Process evaluation of an educational intervention to improve end-of-life care: the Education for Physicians on End-of-Life Care (EPEC) program.

Despite the growing importance of end-of-life care and the need to improve it, physicians receive little formal training in palliative care. The Education for Physicians on End-of-life Care (EPEC) project, developed by the American Medical Association and the Robert Wood Johnson Foundation, tested a train-the-trainer educational intervention to address this deficiency. This paper presents data from a process evaluation of the initial rollout of EPEC. By all accounts, EPEC provided a state-of-the-art curriculum covering important and clinically relevant topics to the care of the dying patient. It was less clear, however, if EPEC adequately prepared trainees to teach these new skills to other practicing physicians. Factors that may advance efforts to generalize EPEC to other settings and improve future applications of the program are discussed.

Effects of different monetary incentives on the return rate of a national mail survey of physicians.

BACKGROUND: Mail surveys of physicians have been characterized by lower response rates than general population surveys, raising concerns about nonresponse bias. Although monetary incentives have routinely been used to improve survey response among physicians, questions remain regarding how much of an incentive is most cost-effective. The present study seeks to further examine the effects of incentive size on response rates to a national mail survey of physicians. METHODS: This study used a random sample of 873 physicians practicing in the United States; the response rate was 65% (n = 563). Respondents were randomly assigned to receive a $5, $10, or $20 cash incentive in the initial mailing. Except for the magnitude of the incentive, the procedures for each condition were identical, with each respondent receiving up to 3 follow-up mailings and 2 telephone calls. RESULTS: Overall response rates ranged from 60.3% for the $5 incentive category to 68.0% for the $10 incentive category. Differences in overall response rates across the incentive categories, however, were not significant. Higher levels of incentives also did not significantly reduce the number of mail and/or telephone interventions required to reach the target response rate of 60.0%. As expected, aggregate costs (excluding labor) were lowest for the $5 incentive group. CONCLUSIONS: Our findings suggest that changes in the magnitude of incentive do not automatically result in increases in survey response among physicians. Possible reasons for this lack of effect as well as alternatives to monetary incentives are addressed.

Physician manipulation of reimbursement rules for patients: between a rock and a hard place.

CONTEXT: Health plan utilization review rules are intended to enforce insurance contracts and can alter and constrain the services that physicians provide to their patients. Physicians can manipulate these rules, but how often they do so is unknown. OBJECTIVE: To determine the frequency with which physicians manipulate reimbursement rules to obtain coverage for services they perceive as necessary, and the physician attitudes and personal and practice characteristics associated with these manipulations. DESIGN, SETTING, AND PARTICIPANTS: A random national sample of 1124 practicing physicians was surveyed by mail in 1998; the response rate was 64% (n = 720). MAIN OUTCOME MEASURE: Use of 3 different tactics "sometimes" or more often in the last year: (1) exaggerating the severity of patients' conditions; (2) changing patients' billing diagnoses; and/or (3) reporting signs or symptoms that patients did not have to help the patients secure coverage for needed care. RESULTS: Thirty-nine percent of physicians reported using at least 1 tactic "sometimes" or more often in the last year. In multivariate models comparing these physicians with physicians who "never" or "rarely" used any of these tactics, physicians using these tactics were more likely to (1) believe that "gaming the system" is necessary to provide high-quality care today (odds ratio [OR], 3.67; 95% confidence interval [CI], 2.54-5.29); (2) have received requests from patients to deceive insurers (OR, 2.44; 95% CI, 1.72-3.45); (3) feel pressed for time during patient visits (OR, 1.69; 95% CI, 1.21-2.37); and (4) have more than 25% of their patients covered by Medicaid (OR, 1.60; 95% CI, 1.08-2.38). Notably, greater worry about prosecution for fraud did not affect physicians' use of these tactics (P = .34). Of those reporting using these tactics, 54% reported doing so more often now than 5 years ago. CONCLUSIONS: A sizable minority of physicians report manipulating reimbursement rules so patients can receive care that physicians perceive is necessary. Unless novel strategies are developed to address this, greater utilization restrictions in the health care system are likely to increase physicians' use of such manipulative "covert advocacy" tactics.

Substance use patterns among homeless migrants and nonmigrants in Chicago.

This paper uses data abstracted from 465 client records randomly selected from the current files of a downtown medical clinic in Chicago, Illinois to examine substance use among 85 immigrant and 380 nonimmigrant homeless and "at-risk" homeless adults. Immigrants to the United States reported lower levels of current cigarette, alcohol, and drug use compared to nonimmigrants in the sample. Immigrants were also less likely to report potential substance user treatment needs. Immigrants, however, did not differ from nonimmigrants in the reported quantity or frequency of cigarette and alcohol use. Drug use among homeless immigrants was also higher than estimates of misuse in the general population. The literally homeless in the sample reported higher levels of substance use compared to "at-risk" homeless. The literally homeless were also more likely to report higher levels of consumption and were more likely to have potential substance user treatment needs. The role of stress in the etiology of substance misuse among homeless immigrants and nonimmigrants is discussed. Implications for the treatment of these diverse populations are also addressed.

Substance abuse and homelessness: social selection or social adaptation?

Although substance abuse has for many years been documented as a serious problem among homeless populations, there is as yet no clear understanding of the nature of the relationship between substance abuse and homelessness. We evaluate alternative social selection and social adaptation models of this process. Using data from a random probability sample, the substance abuse and homeless experiences of 303 homeless people and people at risk of homelessness in Cook County, Illinois, were investigated. Proportional hazards regression models were employed to assess both social selection and social adaptation models. Drug but not alcohol abuse was associated with first homeless episode. Prior homeless experiences were found to be predictive of first symptoms of both alcohol and drug abuse. Other variables, including the availability of social and economic resources, were also associated with each of these outcomes. Models of both selection and adaptation processes are necessary to account for the association between homelessness and substance abuse, indicating that a multi-directional model is more appropriate. In addition findings suggest that, in recent years, drugs may have displaced alcohol as an important precursor of homelessness for many individuals.