An incentive approach to physician implementation of medical practice guidelines

We propose a probabilistically based incentive payment system for guideline implementation that provides rewards for physicians who follow practice guidelines and additional remuneration for physician leaders who engage in information sharing. All payments are based on observed outcomes of patient treatment. A fixed base payment forms the core of the system with probabilistic offsets calculated from the chance that a ‘good’ outcome occurs without optimal treatment or information. The system pays different physician types for different task sets. © 1997 John Wiley & Sons, Ltd.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/35158/1/289_ftp.pd

Knowledge of hepatitis C screening and management by internal medicine residents: trends over 2 years

Over 2 million people in the United States are infected with hepatitis C, and there has been an explosion in knowledge regarding this disease in the last decade. Internal medicine residents must be able to identify patients at risk for hepatitis C and institute appropriate diagnostic testing and referral of these patients. Methods : A survey regarding hepatitis C risk factors and the management of hepatitis C patients was administered on three occasions over 15 months (time 0, 1 month, and 15 months) to members of a large university-based internal medicine residency. Results : During the study period 59 residents completed all three surveys. Less than half of the residents (39%) ask patients about hepatitis C risk factors. Only 58% reported that they would refer a hepatitis C antibody positive patient with elevated liver enzymes to a subspecialist on the initial survey. The residents who did not refer patients cited low response rates, high side-effect profiles, and the high cost of therapy as reasons for not referring the patient. There was significant improvement (58% vs 78%, p < 0.01 ) in the rate of patient referral during the 15-month study period but no substantial improvement in the other knowledge deficits. Conclusions : The knowledge base of the internal medicine residents about hepatitis C screening and management is suboptimal. New, more effective hepatitis C education programs for internal medicine residents should be initiated.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/75407/1/j.1572-0241.2002.05708.x.pd

Diffusion of published cost-utility analyses in the field of health policy and practice

OBJECTIVES: The diffusion of cost-utility analyses (CUAs) through the medical literature was examined, documenting visible patterns and determining how they correspond with expectations about the diffusion of process innovations. METHODS: This study used 539 CUAs from a registry. It includes data elements comprising year of publication, the research center in which the study was performed, the clinical area covered by the CUA, and the specific journal. Finally, each paper was assigned to a journal type that could be one of the three categories: health services research, general medicine, or clinical specialty. RESULTS: When the average number of publications is plotted against time, the plot reveals an S-shaped curve. It appears that, whereas CUAs initially were published more frequently in general medical or health services research journals, there was a clear increase in the diffusion of CUA into subspecialty journals over time. The concentration ratio for research centers as measured by the Herfindhal-Hirschman Index decreased over time. CONCLUSIONS: The spread of CUA through the medical literature follows patterns identified for the diffusion of other new technologies and processes. Future research should focus on what impact this spread has had on the practice of medicine and formulation of health policy

Current practice patterns of primary care physicians in the management of patients with hepatitis C

Approximately 4 million Americans are infected with the hepatitis C virus (HCV). Most patients with hepatitis C have no symptoms until cirrhosis is established. Thus, initial diagnosis and management of hepatitis C rely on primary care physicians identifying and screening high-risk individuals. We administered a survey to 1,233 primary care physicians in a health maintenance organization (HMO) in April 1997 to assess their knowledge of the risk factors for HCV infection and approach to the management of 2 hypothetical HCV antibody–positive patients, 1 with elevated and the other with normal alanine transaminase (ALT). Four hundred four (33%) physicians returned the survey. Ninety percent of respondents correctly identified the risk factors for HCV infection, but 20% still considered blood transfusion in 1994 as a significant risk factor for HCV infection. Sixty-two percent of respondents would refer HCV antibody–positive patients with abnormal transaminase levels, but 33% would follow these patients themselves, even though none of the respondents had treated any hepatitis C patient on their own. Forty-three percent of respondents overestimated, while 29% did not know the efficacy of interferon treatment. Sixty-five percent of respondents would retest patients for HCV antibody, regardless of risk factors and transaminase levels. We found that most primary care physicians correctly identified the significant risk factors for HCV infection and appropriately managed the 2 hypothetical patients, but there was considerable confusion about the use of HCV tests and the effectiveness of treatment. Educational programs for primary care physicians are needed to implement hepatitis C screening and to initiate further evaluation and management of those who test positive.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/34775/1/510300328_ftp.pd

Mammography messages in popular media: implications for patient expectations and shared clinical decision-making

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/75005/1/j.1369-6513.2001.00120.x.pd

Using EMS Dispatch to Trigger STEMI Alerts Decreases Door-to-Balloon Times

Introduction: We sought to determine the potential reduction in door-to-balloon time (DTB) by allowing paramedics to perform prehospital ST-Elevation Myocardial Infarction (STEMI) notification using brief communications via emergency medical services (EMS) 9-1-1 dispatchers as soon as they saw a STEMI on 12-lead electrocardiogram (EKG). Our hypothesis was that earlier cardiac catheterization lab (CCL) activation would improve overall DTB and avoid delays arising from on-scene issues or the time required to deliver a full report. Methods: The study setting was a single suburban community teaching hospital, which is a regional percutaneous coronary intervention (PCI) center with more than 120,000 Emergency Department (ED) visits/year and is serviced by a single tiered-response, advanced life support (ALS) paramedic-level agency. STEMI notifications from July 2009 to July 2012 occurred by either standard direct EMS-to-physician notification or by immediate 9-1-1 dispatch notification. In the 9-1-1 dispatcher-aided notification method, paramedics were asked to provide a brief one-sentence report using their lapel microphones upon immediate realization of a diagnostic EKG (usually within 1-2 minutes of patient contact). This report to the 9-1-1 dispatcher included the patient’s sex, age, and cardiologist (if known). The dispatcher then called the emergency department attending and informed them that a STEMI was being transported and that CCL activation was needed. We used retrospective chart review of a consecutive sample of patients from an existing STEMI registry to determine whether there was a statistically significant difference in DTB between the groups. Results: Eight hundred fifty-six total STEMI alert patients arrived by EMS during the study. We excluded 730 notifications due to events such as cardiac arrest, arrhythmia, death, resolution of EKG changes and/or symptoms, cardiologist decision not to perform PCI, arrival as a transfer after prior stabilization at a referring facility or arriving by an EMS agency other than New Castle County EMS (NCC*EMS). Sixty-four (64) sequential patients from each group comprised the study sample. The average DTB (SD) for the standard communication method was 57.6 minutes (17.9), while that for dispatcher-aided communication was 46.1 minutes (12.8), (mean difference 57.6-46.1 minutes=11.5 minutes with a 95% CI [6.06,16.94]) p=0.0001. In the dispatcher-aided group, 92% of patients (59/64) met standards of ≤60 minute DTB time. Only 64% (41/64) met this goal in the standard communication group (p=0.0001). Conclusion: Brief, early notification of STEMI by paramedics through 9-1-1 dispatchers achieves earlier CCL activation in a hospital system already using EMS-directed CCL activation. This practice significantly decreased DTB and yielded a higher percentage of patients meeting the DTB≤60 minutes quality metric. [West J Emerg Med. 2015;16(3):472–480.

Using EMS Dispatch to Trigger STEMI Alerts Decreases Door-to-Balloon Times

Introduction: We sought to determine the potential reduction in door-to-balloon time (DTB) by allowing paramedics to perform prehospital ST-Elevation Myocardial Infarction (STEMI) notification using brief communications via emergency medical services (EMS) 9-1-1 dispatchers as soon as they saw a STEMI on 12-lead electrocardiogram (EKG). Our hypothesis was that earlier cardiac catheterization lab (CCL) activation would improve overall DTB and avoid delays arising from on-scene issues or the time required to deliver a full report. Methods: The study setting was a single suburban community teaching hospital, which is a regional percutaneous coronary intervention (PCI) center with more than 120,000 Emergency Department (ED) visits/year and is serviced by a single tiered-response, advanced life support (ALS) paramedic-level agency. STEMI notifications from July 2009 to July 2012 occurred by either standard direct EMS-to-physician notification or by immediate 9-1-1 dispatch notification. In the 9-1-1 dispatcher-aided notification method, paramedics were asked to provide a brief one-sentence report using their lapel microphones upon immediate realization of a diagnostic EKG (usually within 1-2 minutes of patient contact). This report to the 9-1-1 dispatcher included the patient’s sex, age, and cardiologist (if known). The dispatcher then called the emergency department attending and informed them that a STEMI was being transported and that CCL activation was needed. We used retrospective chart review of a consecutive sample of patients from an existing STEMI registry to determine whether there was a statistically significant difference in DTB between the groups. Results: Eight hundred fifty-six total STEMI alert patients arrived by EMS during the study. We excluded 730 notifications due to events such as cardiac arrest, arrhythmia, death, resolution of EKG changes and/or symptoms, cardiologist decision not to perform PCI, arrival as a transfer after prior stabilization at a referring facility or arriving by an EMS agency other than New Castle County EMS (NCC*EMS). Sixty-four (64) sequential patients from each group comprised the study sample. The average DTB (SD) for the standard communication method was 57.6 minutes (17.9), while that for dispatcher-aided communication was 46.1 minutes (12.8), (mean difference 57.6-46.1 minutes=11.5 minutes with a 95% CI [6.06,16.94]) p=0.0001. In the dispatcher-aided group, 92% of patients (59/64) met standards of ≤60 minute DTB time. Only 64% (41/64) met this goal in the standard communication group (p=0.0001). Conclusion: Brief, early notification of STEMI by paramedics through 9-1-1 dispatchers achieves earlier CCL activation in a hospital system already using EMS-directed CCL activation. This practice significantly decreased DTB and yielded a higher percentage of patients meeting the DTB≤60 minutes quality metric. [West J Emerg Med. 2015;16(3):472–480.

Using EMS Dispatch to Trigger STEMI Alerts Decreases Door-to-Balloon Times

Full text available through open access a