Effect of managed care on cardiovascular specialists: involvement, attitudes and practice adaptations

Physicians’ Perceptions of Managed Care: A Review of the Literature

In this article, the authors review the health services research literature regarding physician attitudes and opinions relating to managed care and how managed care has affected their clinical practice. This literature suggests that physician perceptions of managed care are largely related to the nature of their ties to managed care plans and to their selection of practice setting. There are substantial limitations in study designs and execution, suggesting that many of the published findings should be viewed with caution; the research basis regarding physicians’ perceptions of managed care is not as strong as the number of articles published on this subject would suggest. The review concludes with suggestions for the conduct of future research on this topic.

Aortic stenosis: the spectrum of practice

There is significant variation in practice patterns in managing congenital aortic valve stenosis. Review of medical literature reveals no significant information regarding the current practice methods in the treatment of a simple lesion such as aortic stenosis (AS). Therefore, this survey-based study was conducted in an attempt to better understand the uniformity or heterogeneity of practice in treating AS. A questionnaire was prepared to evaluate the style of management of AS. This survey was designed to assess the practice of follow-up visitations, type and frequency of investigative studies, pharmacological therapy, and exercise recommendations. Questions about therapeutic intervention included those of timing and type of intervention. Questionnaires were sent to all academic pediatric cardiology programs in the United States (48 program) and selected international programs from Europe, Asia, and Australasia (19 program). The total number of surveys sent out was 67, and the total number of respondents was 25 (37%), 15 (31%) from the United States and 9 (53%) from outside the United States. The definition of moderate AS varied among respondents. The range provided for mild AS was identified as that with a peak-to-peak pressure gradient of < 25-30 mmHg, peak instantaneous Doppler gradient of < 36-50 mmHg, or mean Doppler gradient of < 25-40 mmHg. On the other hand, severe AS was defined as that with a peak-to-peak gradient of > 50-60 mmHg, peak instantaneous Doppler gradient of > 64-80 mmHg, or mean Doppler gradient of > 45-64 mmHg. In assessing follow-up patterns, 84% of respondents recommended seeing patients with mild AS annually, the longest time of follow-up listed in the questionnaire, whereas 20% suggested follow-up every 6 months. There was no consensus among survey centers regarding follow-up of patients with moderate AS. For severe AS, 16% recommend immediate intervention, 16% arrange follow-up every 6 months, and 56 and 28% recommend follow-up in 3 and 1 month(s), respectively. In making the decision to proceed with biventricular versus univentricular repair in patients with AS in the neonatal period, many factors were considered. Ninety-two percent of respondents rely on mitral valve z score, 84% on aortic valve z score, 52% on left ventricle length, 48% on the presence of antegrade ascending aorta flow, and only 32% considered significant endocardial fibroelastosis as a factor. Rhodes score was used by 20% of respondents in decision making regarding the approach to management of this subset of AS. This study shows that there is consensus in the management of mild and severe forms of AS. As expected, disagreement is present in the definition, evaluation, and therapy of moderate aortic valve stenosis. There is a tendency for catheter intervention except in the presence of dysplastic aortic valve or moderate to severe aortic regurgitation. There is also disagreement regarding methods used to determine biventricular versus univentricular repair of a borderline hypoplastic left heart.

Medications used to manage supraventricular tachycardia in the infant a North American survey

Supraventricular tachycardia is the most common pediatric arrhythmia, but there is no consensus and little evidence to guide its treatment. We sent a questionnaire to pediatric cardiologists in North America to assess the current practice pattern. Of 1534 surveys mailed, 352 (23%) were returned and 295 (19%) had complete data for analysis. In the acute setting, 11 different medications were chosen. The most commonly used in the infant without preexcitation were digoxin (42%), procainamide (21%), esmolol (13%), propranolol (10%), and amiodarone (8%). In the infant with preexcitation, propranolol (34%), procainamide (23%), esmolol (17%), amiodarone (11%), and digoxin (6%) were used. In the chronic setting, 8 different medications were chosen. The most commonly used in this scenario were digoxin (52%), propranolol (33%), amiodarone (4%), and sotalol (3%). In the infant with preexcitation, propranolol (70%), amiodarone (6%), digoxin (6%), atenolol (6%), and flecainide (5%) were used. Medication choices were influenced by additional electrophysiology training and preexcitation. Digoxin was used less in the setting of preexcitation. There are no comparative trials to explain the different medication choices. Although a number of medications may be efficacious, a randomized clinical trial is needed to offer further guidance.

“Well Read”

Managed care pharmacists are involved formally with the interface between the delivery and financing of health care; their work thus entails an accountability for both elements. Interpreted broadly managed care pharmacists are pharmacists working within the sphere of a health care system, health care purchaser, health insurer, managed care organization, or benefit administration agency. Patients, the pharmacy profession, and society are best served by this broad interpretation, because the interdependency of financing and delivery is inextricably linked to the achievement of good health outcomes. This continuing feature will explore contemporary issues facing managed care pharmacists.

Private medical practitioners and managed care in Malaysia: a survey of knowledge and attitudes held by Federal Territory based doctors

This paper considers the subject of managed care in Malaysia, providing a questionnaire-based analysis of the position adopted by private medical practitioners. Managed care is now seen as the dominant health care system in the United States, with many other countries around the world including Malaysia beginning to selectively use component parts to tackle particular health care problems. In this survey it was found that three out of four respondents have concerns regarding the implementation of managed care. The survey was used to identify and categorise these concerns. At the same time, three out of four respondents held the opinion that principles of managed care were already a reality or would be in the next 5 years. This group expressed an eagerness to be trained in managed care principles and be given the opportunity to be part of managed care organisations. It is argued that clinicians' knowledge and interest perceptions are an important influence on the implementation of managed care based systems. The survey-based evidence presented in this article is intended as a measure of current understandings and beliefs, in relation to clinical micro-management process associated with managed care.

Knowledge, patterns of care, and outcomes of care for generalists and specialists

OBJECTIVE

To critically evaluate the differences between generalist physicians and specialists in terms of knowledge, patterns of care, and clinical outcomes of care.

METHODS

English-language articles (January 1981 to January 1998) were identified through a Medline search and examination of bibliographies of identified articles. Systematic evaluation of articles relevant to adult medicine that had a direct comparison between generalist physicians and specialists in terms of knowledge relative to widely accepted standards of care, patterns of care (including use of medications, ancillary services, procedures, and resource utilization), and outcomes of care was performed.

MAIN RESULTS

In many survey studies, specialists were reported to be more knowledgeable about conditions encompassed within their specialty. In terms of overall practice patterns, specialists practicing in their area of expertise were more likely to use medications associated with improved survival and to comply with routine health maintenance screening guidelines; they used more resources including diagnostic tests, procedures, and longer hospital stays. In the limited number of studies examining the care of patients with acute myocardial infarction, acute nonhemorrhagic stroke, and asthma, specialists had superior outcomes compared with generalists.

CONCLUSIONS

There is evidence in the literature suggesting differences between specialists and generalists in terms of knowledge, patterns of care, and clinical outcomes of care for a broad range of diseases. In published studies, specialists were generally more knowledgeable about their area of expertise and quicker to adopt new and effective treatments than generalists. More research is needed to examine whether these patterns of care translate into superior outcomes for patients. Further work is also needed to delineate the components of care for which generalists and specialists should be responsible, in order to provide the highest quality of care to patients while most effectively utilizing existing physician manpower.

Promises and perils of managed care for older patients with cardiac disease

Managed care for elderly patients with cardiovascular disease will likely become more widespread because it has the propensity to provide comprehensive care while controlling costs. The issues of comorbidity and the changes of aging per se become increasingly important with increasing age and emphasize the need to use the basic principles of clinical decision making in the management of elderly patients, rather than focusing exclusively on a specific acute problem. Currently, there is great turmoil in the managed care market for the elderly with multiple models being tried with highly variable degrees of success from both the financial and patient satisfaction perspective. Physician leadership can be a critical element in resolving many of the dilemmas.

Electrical cardioversion of atrial fibrillation or flutter with conscious sedation in the age of cost containment

BACKGROUND

The purpose of this study was to compare the safety, efficacy, and cost of conscious sedation administered by electrophysiologists certified in the use of conscious sedation with sedation administered by anesthesiologists during cardioversion of atrial fibrillation or atrial flutter to sinus rhythm.

METHODS AND RESULTS

Patients with hemodynamically stable persistent atrial fibrillation and flutter were included in this study. Group 1 patients (n = 33) were sedated by an anesthesiologist and group 2 patients (n = 26) were sedated by an electrophysiologist. Anesthesiologists used propofol and electrophysiologists used midazolam and morphine for sedation. A cost analysis based on professional charges and cost of medications was performed for both groups and compared. Hospital charges were similar for both groups and were excluded from the cost analysis. Although time to sedation in group 1 was shorter than that in group 2, sedation was adequate in both groups such that no patient in group 1 and only 1 patient in group 2 recalled being shocked. There were no complications in either group. The cost incurred in group 2 was less than that in group 1.

CONCLUSIONS

Sedation administered by electrophysiologists for cardioversion of atrial arrhythmias is safe and cost effective. Midazolam and morphine, the sedative agents administered by electrophysiologists, were effective and well tolerated by patients.

Process improvements reduce utilization of resources for aortic aneurysm repair

In conjunction with the VA reorganization to promote greater efficiency of health care provision, ambulatory surgery (AS) programs have been created. These programs institute outpatient preoperative assessment and operative management. This study examines the impact of these process changes on resources utilized by patients requiring repair of abdominal aortic aneurysms (AAAs). The medical records of 15 consecutively treated patients undergoing elective, infrarenal AAA repair before (1992-1993) and after (1995-1996) AS implementation were reviewed. Resource utilization was assessed by evaluating preoperative tests performed (inpatient or outpatient), ICU days, and inpatient length of stay (LOS). Postoperative morbidity and mortality were noted. Patient age, AAA size, and prevalence of diabetes mellitus, hypertension, cardiac disease, COPD, and tobacco use were similar between the two groups. Abdominal ultrasound, CT scanning, and angiography were significantly more frequently performed on an outpatient basis after implementation of the AS program. The median preoperative LOS was reduced in the AS group (1 vs 6 days, P = 0.001, Student t test), resulting in a lower inpatient LOS (11 vs 16, P < 0.01, Student t test). All patients survived and the incidence of complications was similar between the groups. Hospital resource utilization was significantly decreased, largely by shifting preoperative assessment to the outpatient setting. This study illustrates that benefits of an ambulatory surgery program can be extended beyond facilitating outpatient operations and should result in decreased length of hospitalization for other major surgical procedures, such as abdominal aortic aneurysm repair.