The effect of education and drug samples on antihistamine prescribing costs in an HMO.

OBJECTIVE: To examine the effect of an intervention designed to reduce antihistamine prescribing costs in an HMO. DESIGN: A quasi-experimental design with clinicians at one HMO site receiving an intervention. Their prescribing behavior before and after the intervention was compared to the prescribing behavior of clinicians at other HMO sites in a non-randomized control group. SETTING: A mixed model HMO in metropolitan Washington, DC. PARTICIPANTS: Group model clinicians at a single site received the intervention; network and group model clinicians at other sites composed the control group. INTERVENTION: An education memo addressed to clinicians discussing antihistamine prescribing costs and strategies for initial use of nonprescription or less expensive prescription agents, coupled with free antihistamine sample "trial packs" for patient use. OUTCOME MEASURE: The prescribing costs of the intervention group were compared to the prescribing costs of the non-randomized control group. The intervention group was surveyed regarding their attitudes toward the intervention. RESULTS: A 2% decline in costs was noted between the baseline and intervention year for both the intervention and control groups. Though clinicians indicated they were well disposed toward the intervention, they believe patient expectations were a major obstacle to the use of cheaper agents. CONCLUSION: We conclude that an effective intervention would require the targeting of major patient-related barriers to clinician behavior change.

HMO physician attitudes toward drug cost containment strategies.

OBJECTIVE: To compare network and group model physician attitudes toward prescription drug cost containment strategies. DESIGN: Mailed survey with two reminders for non-respondents. SETTING: Mixed model (network and group) HMO in metropolitan Washington, DC. MAIN OUTCOME MEASURE: Response on agreement scale to questions regarding receptivity to drug cost containment strategies. PARTICIPANTS: All primary care providers (N = 311) affiliated with the George Washington University Health Plan. The response rate was 78% (N = 243). RESULTS: Almost all clinicians believed that education and feedback were appropriate methods to control costs in an HMO. Network physicians were significantly less likely to agree with more intrusive administrative interventions. Both groups generally believed that patient expectations often dictate more costly prescribing than is necessary. CONCLUSIONS: Managed care physicians were generally amenable to cooperative behavior change strategies (i.e., education and feedback) and often opposed to mandated administrative or incentive approaches, especially physicians from the network setting. It remains to be seen whether use of cooperative methods to promote cost-conscious physician behavior can result in substantial savings.

The effect of an education and feedback intervention on group-model and network-model health maintenance organization physician prescribing behavior.

The authors evaluated the effect of an educational and feedback intervention on H2-blocker prescribing patterns and determined, if such effects differed for network- versus group-model health maintenance organization (HMO) physicians and in academic versus nonacademic settings. Physicians were randomized to receive an educational memorandum alone or combined with feedback regarding their individual prescribing behavior. The memo suggested preferred use of an H2-blocker (cimetidine) that would be less expensive to the HMO. Prescribing was monitored during the 6 months before and after the intervention. The study was undertaken at the primary care practices of a mixed group- and network-model university-affiliated HMO. Thirty group-model (at two academic and four nonacademic sites) and 33 network-model (all in full-time private practice) primary care physicians participated in the study. The analysis utilized weighted and unweighted analysis of covariance of the change in physicians' cimetidine-prescribing rates between the baseline and study periods. A significant response to the intervention was noted among academic and nonacademic group-model HMO physicians, but not among network physicians (adjusted mean absolute prescribing changes of +9.9% and +8.9% versus -2.8%, P = .02). There was no difference in prescribing change based on type of intervention (education versus feedback). The authors conclude that a simple passive educational intervention can be effective at changing group-model HMO physician behavior.

Association between physician counseling for hypercholesterolemia and patient dietary knowledge.

High blood cholesterol is a prime target for preventive intervention in the primary care setting; however, the current effectiveness of clinicians at educating their patients about appropriate dietary modification is questionable. This report examines the association between dietary knowledge and physician counseling among primary care patients with hypercholesterolemia. Subjects were 325 patients continuously enrolled in one of two group model HMO offices for two years following a screening cholesterol level above 200 mg/dL. One office had American Heart Association educational materials and training in its use; one offered usual care. A chart audit and telephone survey (response 59%) 18 months following the screening cholesterol assessed clinician counseling and cholesterol monitoring as well as patient knowledge (from 14-item survey), attitudes, and behavior. Multiple linear regression analysis revealed no association between patient knowledge and physician dietary counseling (P = .53). Only patient educational background (P = .03) and baseline dietary knowledge (P = .005) independently predicted subsequent dietary knowledge. When added to the model, self-reported dietary change was also independently associated with patient knowledge (P = .0003). Though public awareness of cholesterol as a risk factor for heart disease has dramatically increased in recent years, specific dietary knowledge is often lacking. This article questions the adequacy of current primary care dietary treatment efforts in this regard.

Utilization of medical services for the treatment of acute low back pain: conformance with clinical guidelines.

OBJECTIVE: To assess the utilization of diagnostic and therapeutic medical services for the management of acute low back pain in a primary care setting, and to determine whether such utilization conforms to suggested guidelines for the management of this condition. STUDY DESIGN: A retrospective chart audit of consecutive cases of acute low back pain. Specific elements of the diagnostic and therapeutic approach were judged appropriate or inappropriate based on comparison with published recommendations supported by the medical literature. SETTING: The primary care adult practice of a university-affiliated health maintenance organization. PATIENTS: One hundred eighty-three patients presenting with acute low back pain of musculoskeletal origin. MEASUREMENTS AND MAIN RESULTS: According to suggested guidelines for the care of acute low back pain, 26% of plain lumbar x-rays (10/38), 66% of computed tomography (CT) and magnetic resonance imaging (MRI) scans (12/18), and 82% (23/28) of subspecialty referrals were categorized as inappropriate. Among patients without indications for these services, 12% (10/85) had received lumbar x-rays, 7% (12/168) had received lumbar MRI or CT scans, and 14% (23/168) had received subspecialty referrals. Underutilization of these services had occurred in 71% (70/98) of patients with an indication for plain lumbar radiography, and 47% (7/15) of patients with potential indications for surgical referral or CT/MRI scanning. Neither overutilization nor underutilization had led to adverse outcomes or delays in diagnosis in this small sample. CONCLUSIONS: According to guidelines from the medical literature, the primary care physicians in this study both overutilized and underutilized diagnostic and referral services in cases of acute low back pain. It is necessary to determine whether underutilization of plain lumbar radiography adversely affects diagnostic accuracy and whether overutilization of other services improves important clinical outcomes, given the generally benign natural history of this condition.

Self-reported versus actual test ordering behavior among primary care clinicians.

To determine the accuracy of clinician self-reports, 38 clinicians were surveyed in a university-based health maintenance organization (HMO) practice on their thyroid function testing (TFT) patterns one year after the distribution of an educational intervention (the intervention). The mean of the absolute difference between self-reported and actual test ordering rates was 12%; the difference was greater than 20% for only 3 of 33 clinicians who ordered TFT for at least five patients during the study period. A strong association was found between self-reported change and the actual mean change in TFT postintervention ordering rates (p less than 0.0001). Results suggest that clinicians, at least in certain settings, can accurately estimate their utilization patterns and the effect of practice guidelines.

Magnetic resonance imaging. Diffusion of technology in an ambulatory setting.

To better understand technology diffusion in an ambulatory care setting, we analyzed adult outpatients' use of magnetic resonance (MR) and computed tomography (CT) imaging in a group-model HMO between 1986 and 1989. The use of MR, but not CT, increased at a rapid pace with only a small proportion of the scans being accounted for by primary care physicians.

Effect of education and feedback on thyroid function testing strategies of primary care clinicians.

We examined the effect of an educational memorandum incorporating simple guidelines for thyroid function testing on test utilization in a primary care health maintenance organization practice. We then compared the effectiveness of a reminder alone or combined with individual test ordering feedback at maintaining an effect. The subjects were 17 physicians and 13 physician assistants and nurse practitioners separated into two similar study groups with little clinical interaction. Both groups responded to the education with increased compliance (from 36% to greater than 67%) with the recommended testing strategy. The group subsequently receiving only a reminder showed a further increase in compliance from 68% to 81% at 6 months and 79% at 12 months. The group receiving a reminder and feedback showed no subsequent change in testing pattern (65% compliance before the reminder-feedback and 64% at both subsequent measurements). The effect of the educational intervention was greater on nurse practitioners and physician assistants than physicians (absolute increase in compliance, 63% vs 28%). We conclude that education can be an effective tool for modifying clinician testing patterns to conform to simple clinical guidelines. Further study of the effect of education and other strategies on compliance with more complex guidelines is needed.

Primary care clinician compliance with cholesterol treatment guidelines.

OBJECTIVE: To determine the rate and predictors of clinician compliance with treatment guidelines for high cholesterol in a primary care practice and establish quality assurance thresholds for monitoring patient management. DESIGN: Retrospective chart audit one year after high (greater than 240 mg/dL) cholesterol level. PATIENTS: 257 (243 after exclusions) consecutive patients with serum cholesterol levels greater than 240 mg/dL. SETTING: Primary care practice of group-model university-based HMO. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In the one-year interval following the index elevated cholesterol level, 67% of 243 patients had received documented dietary counseling, 53% had had a follow-up cholesterol test, and 8% were started on drug treatment. Only two patients (1.8%) without a history of hypercholesterolemia prior to the index level were started on drug treatment, compared with 18 patients (15%) with such a history. The odds (and 95% confidence intervals) of patient dietary counseling increased twofold (1.35 to 2.95) for each 25-mg/dL increment in serum cholesterol, and by 1.45 times (1.12 to 1.87) for each additional coronary risk factor. Patients who had high cholesterol levels obtained as isolated determinations had 2.46 times (1.32 to 4.64) higher odds of being followed by counseling than did those whose levels had been obtained as part of a chemistry panel. CONCLUSIONS: Compliance with National Cholesterol Education Panel guidelines for dietary counseling, but not drug therapy, was higher in this setting than in other published compliance studies. Quality assurance monitoring of compliance with dietary counseling and obtaining lipid measurements using a threshold approach are suggested. A similar approach to drug therapy of hypercholesterolemia appears premature.