Objectives: To identify physician and practice characteristics associated with a physician's propensity to involve patients in diagnostic and treatment decisions, or participatory decision-making s

Characteristics of Physicians with Participatory Decision-Making Styles

BACKGROUND: It is crucial that research findings are implemented in general practice if high-quality care is to be achieved. Multifaceted interventions are usually assumed to be more effective than single interventions, but this hypothesis has yet to be tested for general practice care. This review evaluates the effectiveness of interventions in influencing the implementation of guidelines and adoption of innovations in general practice. A systematic literature study was carried out using MEDLINE searches for the period from January 1980 until June 1994, and 21 medical journals were searched manually. Randomized controlled trials and controlled before and after studies (with pre- and post-intervention measurements in all groups) were selected for the analysis. Clinical area, interventions used, methodological characteristics and effects on clinical behaviour were noted independently by two researchers using a standardized scoring form. Of 143 studies found, 61 were selected for the analysis, covering 86 intervention groups that could be compared with a control group without the intervention. Information transfer alone was effective in two out of 18 groups, whereas combinations of information transfer and learning through social influence or management support were effective in four out of eight and three out of seven groups respectively. Information linked to performance was effective in 10 out of 15 groups, but the combination of information transfer and information linked to performance was effective in only three out of 20 groups. Some, but not all, multifaceted interventions are effective in inducing change in general practice. Social influence and management support can improve the effectiveness of information transfer, but information linked to performance does not necessarily do so. The variation in the effectiveness of interventions needs further analysis.

Implementing guidelines and innovations in general practice: which interventions are effective?

Background. To assess possible differences in physicians' practices with respect to diagnostic imaging, we compared the frequency and costs of imaging examinations as performed by primary physicians who used imaging equipment in their offices (self-referring) and as ordered by physicians who always referred patients to radiologists (radiologist-referring). Methods. Using a large, private insurance-claims data base, we analyzed 65,517 episodes of outpatient care by 6419 physicians for acute upper respiratory symptoms, pregnancy, low back pain, or (in men) difficulty urinating. The respective imaging procedures studied were chest radiography, obstetrical ultrasonography, radiography of the lumbar spine, and excretory urography, cystography, or ultrasonography. Results. For all four clinical presentations, the self-referring physicians obtained imaging examinations 4.0 to 4.5 times more often than the radiologist-referring physicians (P<0.0001 for all four). For chest radiography, obstetrical ultras...

Frequency and costs of diagnostic imaging in office practice--a comparison of self-referring and radiologist-referring physicians.

Over 90 percent of health maintenance organizations (HMOs) use primary care physicians as gatekeepers,1 whose role is to authorize access to specialty, emergency, and hospital care and to diagnosti...

Gatekeeping revisited--protecting patients from overtreatment.

Context.—Academic medical centers are under enormous pressure to improve quality
and cut costs while preserving education.Objective.—To determine whether a reorganized academic medical service, led by
faculty members who attended more often and became involved earlier and more
intensively in care, would lower costs without compromising quality and education.Design.—Alternate-day controlled trial.Setting.—Inpatient academic general medical service.Patients.—The 1623 patients discharged from the Moffitt-Long medical service between
July 1, 1995, and June 30, 1996.Interventions.—We divided our 4-team inpatient general medical service into 2 managed
care service (MCS) teams and 2 traditional service (TS) teams. The MCS faculty
served as attending physicians more often and were required to provide early
input into clinical decisions. Patients were assigned to teams based on alternate
days of admission.Main Outcome Measures.—Outcome measures included resource use and outcomes for MCS vs TS patients,
and for MCS patients vs patients seen the previous year, adjusted for demographic
characteristics and case mix. Satisfaction of patients, house staff, and faculty
was also assessed, as was educational emphasis.Results.—A total of 806 patients were admitted to the MCS and 817 to the TS.
Demographic characteristics and case mix were similar. Clinical outcomes,
including mortality and readmission rates, were also similar, as was patient
satisfaction. Resident and faculty satisfaction were high on both services.
The average adjusted length of stay of patients on the MCS was 4.3 days vs
4.9 days on the TS and 5 days in 1994-1995 (adjusted P=.01
for MCS vs TS; MCS vs 1994-1995, P<.001). Average
adjusted hospital costs were $7007 on the MCS vs $7777 on the TS and $8078
in 1994-1995 (adjusted P=.05 for MCS vs TS; MCS vs
1994-1995, P=.002).Conclusions.—A reorganized academic medical service, led by faculty members who attended
more often and became involved earlier and more intensively, resulted in significant
resource savings with no changes in clinical outcomes or patient, faculty,
and house staff satisfaction.

Reorganizing an Academic Medical Service: Impact on Cost, Quality, Patient Satisfaction, and Education

Health Stop is a major chain of ambulatory care centers operating for profit. Until 1985 its physicians were paid a flat hourly wage. In the middle of that year, a new compensation plan was instituted to provide doctors with financial incentives to increase revenues. Physicians could earn bonuses the size of which depended on the gross incomes they generated individually. We compared the practice patterns of 15 doctors, each employed full time at a different Health Stop center in the Boston area, in the same winter months before and after the start of the new arrangement. During the periods compared, the physicians increased the number of laboratory tests performed per patient visit by 23 percent and the number of x-ray films per visit by 16 percent. The total charges per month, adjusted for inflation, grew 20 percent, mostly as a result of a 12 percent increase in the average number of patient visits per month. The wages of the seven physicians who regularly earned the bonus rose 19 percent. We ...

Physicians' responses to financial incentives. Evidence from a for-profit ambulatory care center.

This article describes physicians at a major chain of investor-owned free-standing walk-in centers and reports on their job satisfaction. They derived satisfaction from a sense of autonomy and the corporation's reliable provision of staff and supplies. Their job dissatisfaction results from the corporate emphasis on generating revenue and the lack of opportunity for professional interaction with colleagues.

Physician satisfaction in a major chain of investor-owned walk-in centers.

As children survive: dilemmas of aging in the developing world.

In sum, people go to a walk-in office for quick, convenient service, and overall they are happy with their experience. Although we cannot generalize from this case study of one chain of walk-in centers to walk-ins nationally, results from other studies of walk-in patient populations are approximately similar to ours.

Cindy Lou Parks

Papers

Physicians' responses to financial incentives. Evidence from a for-profit ambulatory care center.

Physician satisfaction in a major chain of investor-owned walk-in centers.

As children survive: dilemmas of aging in the developing world.

The patient population of a major chain of investor-owned ambulatory care walk-in centers.

Quality of care in a chain of walk-in centers.