Implementation of local guidelines for cost-effective management of hypertension. A trial of the firm system

Development of a Multistep Hypertension Quality Improvement Program in an Academic General Medicine Practice

Hypertension is a common problem and a major risk factor for cardiovascular disease. It is unclear whether efforts to control blood pressure (BP) known to be effective in integrated healthcare systems can be successfully implemented in an academic setting. We describe our experience implementing a multistep quality improvement program within an academic general medicine practice aimed at improving BP among patients with uncontrolled hypertension. Ensuring medical assistants were correctly measuring BP provided the basis for accurate data entry into the electronic medical record (EMR); our EMR-based registry data allowed us to feedback primary care provider (PCP) level data on BP control for panel management, which resulted in improvements in BP for a substantial proportion of patients, particularly for those with more practice visits. However, due to PCP, patient, and system barriers, our initial attempt to integrate a pharmacist into our team for hypertension management was only successful for a small number of patients who engaged in pharmacist in-person visits. Future improvement efforts will focus on addressing the barriers to more intensive BP management, integrating lessons from this experience. As chronic disease management shifts to a population-based model, team change will be a necessary component for achieving clinical improvement.

A Collaborative Initiative to Improve the Care of Elderly Medicare Patients With Hypertension

Qualidigm, the Connecticut Quality Improvement Organization (QIO), collaborated with 17 primary care physicians (PCPs) in private practice to improve the care of elderly patients with hypertension. Patients were identified from Medicare billing data and care was assessed from medical records. Improvement interventions included feedback of baseline performance data and provision of a variety of practice enhancing materials. Care was assessed for 590 patients in 1997 (16-47 patients/PCP) and 547 patients in 1999 (7-51 patients/PCP). Patient characteristics were similar in both periods. Use of recommended therapies and blood pressure control, ie, percent < 140/90 mm Hg, was low and did not improve significantly between the 2 periods (aggregate 39% in 1997 versus 42% in 1999; P = .24). Care of elderly patients with hypertension was not improved with a multifaceted QIO intervention. Additional study is required to determine incentives, barriers, and facilitating factors for quality improvement in the private practice primary care setting.

A partnered approach to opioid management, guideline concordant care and the stepped care model of pain management

BACKGROUND

Pain is the most common presenting problem in primary care. Opioid therapy (OT) for chronic pain has increased dramatically over the past decade, as have related negative outcomes. Despite the development and dissemination of policy and clinical practice guidelines for pain management and OT, adoption has been variable. The Veterans Health Administration (VHA) has established a Stepped Care Model of Pain Management (SCM-PM) as an evidence-based framework and single standard of pain care to promote guideline-concordant care, but to date its adoption and related outcomes have not been systematically examined.

OBJECTIVE

Our aim was to examine changes in care for Veterans receiving long-term OT for management of chronic pain over a four-year study period.

DESIGN

As part of a comprehensive implementation evaluation of performance improvements, the current evaluation reports performance improvement outcomes related to pain management and OT over a four-year period.

SUBJECTS

We studied Veterans receiving long-term (90+ consecutive days) OT through primary care.

INTERVENTIONS

We engaged an interdisciplinary clinical-research team to develop and implement a multifaceted performance improvement approach that included interactive educational strategies and other organizational initiatives.

MAIN MEASURES

We measured the proportion of patients receiving long-term OT; use of opioid risk mitigation strategies; referrals to pain-related specialty services; and use of non-opioid analgesics.

KEY RESULTS

The proportion of patients receiving high-dose opioids decreased over four years (27.7 % to 24.7 %). The use of opioid risk mitigation strategies increased significantly. Referrals to physical therapy and chiropractic care and prescriptions for topical analgesics increased significantly, while referrals to the pain medicine specialty clinic decreased.

CONCLUSIONS

We demonstrate improvements in the management of veterans receiving OT that are consistent with the SCM-PM and published practice guidelines. We highlight how partnerships among funders, researchers, clinicians, and administrators contributed to the project's design and implementation, and to the dissemination strategy and future directions for improving opioid management and pain care.

Development and application of an electronic health record information extraction tool to assess quality of pain management in primary care

Chronic pain is one of the most common presenting problems in primary care. Standards and guidelines have been developed for managing chronic pain, but it is unclear whether primary care providers routinely engage in guideline-concordant care. The purpose of this study is to develop a tool for extracting information about the quality of pain care in the primary care setting. Quality indicators were developed through review of the literature, input from an interdisciplinary panel of pain experts, and pilot testing. A comprehensive coding manual was developed, and inter-rater reliability was established. The final tool consists of 12 dichotomously scored indicators assessing quality and documentation of pain care in three domains: assessment, treatment, and reassessment. Presence of indicators varied widely. The tool is reliable and can be utilized to gather valuable information about pain management in the primary care setting.

Improved blood pressure control associated with a large-scale hypertension program

IMPORTANCE

Hypertension control for large populations remains a major challenge.

OBJECTIVE

To describe a large-scale hypertension program in Northern California and to compare rates of hypertension control in that program with statewide and national estimates.

DESIGN, SETTING, AND PATIENTS

The Kaiser Permanente Northern California (KPNC) hypertension program included a multifaceted approach to blood pressure control. Patients identified as having hypertension within an integrated health care delivery system in Northern California from 2001-2009 were included. The comparison group comprised insured patients in California between 2006-2009 who were included in the Healthcare Effectiveness Data and Information Set (HEDIS) commercial measurement by California health insurance plans participating in the National Committee for Quality Assurance (NCQA) quality measure reporting process. A secondary comparison group was included to obtain the reported national mean NCQA HEDIS commercial rates of hypertension control between 2001-2009 from health plans that participated in the NCQA HEDIS quality measure reporting process.

MAIN OUTCOMES AND MEASURES

Hypertension control as defined by NCQA HEDIS.

RESULTS

The KPNC hypertension registry included 349,937 patients when established in 2001 and increased to 652,763 by 2009. The NCQA HEDIS commercial measurement for hypertension control within KPNC increased from 43.6% (95% CI, 39.4%-48.6%) to 80.4% (95% CI, 75.6%-84.4%) during the study period (P < .001 for trend). In contrast, the national mean NCQA HEDIS commercial measurement increased from 55.4% to 64.1%. California mean NCQA HEDIS commercial rates of hypertension were similar to those reported nationally from 2006-2009 (63.4% to 69.4%).

CONCLUSIONS AND RELEVANCE

Among adults diagnosed with hypertension, implementation of a large-scale hypertension program was associated with a significant increase in hypertension control compared with state and national control rates. Key elements of the program included a comprehensive hypertension registry, development and sharing of performance metrics, evidence-based guidelines, medical assistant visits for blood pressure measurement, and single-pill combination pharmacotherapy.

Evaluation of the agreement between guidelines and initial antihypertensive drug treatment using a national health care reimbursement database

RATIONALE, AIMS AND OBJECTIVES

To test the agreement between guidelines for the management of hypertension and medical practices while avoiding frequent limitations such as the use of non-representative samples of practitioners and self-reporting of their practices over a short period of time.

METHODS

The characteristics of initial antihypertensive drug treatment in a large representative sample of the French population aged 50-80 (n = 17 855) were collected from a national health care reimbursement database and compared with national guidelines over a 5-year period.

RESULTS

Major discrepancies are observed including the use of non-recommended drug classes such as loop and potassium sparing diuretics alone or in association and the absence of distinction between patients according to their age. More minor discrepancies are the preferential use of mono-therapies over drug combinations and of some bi-therapies among those recommended. Some degree of concordance with the guidelines is also observed including the specific characteristics of the treatment of diabetics compared with other categories of patients and the preferential use of long-acting dihydropyridine calcium antagonists and of low-dose thiazide diuretics when these drug classes are chosen. Several of these discrepancies or concordances, which mainly reflect general practitioner (GP) activity, show time trends over the entire follow-up period with no significant effect of the guideline released during this period.

CONCLUSIONS

At the French national level, the agreement between initial antihypertensive drug treatment and guidelines varies considerably depending on the characteristics of the treatment that are considered. The GPs who delivered the treatment do not seem to have been influenced by the guidelines released over the last decade.

Effect of general practitioner education on adherence to antihypertensive drugs: cluster randomised controlled trial

OBJECTIVE

To determine the impact of a simple educational package for general practitioners on adherence to antihypertensive drugs.

DESIGN

Cluster randomised controlled trial.

SETTING

Six randomly selected communities in Karachi, Pakistan.

PARTICIPANTS

200 patients with hypertension taking antihypertensive drugs; 78 general practitioners.

INTERVENTION

Care by general practitioners specially trained in management of hypertension compared with usual care.

MAIN OUTCOME MEASURE

Correct dosing, defined as percentage of prescribed doses taken, measured with electronic medication event monitoring system (MEMS) bottle.

RESULTS

200 patients were enrolled, and 178 (89%) successfully completed six weeks of follow-up. Adherence was significantly greater in the special care group than in the usual care group (unadjusted mean percentage days with correct dose 48.1%, 95% confidence interval 35.8% to 60.4%, versus 32.4%, 22.6% to 42.3%; P=0.048). Adherence was also higher among patients who had higher levels of education (P<0.001), were encouraged by family members (P<0.001), believed in the effect of drugs (P<0.001), and had the purpose of the drugs explained to them (P<0.001).

CONCLUSIONS

Special training of general practitioners in management of hypertension, emphasising good communication between doctors and patients, is more effective than usual care provided in the communities in Karachi. Such simple interventions should be adopted by other developing countries that are now facing an increasing burden of hypertension.

TRIAL REGISTRATION

Clinical trials NCT00330408 [ClinicalTrials.gov].

Economic analysis of a randomized trial of academic detailing interventions to improve use of antihypertensive medications

The authors estimated the costs and cost savings of implementing a program of mailed practice guidelines and single-visit individual and group academic detailing interventions in a randomized controlled trial to improve the use of antihypertensive medications. Analyses took the perspective of the payer. The total costs of the mailed guideline, group detailing, and individual detailing interventions were estimated at 1000 dollars, 5500 dollars, and 7200 dollars, respectively, corresponding to changes in the average daily per person drug costs of -0.0558 dollars (95% confidence interval, -0.1365 dollars to 0.0250 dollars) in the individual detailing intervention and -0.0001 dollars (95% confidence interval, -0.0803 dollars to 0.0801 dollars) in the group detailing intervention, compared with the mailed intervention. For all patients with incident hypertension in the individual detailing arm, the annual total drug cost savings were estimated at 21,711 dollars (95% confidence interval, 53,131 dollars savings to 9709 dollars cost increase). Information on costs of academic detailing could assist with health plan decision making in developing interventions to improve prescribing.

Effectiveness of a two-part educational intervention to improve hypertension control: a cluster-randomized trial

STUDY OBJECTIVE

To measure the effectiveness of a multifaceted educational intervention to improve ambulatory hypertension control.

DESIGN

Cluster-randomized trial.

SETTING

Academic health system using an ambulatory electronic medical record.

SUBJECTS

A total of 10,696 patients with a diagnosis of hypertension cared for by 93 primary care providers.

INTERVENTION

Academic detailing, provision of provider-specific data about hypertension control, provision of educational materials to the provider, and provision of educational and motivational materials to patients.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was blood pressure control, defined as a blood pressure measurement below 140/90 mm Hg, and was ascertained from electronic medical records over 6 months of follow-up. We determined the adjusted odds ratio for the association between the intervention and the achievement of controlled blood pressure. When we accounted for clustering by provider, this adjusted odds ratio was 1.13 (95% confidence interval 0.87-1.47). Adjusted odds ratios were 1.03 (95% confidence interval 0.78-1.36) in patients whose blood pressure was controlled at baseline and 1.25 (95% confidence interval 0.94-1.65) in those whose blood pressure was not. These odds ratios were not significantly different (p=0.11).

CONCLUSIONS

These results were consistent with no effect or, at best, a relatively modest effect of the intervention among patients with hypertension. Had we not included a concurrent control group, the data would have provided an unduly optimistic view of the effectiveness of the program. The effectiveness of future interventions may be improved by focusing on patients whose blood pressure is uncontrolled at baseline.

The relationship between organisational characteristics and the effects of clinical guidelines on medical performance in hospitals, a meta-analysis

Objective

To measure the effectiveness of strategies to implement clinical guidelines andthe influence of organisational characteristics on hospital care.

Methods

Systematic review and meta regression analysis including randomisedcontrolled trials, controlled clinical trials and controlled before-and-after studies.

Results

53 studies were identified, including 81 comparisons. The total effect of allintervention strategies appeared to be Odds ratio 2.13 (SD 1.72-2.65). Interventionstrategies (such as educational material, reminders, feedback) and other professionalinterventions that mostly comprised revisions of professional roles were found to berelatively strong components of multi faceted interventions. Outcomes of organisationaleffect modifiers were better in a learning environment in inpatient studies than inoutpatient studies. Interventions developed outside hospitals yielded better outcomes; OR4.62 (SD 2.82-7.57) versus OR 1.78 (SD 1.36-2.23).

Conclusion

Both single and multifaceted interventions seemed to be effective in hospitalsettings. Evidence for the effects of organisational determinants remained limited.

Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes

BACKGROUND

Strategies to implement change in health professional performance have variable impact. A potential explanation is that the barriers to implementation are different in different settings and at different times. Change may be more likely if the strategies were specifically chosen to address the identified barriers.

OBJECTIVES

To assess the effectiveness of strategies tailored to address specific, identified barriers to change in professional performance.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register and pending files until end of December 2002. English language articles only were included.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that reported objectively measured professional practice or health care outcomes in which at least one group received an intervention designed (or tailored) to address prospectively identified barriers to change.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed quality. We also contacted study authors to obtain any missing information. Quantitative and qualitative analyses were undertaken.

MAIN RESULTS

We included 15 studies. For Comparison 1 (an intervention tailored to address identified barriers to change compared to no intervention or an intervention(s) not tailored to the barriers), there was no consistency in the results and the effect sizes varied both across and within studies.A meta-regression of a subset of the included studies, using a classical approach estimated a combined OR of 2.18 (95% CI: 1.09, 4.34), p = 0.026 in favour of tailored interventions. However, when a Bayesian approach was taken, meta-regression gave a combined OR of 2.27 (95% Credible Interval: 0.92, 4.75), which was not statistically significant.

AUTHORS' CONCLUSIONS

Interventions tailored to prospectively identify barriers may improve care and patient outcomes. However, from the studies included in this review, we were unable to determine whether the barriers were valid, which were the most important barriers, whether all barriers were identified and if they had been addressed by the intervention chosen. Based on the evidence presented in this review, the effectiveness of tailored interventions remains uncertain and more rigorous trials (including process evaluations) are needed. Further research needs to address explicitly the questions of identifying and addressing barriers.

Group versus individual academic detailing to improve the use of antihypertensive medications in primary care: a cluster-randomized controlled trial

PURPOSE

To compare group versus individual academic detailing to increase diuretic or beta-blocker use in hypertension.

METHODS

We conducted a cluster-randomized controlled trial in a large health maintenance organization. Subjects (N=9820) were patients with newly treated hypertension in the year preceding the intervention (N=3692), the 9 months following the intervention (N=3556), and the second year following intervention (N=2572). We randomly allocated 3 practice sites to group detailing (N=227 prescribers), 3 to individual detailing (N=235 prescribers), and 3 to usual care (N=319 prescribers). Individual detailing entailed a physician-educator meeting individually with clinicians to address barriers to prescribing guideline-recommended medications. The group detailing intervention incorporated the same social marketing principles in small groups of clinicians.

RESULTS

In the first year following the intervention, the rates of diuretic or beta-blocker use increased by 13.2% in the group detailing practices, 12.5% in the individual detailing practices, and 6.2% in the usual care practices. As compared with usual care practices, diuretic or beta-blocker use was more likely in group detailing practices (adjusted odds ratio (OR), 1.40; 95% confidence interval (CI), 1.11 - 1.76) and individual detailing practices (adjusted OR, 1.30; 95% CI, 0.95 - 1.79). Neither intervention affected blood pressure control. Two years following this single-visit intervention, there was still a trend suggesting a persistent effect of individual (OR, 1.22; 95% CI, 0.92 - 1.62), but not group, detailing (OR, 1.06; 95% CI, 0.80 - 1.39), as compared with usual care.

CONCLUSION

Both group and individual academic detailing improved antihypertensive prescribing over and above usual care but may require reinforcement to sustain improvements.

The veterans' study to improve the control of hypertension (V-STITCH): design and methodology

BACKGROUND

Among the 60 million Americans with hypertension, only approximately 31% have their blood pressure (BP) under control (<140/90 mm Hg). Despite the damaging impact of hypertension and the availability of evidence-based target values for BP, interventions to improve BP control have had limited success.

OBJECTIVES

A randomized controlled health services intervention trial with a split-plot design is being conducted to improve BP control. This 4-year trial evaluates both a patient and a provider intervention in a primary care setting among diagnosed hypertensive veterans.

METHODS

In a cluster-randomization, 30 primary care providers in the Durham VAMC Primary Care Clinic were randomly assigned to receive the provider intervention or control. The provider intervention is a patient-specific electronically generated hypertension decision support system (DSS) delivering guideline-based recommendations to the provider at each patient's visit, designed to improve guideline-concordant therapy. For these providers, a sample of their hypertensive patients (n=588) was randomly assigned to receive a telephone-administered patient intervention or usual care. The patient intervention incorporates patients' need assessments and involves tailored behavioral and education modules to promote medication adherence and improve specific health behaviors. All modules are delivered over the telephone bi-monthly for 24 months. In this trial, the primary outcome is the proportion of patients who achieve a BP < or =140/90 mm Hg at each outpatient clinic visit over 24 months.

CONCLUSION

Despite the known risk of poor BP control, a majority of adults still do not have their BP controlled. This study is an important step in testing the effectiveness of a patient and provider intervention to improve BP control among veterans in the primary care setting.

Improving prescribing of antihypertensive and cholesterol-lowering drugs: a method for identifying and addressing barriers to change

BACKGROUND

We describe a simple approach we used to identify barriers and tailor an intervention to improve pharmacological management of hypertension and hypercholesterolaemia. We also report the results of a post hoc exercise and survey we carried out to evaluate our approach for identifying barriers and tailoring interventions.

METHODS

We used structured reflection, searched for other relevant trials, surveyed general practitioners and talked with physicians during pilot testing of the intervention. The post hoc exercise was carried out as focus groups of international researchers in the field of quality improvement in health care. The post hoc survey was done by telephone interviews with physicians allocated to the experimental group of a randomised trial of our multifaceted intervention.

RESULTS

A wide range of barriers was identified and several interventions were suggested through structured reflection. The survey led to some adjustments. Studying other trials and pilot testing did not lead to changes in the design of the intervention. Neither the post hoc focus groups nor the post hoc survey revealed important barriers or interventions that we had not considered or included in our tailored intervention.

CONCLUSIONS

A simple approach to identifying barriers to change appears to have been adequate and efficient. However, we do not know for certain what we would have gained by using more comprehensive methods and we do not know whether the resulting intervention would have been more effective if we had used other methods. The effectiveness of our multifaceted intervention is under evaluation in a randomised controlled trial.

Identifying barriers and tailoring interventions to improve the management of urinary tract infections and sore throat: a pragmatic study using qualitative methods

BACKGROUND

Theories of behaviour change indicate that an analysis of factors that facilitate or impede change is helpful when trying to influence professional practice. The aim of this study was to identify barriers to implementing evidence-based guidelines for urinary tract infection and sore throat in general practice in Norway, and to tailor interventions to address these barriers.

METHODS

We used a checklist to identify barriers and possible interventions to address these in an iterative process that included a review of the literature, brainstorming, focus groups, a pilot study, small group discussions and interviews.

RESULTS

We identified at least one barrier for each category. Both guidelines recommended increased use of telephone consultations and reduced use of laboratory tests, and the barriers and the interventions were similar for the two guidelines. The complexity of changing routines involving patients, general practitioners and general practitioner assistants, loss of income with telephone consultations, fear of overlooking serious disease, perceived patient expectations and lack of knowledge about the evidence for the guidelines were the most prominent barriers. The interventions that were tailored to address these barriers included support for change processes in the practices, increasing the fee for telephone consultations, patient information leaflets and computer-based decision support and reminders.

CONCLUSION

A systematic approach using qualitative methods helped identify barriers and generate ideas for tailoring interventions to support the implementation of guidelines for the management of urinary tract infections and sore throat. Lack of resources limited our ability to address all of the barriers adequately.

Costs and cost-effectiveness of a clinical intervention to increase mammography utilization in an inner city public health hospital

BACKGROUND

Studies have demonstrated the cost-effectiveness of screening women for breast cancer; however, the cost-effectiveness of strategies to motivate women to receive breast cancer screening has been less well studied.

METHODS

A total of 196 women, aged 50 to 74, who were enrolled in a public health hospital clinic, were noncompliant with mammography screening, and had at least one routine clinic appointment during the study period (15 months) were entered into a randomized, controlled trial of a motivational intervention to increase mammography rates. Costs were captured via a modified Delphi technique, accounting records, sampling of staff time logs, and an estimation of miscellaneous and overhead costs. Summary costs were calculated using Excel spread sheets.

RESULTS

Overall, 49% of women who received the intervention had a mammogram within 8 weeks of an index visit compared with 22% of control women. Calculation of the cost-effectiveness of the project showed an additional cost of $151 (1996 U.S.$) for each woman receiving the intervention and $559 for each additional woman motivated to receive a mammogram.

CONCLUSIONS

Cost tracking and cost-effectiveness analysis can be done when intervening in a clinical setting, thereby allowing clinics to make informed decisions about implementing programs to increase motivation of their patients to receive screening.

Benchmarking Veterans Affairs Medical Centers in the delivery of preventive health services: comparison of methods

OBJECTIVE

To identify consistent provision of clinical preventive services, we sought to benchmark all acute care Veterans Affairs Medical Centers (VAMCs) against each other nationally on the basis of multiple evidence-based, performance measures to identify facilities performing consistently higher and lower than expected.

METHODS

The 1998 Veterans Health Survey assessed the self-reported delivery of evidence-based clinical preventive services in a stratified national sample of 450 ambulatory care patients seen at each VAMC. Proportions appropriately receiving each service within the recommended time interval were calculated for 138 VAMCs. Percentile ranks for each outcome were assigned. Two approaches were used for benchmarking performance. First, a scaled score for each facility was calculated across the set of 12 measures. Second, facilities were ranked based on the sum of the percentile ranks over a range of specific high cutoffs (eg, 70-80%) and above a range of lower cutoffs (eg, 40-50%). Ranking was validated by comparing with deciles of ranks on chart audit (External Peer Review Program, EPRP) data using Kendall's tau-b and chi2 quality-of-fit test. Differences between consistently high adherence (CHA) and low adherence (CLA) facilities were compared using the Wilcoxon rank sum test on 14 VHS and 11 EPRP outcomes.

RESULTS

Data from 39,939 patients (67% response rate) were examined. In combination, cutoffs of greater than 50th percentile and greater than 75th percentile rank yielded 12 of 14 VHS and 6 of 11 EPRP measures different between CHA and CLA facilities. The scaled-score approach resulted in 20 CHA and 14 CLA facilities. The sum of outcomes ranked above 50th percentile and over 75th percentile for CHA facilities (n = 17) was 15 or more. The sum of outcomes ranked above the same cutoffs for CLA facilities (n = 16) was 3 or less. EPRP and 1998 VHS data demonstrated that the survey measures and benchmarking approaches were both reliable and valid. Both approaches resulted in multiple differences between CHA and CLA facilities; differences were greater using the percentile rank approach.

CONCLUSIONS

The VA has successfully encouraged adoption of evidence-based clinical preventive services throughout its health care system. However, facilities show wide variation in their levels of delivery and can be distinguished on the basis of their consistently high or low levels of adherence. Examining service delivery across multiple performance indicators allows identification of opportunities to improve clinical practice guideline implementation and the delivery of preventive services. This approach identifies model institutions where focused investigation of factors associated with consistent performance may be particularly fruitful.

Quality of clinical reports on behavioral interventions for hypertension

PURPOSE

The purpose of this study was to provide clinicians with the confidence to employ behavioral interventions for hypertension and to guide researchers in the development and reporting of studies.

METHODS

We systematically reviewed English language articles (1970-1999) describing behavioral interventions for hypertension, evaluating aspects of design, analysis, reporting of results, and factors that were associated with higher quality of these studies.

RESULTS

Of 100 articles, 49 were randomized controlled trials (RCT), 33 were observational studies with control groups, and 18 were observational studies without control groups; mean (SE) quality scores were 69.2 (1.6), 57.6 (5.3), and 60.3 (2.2), respectively. RCTs were more likely than observational studies to attain high scores in descriptions of appropriateness of control group, inclusion and exclusion criteria, study population, and the intervention protocol. In multivariate analysis, date of publication, reported funding source, and intervention type were independently associated with greater quality scores: 7.4 [95% CI: 0.03, 14.7] points greater for articles published 1990-1999 vs 1970-1979, 6.5 [95% CI: 1.4, 11.6] points greater for articles reporting government funding vs those not reporting funding sources, and 8.6 [95% CI: 0.3, 17.1], 12.9 [95% CI: 3.4, 22.4], and 14.2 [4.1, 24.4] points greater for articles examining patient education/support, change in delivery system, and mass health campaigns vs articles examining patient reminders, respectively.

CONCLUSIONS

While quality has improved over time, there is considerable room for improvement. Investigators should pay particular attention to description of study population and allocation of subjects, the use of standardized outcomes reporting, and appropriate statistical analysis.

Disease management and pharmacoeconomics as tools for mass prevention of hypertensive complications

Hypertension has been identified as a major predictor of cardiovascular disease, which is a worldwide cause of morbidity and premature mortality. Optimal management of hypertension involves finding a balance among the benefits, risks, and costs of disease treatment and prevention of hypertensive sequelae. Cost-effectiveness analysis helps to clarify the trade-offs between the costs and benefits of treatment and also to evaluate the effects on quality of therapy. Disease management programs that incorporate pharmacoeconomic analysis and computerized methods of targeting patients at high risk of hypertensive sequelae are useful and cost-effective tools. Critical to these cost-effectiveness analyses and disease management programs are the expected benefits attributable to blood pressure reduction. The utility of these programs in helping to determine which patients will benefit from intensive intervention depends to a great extent on the assumptions made and the quality of the data used for the analyses--that is, the degree to which the data are evidence based.

Successful implementation of guidelines for encouraging the use of beta blockers in patients after acute myocardial infarction

PURPOSE

To assess whether implementation of guidelines increases the prescription of drugs, particularly beta blockers, recommended for secondary prevention after acute myocardial infarction.

SUBJECTS AND METHODS

Prescription patterns among 355 patients discharged from a public teaching hospital after recovery from myocardial infarction were prospectively monitored in a before-after trial. The implementation strategies included educational interventions (large group meetings), placement of guidelines in patients' records, and bimonthly general reminders sent to physicians.

RESULTS

Beta blockers were prescribed in 93 (38%) of 243 survivors of acute myocardial infarction before guideline implementation (12-month control period), as compared with 71 (63%) of 112 patients (P <0.001) after their implementation (6-month period). During the entire study period, the prescription of beta blockers at a neighboring public teaching hospital, used as a comparison, was unchanged. After adjusting for potential confounders, implementation of the guidelines remained significantly associated with prescription of beta blockers at discharge [odds ratio (OR) = 10; 95% confidence interval (CI), 3.2 to 33; P <0.001]. Other independent predictors of prescription of beta blockers were previous coronary artery bypass grafting (OR = 8.7; 95% CI, 2.5 to 31; P = 0.001), hypertension (OR = 2.5; 95% CI, 1.4 to 4.5; P = 0.003), age per 10-year increase (OR = 0.82; 95% CI, 0.67 to 0.99; P = 0.04), secular trend in prescription patterns expressed in months (OR = 0.9; 95% CI, 0.8 to 1.0; P = 0.02), a left ventricular ejection fraction < or = 40% (OR = 0.2; 95% CI, 0.1 to 0.4; P <0.001), the presence of atrioventricular block (OR = 0.1; 95% CI, 0.02 to 0.7; P = 0.02), and concomitant prescription of digoxin (OR = 0.2; 95% CI, 0.05 to 0.8; P = 0.02) or calcium antagonists (OR = 0.06; 95% CI, 0.01 to 0.3; P = 0.001).

CONCLUSION

When appropriately developed and implemented by local experts, literature-based guidelines may be effective in modifying use of recommended drugs for secondary prevention of coronary artery disease, such as prescription of beta blockers.

A clinic-based mammography intervention targeting inner-city women

OBJECTIVE

The objective was to evaluate the effect of a clinic-based intervention program on mammography use by inner-city women.

DESIGN

A randomized controlled trial employing firm system methodology was conducted.

SETTING

The study setting was a general internal medicine clinic in the university-affiliated county hospital serving metropolitan Seattle.

PARTICIPANTS

Women aged 50 to 74 years with at least one routine clinic appointment (when they were due for mammography) during the study period were enrolled in the trial (n = 314).

INTERVENTIONS

The intervention program emphasized nursing involvement and included physician education, provider prompts, use of audiovisual and printed patient education materials, transportation assistance in the form of bus passes, preappointment telephone or postcard reminders, and rescheduling assistance. Control firm women received usual care.

MEASUREMENTS AND MAIN RESULTS

Mammography completion within 8 weeks of clinic visits was significantly higher among intervention (49%) than control (22%) firm women (p < .001). These effects persisted after adjustment for potential confounding by age, race, medical insurance coverage, and previous mammography experience at the hospital (odds ratio 3.5; 95% confidence interval 1.9, 6.5). The intervention effect was modified by type of insurance coverage as well as prior mammography history. Process evaluation indicated that bus passes and rescheduling efforts did not contribute to the observed increases in screening participation.

CONCLUSIONS

A clinic-based program incorporating physician education, provider prompts, patient education materials, and appointment reminders and emphasizing nursing involvement can facilitate adherence to breast cancer screening guidelines among inner-city women.

The organizational structure of medical group practices in a managed care environment

This article analyzes the organizational structures of 155 medical group practices providing services in the highly competitive managed care environment in the upper midwest. The structure of the group practices and the methods of physicians' payment are analyzed in terms of the proportion of revenue obtained from financial risk-sharing managed care payment systems and the length of time involved with those systems.

Health services research and the endocrinologist

This article highlights the importance of health services research to endocrinologists. The content and goals of health services research are defined, and, with examples related to endocrinology, the field's focus and key themes are described and its methods and sources of data delineated. Considerations that informed readers should keep in mind when reading this literature are illustrated, with a recent example that has important implications for the role of endocrinologists in the management of diabetic patients.