelines on quality of care. OBJECTIVE: To determine whether real-time presentation of clinical guidelines using an electronic medical record can increase compliance with guidelines. DESIGN: Prospective off-on-off, interrupted time series with intent-to-treat analysis. SETTING: University hospital emergency department. SUBJECTS: Patients were 280 health care workers (50 in the baseline control phase, 156 in the intervention phase, and 74 in the postintervention control phase) who presented for initial treatment of occupational body fluid exposures, including 89% (248/280) who sustained punctures and 81% (208/257) who were exposed to blood. Physicians included resident physicians and attending physicians working in the emergency department during the study. INTERVENTIONS: Implementation of a computer charting system that provides real-time information regarding history and recommendations for laboratory testing, treatment, and disposition based on rules derived from clinical guidelines. MAIN OUTCOME MEASURES: Quality of care as determined by essential items documented in the medical record and in aftercare instructions, compliance with testing and treatment guidelines, and total charges and percentage of charges attributable to guideline-endorsed activities. RESULTS: Mean percent documentation of 7 essential items regarding patient history in the medical record increased from 57% during the baseline period to 98% in the intervention phase (42% increase; 95% confidence interval [CI], 34%-49%) and 11 items in aftercare instruction increased from 31 % at baseline to 93% during the intervention phase (62% increase; 95% CI, 51%-74%), but both decreased to baseline when the computer system was removed. Percent compliance with 4 laboratory testing guidelines increased from 63% at baseline to 83% during the intervention phase (20% increase; 95% CI, 9%-31 %) but decreased to 52% when the computer system was removed. Compliance with 5 treatment guidelines increased from 83% at baseline to 96% during the intervention phase (13% increase; 95% CI, 9%-17%) and decreased to 84% following the intervention. Percentage of charges incurred for indicated laboratory tests and treatment increased from 44% at baseline to 81% during the intervention phase (37% increase; 95% CI, 22%-52%) and decreased to 36% following the intervention. Average total per-patient charges were $460, $384, and $373 in each phase, respectively. CONCLUSIONS: Use of a computer-based system for clinical guidelines for management of patients with occupational exposure to body fluids improved documentation, compliance with guidelines, and percentage of charges spent on indicated activities, while decreasing overall charges. The parameters returned to baseline when the computer system was removed.