Physician practice change I: a critical review and description of an Integrated Systems Model.

The long lag time between medical discovery and when Americans benefit from that discovery has a huge cost in terms of morbidity and mortality. Medicine needs more effective methods for moving discovery to practice. In this article, the authors first offer a critical review of the models of structure and change process gleaned from the physician change literature. Next, they describe the Integrated Systems Model (ISM) that they derive from this review. The ISM has four major components: superstructure, change motivators, change process, and functional interactions. The ISM considers the physician practice to operate as a complex adaptive system requiring diversion of resources from reserves to make a change. In the ISM, resource return is a function of improved quality of care and reimbursement for services. Changes decreasing the resources of the system (parasitic) will be harder to make than those that increase resources (symbiotic) because of resistance to resource loss. The authors extend the ISM to the individual level and describe the need to consider whether individuals within the practice have sufficient reserves to fulfill their part in making the change. Any given change is generally competing with other changes for adoption. Finally, the authors consider the strengths and weaknesses of their model, concluding that by keeping patient welfare, quality care, and finances in the forefront, the ISM provides a more complete picture of forces affecting medical practice change.

Physician practice change II: implications of the Integrated Systems Model (ISM) for the future of continuing medical education.

In a companion paper, the authors provide the development and description of the Integrated Systems Model (ISM). In this article, they describe 14 general implications of the ISM for continuing medical education (CME). They discuss how applying the ISM would change CME by describing (1) how CME and the larger health care environment would be restructured if they were based on the ISM and (2) how the ISM would impact CME under the current environment of health care in the United States. They close by describing how the ISM can be used as CME moves to address the long lag between discovery and practice and begins to decrease its dependence on pharmaceutical companies. The ISM helps not only explain why the current health care system in the United States (or anywhere) produces what it produces, but also predict what that system would produce if it changed. At present, the ISM is a conceptual model, but with more research into measures of its various elements, it could become a more quantitatively predictive model. In its present form, however, the ISM can serve Marinopoulos's call for a "sound conceptual model of what influences the effectiveness of CME" and address Grimshaw's concern that current research lacks "a theoretical base to support the choice and development of interventions as well as the interpretation of study results." The statistician George Box said, "All models are wrong, some models are useful." The authors believe that the ISM is useful and that maybe it will prove Box wrong.

Are patients who use a generalist physician healthier than those who seek specialty care directly?

BACKGROUND: American health care consumers want the option of seeing specialists whenever they wish, but given this option, do they in fact use it without consideration of their health status? This paper reports on a cross-sectional analysis that compares the demographics and health status of fee-for-service Medicare enrollees who exhibited four different patterns of physician access. METHODS: The Medicare Beneficiary Survey data from 1998 were used. Subjects ages 65 and older were categorized into one of four groups: those with no physician claim, those who saw a generalist only, those who saw a specialist only, and those who saw both. Age, income, education, health status, level of impairment, and disease burden for the four patient groups were compared using ANOVA. Urban/rural status, race, ethnicity, mortality rates, and gender for the four patient groups were compared using chi-square. A predictive model using mutinomial logistic regression was created. RESULTS: Twelve percent of subjects saw no physician in 1998, 11.6% saw a generalist only, 14.2% visited a specialist only, and 62.1% visited both types of physicians. Subjects who saw both physician types had significantly worse health status and more chronic diseases than the other groups. Subjects who saw generalists only or specialists only had intermediate levels of health status and disease burden that were not significantly different from each other. Subjects who saw a specialist only were the most affluent and highly educated group. Subjects who saw no physician had the best health status and the fewest chronic diseases of all subject groups. Urban residents were more likely to visit some type of physician than were rural residents and were more likely to see a specialist only. Regional differences were noted, with New England showing the highest rates of specialist only use. DISCUSSION: As expected, the healthiest subjects were least likely to visit any health care provider. Subjects with the worst health status were likely to access both generalists and specialists for their care. Subjects who visited a specialist only had higher incomes, more education, and urban residence but no difference in health status when compared to subjects who visited a generalist only.

Predictors of influenza immunization in persons over age 65.

BACKGROUND: Numerous individual characteristics have been found to be associated with rates of obtaining flu shots. This study creates a predictive model that assesses the relative impact of each of these factors on increasing rates of flu shots in a population. METHODS: The Medicare beneficiary survey from 1998 and 1999 was used. Sixteen factors present in 1998 were compared between subjects who did and who did not receive flu shots. Significant factors were then used in a logistic regression to predict the probability of receiving a flu shot in 1998 and 1999. RESULTS: Seven demographic and 7 health status measures were significantly different between subjects who did and who did not receive flu shots in 1998. Logistic regression showed that twelve of these variables were associated with a subject receiving a flu shot in 1998 and explained 11.4% of the variability in who did and who did not receive a flu shot. For the following year, 1999, 7 measures were significantly associated with receiving a flu shot and explained 64% of the variability in who did and who did not receive a flu shot. One variable, if the subject had received a flu shot in 1998, was highly predictive of a subject receiving a flu shot in 1999, explaining 63% of the observed variability in who did and who did not receive a flu shot in 1999. DISCUSSION: The major predictor of getting a flu shot in future years is having received one in the current year (63% of predictive power). Six other behavior and demographic factors increase the predictive power modestly. Programs that target nonrecipients may increase the overall flu shot rates of a community.

Who provides care to Medicare beneficiaries and what settings do they use?

BACKGROUND: Concerns have been expressed that the physician workforce is unprepared for the explosion in the number of older persons in America. As a step toward informing these discussions, this article will describe how Medicare beneficiaries currently access physician services. METHODS: This study is a descriptive analysis of the physician services used by Medicare beneficiaries. The Medicare Beneficiary Survey (MCBS) data from 1998 are used for the analysis. The locations of service delivery were compared among family physicians, general internists, and geriatricians. RESULTS: The physician office was the most common site of service, comprising 49% of all provider claims. General internists (20.1% of office claims) and family physicians (18.6% of office claims) were the most common providers. Family physicians spent the largest proportion of their time in the office (77%), general internists were the most likely provider to see patients in the hospital (19%), and geriatricians were the most likely to see patients in the nursing home (27%) and at home (1.7%). CONCLUSIONS: Office-based care by general internists and family physicians constitute a major infrastructure element in the delivery of care to Medicare beneficiaries. The practices of geriatric medicine physicians are more heavily weighted toward the nursing home setting.

Curricular framework: core competencies in multicultural geriatric care.

Strategies to reduce the documented disparities in health and health care for the rapidly growing numbers of older patients from diverse ethnic populations include increased cultural competence of providers. To assist geriatric faculty in medical and other health professional schools develop cultural competence training for their ethnogeriatric programs, the University of California Academic Geriatric Resource Program partnered with the Ethnogeriatric Committee of the American Geriatrics Society to develop a curricular framework. The framework includes core competencies based on the format of the Core Competencies for the Care of Older Patients developed by the Education Committee of the American Geriatrics Society. Competencies in attitudes, knowledge, and skills for medical providers caring for elders from diverse populations are specified. Also included are recommended teaching strategies and resources for faculty to pursue the development of full curricula.

Implementing an incontinence management protocol in long-term care. Clinical outcomes and costs.

This article describes clinical outcomes and costs of implementing an incontinence management protocol based on the recommendations contained in the Agency for Health Care Quality and Research clinical practice guidelines on incontinence and pressure ulcer prevention. Following implementation of the protocol, 63 nursing home residents were followed for 6 months and assessed for the presence of wetness or pressure ulcers. Facility costs for incontinence management were accumulated. Fifty-four percent of the residents (34 of 63) received treatments for incontinence and 60% (20 of 34) became dry. Pressure ulcer rates decreased from 16 participants developing 26 pressure ulcers to 3 participants developing 5 ulcers. Facility cost of incontinence management for 6 months was $86,436 with 46% attributed to direct labor costs. Toileting was the most expensive component, costing $36,755. Total daily cost of incontinence management was $573 ($9.09 +/- 10.52 per resident). Implementation of the incontinence protocol resulted in improved "dryness" of the participants and reduced pressure ulcer incidence.

A strategy for teaching students concepts of population-based health care for older persons.

The authors present a strategy for organizing and teaching the concepts of population-based health care for patients over the age of 65. The key ingredients are a case study based on a representative sample of 5,000 Medicare recipients and a student guide containing the sample group's demographics, clinical characteristics, and utilization patterns. As part of the case study, three subgroups within the sample are described: the basically healthy 50% that consume only 3% of medical resources, the most severely ill 10% that consume 70% of medical resources, and the moderately ill 40% that consume the remaining 27% of medical resources. These categories introduce the concepts of severity of illness, highlight the clinical challenges facing providers of care to the elderly, and contrast the divergent needs of individual health care consumers in an aging population. Armed with this succinct and manageable information packet, students are asked to play the role of an interdisciplinary team that is responsible for effectively managing the care of this population of 5,000 lives. Included in this article is a description of learning resources provided; sample group discussion questions; one strategy for caring for the population developed by a faculty-student group; and a brief description of the educational implications of the model. At the end of the article the reader is provided a Web address containing a description of the case and supporting materials (http://healthyaging.ucdavis.edu/education/continuing/ManagedMedicareTeachingCase.pdf). Readers are invited to view, print, and/or utilize the case in their own academic settings.

Improving efficiency in a residency training clinic: results from addressing a root cause of inefficiency.

BACKGROUND: Since the early 1980s, primary care teaching clinics have repeatedly been reported to be inefficient. This paper describes the results of a 5-year effort to improve the efficiency of our residency teaching clinic. METHODS: This 5-year longitudinal tracking study of a clinic monitored monthly patient volume, number of providers scheduled per half day, and patient satisfaction with waiting times while interventions occurred to improve clinic efficiency. RESULTS: Prior to rigorously tracking the number of providers in clinic, monthly clinic patient volume increased temporarily (1998-1999) but fell back to baseline the following year. Variation in the number of providers in clinic explained nearly half the variability in the number of patients seen. After beginning a process of tracking and proactively optimizing the number of providers in clinic per half day, patient volumes increased significantly and stabilized at the higher levels. Patient satisfaction with waiting time improved slightly. CONCLUSIONS: Tracking and optimizing a single operational variable can improve clinic performance significantly. Reducing the variation in the number of providers scheduled to see patients toward an optimum number based on the number of available exam rooms resulted in sustainable increases in the number of patients seen without any negative impact on the patient satisfaction with waiting times.