Effects of the revised HCFA evaluation and management guidelines on inpatient teaching.

OBJECTIVE: In 1996, the Health Care Financing Administration (HCFA) introduced new evaluation and management (E&M) guidelines mandating more intensive supervision and documentation by attending physicians. We assessed the effects of the guidelines on inpatient teaching. DESIGN: Pretest-posttest, nonequivalent control group design. SETTING: A university hospital and an affiliated county hospital where the guidelines were implemented and an affiliated VA medical center where they were not. PARTICIPANTS: Sixty-one full-time faculty who had attended on the general medical wards for at least 1 month for 2 of 3 consecutive years prior to July 1996 and for at least 1 month during the 18 following months. MEASUREMENTS AND MAIN RESULTS: We evaluated standardized, confidential evaluations of attending physicians that are routinely completed by residents and students after clinical rotations at all three sites. Comparing 863 evaluations completed before July 1, 1996 and 497 completed after that date, there were no significant differences at any of the hospitals on any items assessed. There were also no differences between the university and county hospitals as compared with the VA. Eighty-seven percent of 39 university and county attending physicians returned a survey about their perceptions of inpatient teaching activities before and after July 1, 1996. They reported highly significant increases in time devoted to attending responsibilities but diminished time spent on teaching activities. CONCLUSIONS: Physicians reported a dramatic increase in overall time spent attending but a decrease in time spent teaching following implementation of the revised E&M guidelines. Yet, evaluations of their teaching effectiveness did not change.

A comprehensive system for quality improvement in ambulatory care: assessing the quality of diabetes care.

A comprehensive state-of-the-art system for quality improvement in ambulatory care has been designed to test (1) whether patients at 8 intervention sites demonstrate improved health status and satisfaction with their care as compared to patients at 8 control sites and (2) the extent to which timely patient self-reported data influences provider practice patterns. During the study pilot period, several investigators developed, tested and analyzed disease-specific questionnaires for 7 common chronic conditions. An advanced automated information system was designed to link hospital computer information and patient questionnaire data in order to provide timely communication between patients and providers about important health problems. This report briefly describes the 3-year quality of ambulatory care clinical trial and details the development and pilot testing of the disease specific questionnaire for diabetes. Reliability testing showed correlations were higher for fixed events such as foot ulcers than for subjective judgments such as satisfaction with providers. Responsiveness testing indicated that this questionnaire could measure behavior and care modifications in patients 6 months following an outpatient education course, compared to the baseline pre-education values. Diabetes severity information has been collected from self-administered questionnaires and laboratory data to assist providers in assessing the patients' likelihood of 4-year mortality. It is anticipated that the rapid identification of important patient issues will assist patients and clinicians in mutually addressing and resolving health care problems, thereby improving the quality of outpatient care.