The relationship between primary care physicians' adherence to guidelines for the treatment of diabetes and patient satisfaction: findings from a pilot study

BACKGROUND: Adherence to clinical guidelines improves health care outcomes, reduces expenditure and prevents the complication of unnecessary interventions. It is uncertain what effect the adherence to guidelines for treating diabetes has on patient satisfaction. Some authors have reported that the use of guidelines does not affect patient satisfaction with care, and have concluded that satisfaction is related to a physician's interpersonal skills, rather than to the quality of care. Others have reported that structured intervention programmes improve patient satisfaction with care. OBJECTIVE: The purpose of our study was to explore the association between adherence to clinical guidelines and satisfaction with care among diabetics. METHODS: The study population included 135 randomly sampled diabetes patients listed with 12 primary care physicians at two health plans in Israel, which together insure >80% of the population. Telephone interviews were conducted with the patients between August and November 2000, using structured questionnaires. Patients were asked to report on the extent to which their primary care physician treated them as indicated by the clinical guidelines of these health plans. They were also asked to rate their satisfaction with their primary care physician and the treatment of their disease. Bi-variate analysis was conducted using the chi-square statistical significance test. Multivariate analysis was conducted using logistic regression models. RESULTS: Adherence to guidelines for diabetes was associated with patient satisfaction with care, independently of the patient's ethnicity (first language), age, gender, education, medication (insulin versus other) and health plan affiliation. CONCLUSION: Patients who report being treated as recommended in practice guidelines were more likely to be satisfied with their care. This finding may encourage primary care physicians to adhere to clinical practice guidelines.     

Managed care plans and the organizational arrangements with group practices

This article addresses the variety of structural and legal arrangements between group practices and health plans. The continuum of relationships will be discussed, including long-term arrangements whereby in exchange for long-term commitments to provide physician capacity, providers are given a capital contribution from managed care plans; management services organizations whereby managed care plans create management companies that provide turnkey management services in exchange for capital, with a commitment by the group practices to provide physician services to the health plan over a long period of time; mixed equity relationships where physicians and managed care plans jointly own the group practice, which group practice also has an ownership interest in the managed care plan itself; and acquisition of the group practice by the managed care plan. Each of these structures will be described, along with the legal issues that may be considered in any of these relationships.     

Teamwork at the Detroit Medical Center. Bridging the gap

In 1992, Harper Hospital, a part of the Detroit Medical Center, initiated a Quality Enhancement and Clinical Resource Management (QE/CRM) program. The program was designed to be physician-driven and multidisciplinary. Its goal is to "look closely and critically at the appropriate use of clinical resources to affect the most desired outcomes." Through the use of teams for different clinical services, led by physicians and comprised mainly of physicians, quality of care and cost issues are identified and investigated. Changes to practice have occurred that have not only improved outcomes and saved the medical center money, but prepared it to go to managed care.     

Managing inpatient clinical nutrition services: a comprehensive program assures accountability and success

A major challenge facing clinical dietitians today is justifying inpatient clinical nutrition services. To meet this challenge, a comprehensive program for the delivery and management of clinical nutrition services was developed at Yale-New Haven Hospital. It is based on seven nutritional risk factors--age, diagnosis/treatment, diet, metabolic or mechanical problems, significant lab values, pertinent medications, and weight for height. These risk factors are used to categorize patients into one of seven classifications. In essence, this classification system is the screening tool used to provide the foundation for standards of practice and nutrition assessment and intervention. The inherent advantage of such a program is that it identifies patients at high nutritional risk, regardless of wide variations in patient population or diagnosis. It also provides standardized criteria for evaluating quality of care, patient acuity, and productivity and staffing. Clinical nutrition services can then be measured for both quality and quantity. Because protein-calorie malnutrition poses a serious threat to cost containment and quality patient care, this type of program can appeal to hospital administrators, physicians, and site visitors alike. It can serve as an adaptable model for the delivery and management of inpatient clinical nutrition services in a wide variety of health care facilities.     

Monitoring quality in Israeli primary care: The primary care physicians' perspective

ABSTRACT: BACKGROUND: Since 2000, Israel has had a national program for ongoing monitoring of the quality of the primary care services provided by the country's four competing non-profit health plans. Previous research has demonstrated that quality of care has improved substantially since the program's inception and that the program enjoys wide support among health plan managers. However, prior to this study there were anecdotal and journalistic reports of opposition to the program among primary care physicians engaged in direct service delivery; these raised serious questions about the extent of support among physicians nationally. Goals To assess how Israeli primary care physicians experience and rate health plan efforts to track and improve the quality of care. METHOD: The study population consisted of primary care physicians employed by the health plans who have responsibility for the quality of care of a panel of adult patients. The study team randomly sampled 250 primary-care physicians from each of the four health plans. Of the 1,000 physicians sampled, 884 met the study criteria. Every physician could choose whether to participate in the survey by mail, e-mail, or telephone. The anonymous questionnaire was completed by 605 physicians - 69% of those eligible. The data were weighted to reflect differences in sampling and response rates across health plans. Main findings The vast majority of respondents (87%) felt that the monitoring of quality was important and two-thirds (66%) felt that the feedback and subsequent remedial interventions improved medical care to a great extent. Almost three-quarters (71%) supported continuation of the program in an unqualified manner. The physicians with the most positive attitudes to the program were over age 44, independent contract physicians, and either board-certified in internal medicine or without any board-certification (i.e., residents or general practitioners). At the same time, support for the program was widespread even among physicians who are young, board-certified in family medicine, and salaried. Many physicians also reported that various problems had emerged to a great or very great extent: a heavier workload (65%), over-competitiveness (60%), excessive managerial pressure (48%), and distraction from other clinical issues (35%). In addition, there was some criticism of the quality of the measures themselves. Respondents also identified approaches to addressing these problems. CONCLUSIONS: The findings provide perspective on the anecdotal reports of physician opposition to the monitoring program; they may well accurately reflect the views of the small number of physicians directly involved, but they do not reflect the views of primary care physicians as a whole, who are generally quite supportive of the program. At the same time, the study confirms the existence of several perceived problems. Some of these problems, such as excess managerial pressure, can probably best be addressed by the health plans themselves; while others, such as the need to refine the quality indicators, are probably best addressed at the national level. Cooperation between primary care physicians and health plan managers, which has been an essential component of the program's success thus far, can also play an important role in addressing the problems identified.     

Physicians Who Treat the Elderly in Rural Florida: Trends Indicating Concerns Regarding Access to Care

CONTEXT: Rural elderly patients are faced with numerous challenges in accessing care. Additional strains to access may be occurring given recent market pressures, which would have significant impact on this vulnerable population. PURPOSE: This study focused on the practice patterns and future plans of rural Florida physicians who routinely see elderly patients. Additionally, we examine those who provide services to a high volume of Medicare (HVM) patients. METHODS: A self-administered mailed survey was sent to rural physicians who identified themselves as practicing family medicine, internal medicine, psychiatry, general surgery, a surgical specialty, or a medical specialty. Questions examined changes in services offered by all rural physicians and among them, the HVM physicians. Impact of the professional liability insurance situation, satisfaction with current practice, and future practice plans on changes in service availability was also examined. RESULTS: Overall, 539 physicians responded for a participation rate of 42.7%. Two hundred eighty eight (54.9%) of all physicians in the study indicated a decrease or elimination of patient services in the last year. HVM physicians, compared to low volume of Medicare providers, were significantly more likely to decrease or eliminate services overall (66% vs 45%, P =.001). Mental health services (47% vs 18%, P =.001), vaccine administration (39% vs 16%, P =.008), and Pap smears (41% vs 13%, P =.008) were more likely to be eliminated among the HVM physicians. HVM physicians were also significantly more likely to be somewhat or very dissatisfied (40% vs 23%, P =.012) with their practice. CONCLUSIONS: Physicians in rural Florida report dissatisfaction with their practice and are decreasing or eliminating services that are important to the elderly. Given the aging population and increasing need for health care services, these trends raise concern about the ability for these patients to receive necessary care.     

Managed care and women's health: access, preventive services, and satisfaction.

This paper examines insured women's access to health care, receipt of preventive services, and satisfaction with care by the types of health plans in which they are enrolled. Three types of plans are compared: managed care (HMOs and PPOs), fee-for-service with utilization controls, and traditional fee-for-service. For women who have been enrolled in their plans for at least one year, we find the same or better access to care in managed care plans as compared with other plans; receipt of more gender-specific clinical preventive services in managed care plans, but no differences among types of plans for non-gender-specific preventive services or counseling services; and lower satisfaction with care in managed care plans. The implications for practice and policy are discussed.     

Trends in acute mental health care: Comparing psychiatric and substance abuse treatment programs

This study compared psychiatric and substance abuse acute care programs, within both inpatient and residential modalities of care, on organization and staffing, clinical management practices and policies, and services and activities. A total of 412 (95% of those eligible) Department of Veterans Affairs' programs were surveyed nationwide. Some 40% to 50% of patients in psychiatric and substance abuse programs, in both inpatient and residential venues of care, had dual diagnoses. Even though psychiatric programs had a sicker patient population, they provided fewer services, including basic components of integrated programs, than substance abuse programs did. Findings also showed that there is a strong emphasis on the use of clinical practice guidelines, performance monitoring, and obtaining client satisfaction and outcome data in mental health programs. The author's suggest how psychiatric programs might better meet the needs of acutely ill and dually diagnosed patients (eg, by incorporating former patients as role models and mutual help groups, as substance abuse programs do; and by having policies that balance patient choice with program demand).     

Medicaid Disease Management Programs

Disease management emphasizes prevention of disease-related exacerbations and complications using evidence-based guidelines and patient empowerment tools. It can help manage and improve the health status of a defined patient population over the entire course of a disease.More than 20 states in the US are developing and implementing Medicaid disease management programs. While most are in an early stage of development, a small number of states were pioneers in disease management and have already gained much insight. Among them, three states — Florida, Virginia, and West Virginia — provide some significant lessons.In the late 1990s, Florida’s Medicaid agency authorized development of disease management programs for patients with asthma, diabetes mellitus, HIV/AIDS, hemophilia, hypertension, cancer, end-stage renal disease, congestive heart failure, and sickle cell anemia. However, an analysis of results in 2001 showed significant problems (e.g. inefficiency, inconsistent care, a failure to address problems of patients with multiple diseases). These problems likely resulted from Florida trying to implement too many programs at once, using contracts with multiple vendors.The Virginia Health Outcomes Project was shown to be effective in reducing use of emergency and urgent care services by Medicaid patients with asthma (average 42% reduction in the third to fifth quarters after introduction of the program) and increasing the appropriate use of asthma medications. It was also shown to be cost effective, with projected direct savings to Medicaid of $US3-5 (2002 values) for every incremental dollar spent providing disease management support to physicians.The goals of the West Virginia Health Initiatives Project were to deliver quality care, improve health status and quality of life, and ensure the efficient and appropriate utilization of resources for Medicaid patients with diabetes. The model program had two critical components: (i) adaptation of clinical treatment guidelines that are in the public domain to blend the highest quality of care with the best practical management strategies; and (ii) feedback reports that provide real-time data about patients’ utilization of services to all providers involved in their care. Participating physicians and other providers received training and reimbursement for their efforts to comply with guidelines.It would be a mistake to attempt to draw firm conclusions about disease management programs for low-income elderly or physically disabled patients in the US Medicaid program given their current stage of development. However, credit should be given to the states that are experimenting with cutting-edge programs to tackle not only their fiscal issues, but perhaps more importantly, the issue of ensuring high-quality, cost-effective healthcare for the patients they serve.     

A Case Study Using a Patient Satisfaction Survey to Improve the Delivery and Effectiveness of Drug Addiction Treatment Services: Marketing Implications and Organizational Impact

Drug abuse and addiction continues to negatively impact many lives in this country. The United States health care system has grappled with how to best serve this vulnerable population. Since the personal and societal costs of addiction are high, all recent iterations of the United States strategic health plans (such as Healthy People 2010) have prioritized this area for improvement. At the local level, health care providers who care for those with addictions are challenged with shrinking insurance coverage for services, a difficult patient population, lack of treatment options, growing ranks of indigent patients, as well as a plethora of additional management challenges. It is known that successful treatment is integrally linked with patient satisfaction with services. The most critical factors in successful addiction treatment (from a patient's perspective) are (1) their belief that the counselor cares about them and, (2) their belief that they can recover. This paper reports a case study in the use of a patient satisfaction survey as a quality management/service refinement tool within a methadone treatment setting. Results indicate that the use of the survey itself provides patients with a tangible cue supporting the presence of the critical success factors. Further, the use of a survey provides a baseline for future measurements and trending. The paper concludes with a discussion of the marketing and organizational implications of incorporating the patient satisfaction survey into the ongoing delivery program for addiction services.     

Family Medicine Education and Rural Health: A Response to Present and Future Needs

The importance of family medicine in providing rural health services has been established for quite some time. The need to train physicians who select the specialty of family medicine is critical at a time when medical student interest in the primary care specialties appears to be diminishing. Renewed efforts by educational institutions and incentives at the state and federal levels will be necessary to assist in the alleviation of shortages of rural physicians. The educational program at the University of Minnesota, Duluth, School of Medicine has achieved a great deal of success in training rural family physicians. A coordinated program effort, featuring the efforts of more than 200 family physicians during the past 15 years, has led to 52.5 percent of all graduates selecting family practice and more than 41 percent choosing practice sites with a population fewer than 20,000. Elements of the program at Duluth could serve as a model for other schools desiring to increase the number of students entering family medicine and rural practice.     

Quality and outcomes management in the primary care practice

In response to the trend away from thinking of health care as a commodity to one in which quality is a differentiating feature among providers, primary care practices must focus on outcomes management. This article reviews the various clinical and office-based processes that influence practice outcomes. These include patient management, chart management, practice guidelines, clinical pathways, case management, and patient information. The key to a quality program and successful outcomes management is a commitment on the part of physicians to managing these processes so that best outcomes are achievable.     

MHSPY: A Children's Health Initiative for Maintaining At-Risk Youth in the Community

The Massachusetts Mental Health Services Program for Youth (MHSPY) is a home-based clinical intervention that seeks to maintain youth with severe functional impairment in the community via delivery of integrated primary care, mental health, substance abuse, and social services. Using blended public agency funding, traditional and nontraditional services are provided within a private, not-for-profit, managed care organization. Individualized, comprehensive care plans are developed by an MHSPY care manager, who works intensively with the family and the Care Planning Team to identify needs and resources. Data on clinical functioning are collected at baseline and every six months during the program. Service utilization and cost are measured on a quarterly basis. Family, youth, and agency satisfaction ratings are collected at disenrollment. Aggregate analyses based on four years of data show that MHSPY participants have improved clinical functioning, including significant reduction in risk to self and others. They also experience reduced service utilization and cost and high rates of family satisfaction.Brian Mullin, BA, is a Senior Data Analyst at Neighborhood Health Plan, 253 Summer St., Boston, MA 02210, USA.     

Strategies for Pharmacists in the Implementation of Diabetes Mellitus Management Programs

Pharmacists are in an ideal position to assess, monitor and treat adherence-related problems that can adversely affect patients’ health outcomes. To accomplish these goals, pharmacists must accept the responsibilities and challenges of a primary care provider. They also must assume an interdisciplinary role in collaborative drug therapy management. Strategies to monitor and improve adherence are key components of pharmaceutical care plans, especially for patients with chronic diseases, such as hypertension, diabetes mellitus and atherosclerotic heart disease.This article gives an overview of guidelines, recommendations, current practices and related issues in the management of patients with diabetes mellitus. It also reviews the behavioral and social factors that influence adherence to therapeutic and lifestyle regimens, and highlights special needs in selected high-risk populations. Finally, best practice strategies that could serve as appropriate models for pharmaceutical care services are discussed.The overall goal is to enhance pharmacists’ professional abilities to coordinate pharmaceutical care services targeted for major modifiable behavioral and biological risk factors. Pharmacists can overcome their apprehension about undertaking a primary care role in diabetes management through adequate preparation (including training and certification). The primary care functions that have been evaluated to date in the care of patients with diabetes mellitus by pharmacists show successful patient outcomes in terms of cost, quality of life and reduction of complications.     

Perceived effectiveness of diagnostic and therapeutic guidelines in primary care quality circles.

OBJECTIVE: The main objectives of this study were to implement quality circle programs among general practitioners and to evaluate this quality management tool as a way to develop clinical guidelines in general practice. DESIGN: The quality circle program was evaluated within a formative and summative evaluation design by both participants and moderators for a period of 18 months using structured questionnaires. At time one, participants were asked about their goals and current job satisfaction, and rated the perceived effectiveness and the usefulness of predefined guidelines of each quality circle meeting. At time two, participants and moderators reported again about their achieved goals and job satisfaction. SETTING AND STUDY PARTICIPANTS: Two hundred and forty-three general practitioners in a district of South Germany (Südbaden), in 25 quality circle groups participated. MAIN MEASURES: Demographic variables of the participating physicians, quality circle goals, job satisfaction, usefulness of guidelines and perceived effectiveness of the quality circle process were collected. RESULTS: One hundred and six quality circle meetings were evaluated. When asked to rank the goals of quality circle work, participants provided the highest rankings for improvement of the doctor-doctor relationship, agreeing on consensus for diagnostic procedures and therapy management, and developing local guidelines. The comparison between time one and time two ratings provided evidence for an increase in overall job satisfaction. Higher benefit is correlated with more regular participation in quality circle meetings. CONCLUSION: Working with predefined guidelines is both feasible and effective in quality circles and may provide a starting point for developing guidelines in primary care. There is some empirical evidence that participating in quality circles may increase general practitioners' job satisfaction. Further studies using intervention and control group designs should investigate whether quality circles really improve daily practice through clinical audit and benchmarking techniques.     

The effect of commitment to the organization on physicians' familiarity with guidelines for diabetes in managed care organizations

Despite continuous efforts, healthcare organizations still find it difficult to influence physicians to follow clinical guidelines. Previous studies have not taken into account the organizational context of the physicians' practice. We conducted a survey of a representative sample of 743 primary care physicians employed in Israel's 2 largest managed care health plans. The findings indicated that "commitment to the health plan" and "perceived monitoring by the health plan" had an independent positive effect on familiarity with guidelines for treating diabetes. We propose that managers of healthcare organizations consider enhancing physicians' commitment to the organization as a means for increasing their adherence with clinical guidelines, thereby improving the quality of care provided to diabetic patients.     

A review of Healthways' Medicare Health Support program and final results for two cohorts

Chronic care management programs have been shown to offer a scalable approach for improving health and reducing health care costs in commercially insured populations. Medicare Health Support (MHS) was a government-sponsored program designed to determine whether that success could be translated to a Medicare fee-for-service population with complex chronic diseases. The purpose of this article is to provide an overview of MHS and its Phase I study design, and to review the officially reported outcomes of the arm of the study in which Healthways, Inc. provided program services. MHS employed a block randomized design; consent was requested after randomization and evaluation included all eligible individuals, irrespective of that consent. Healthways accepted 2 study cohorts. The first cohort included beneficiaries with diabetes and/or heart failure (Intervention, N=19,936; Control, N=9995) for a 3-year study period. The second cohort entered after 1 year and included beneficiaries with heart failure, with or without diabetes (Intervention, N=4238; Control, N=2106). Comparisons of total health care spending between the Intervention and Control groups found gross savings of $3.8 and $5.7 million for the first and second Intervention cohorts, respectively, and these savings exceeded program costs for the second cohort. Improvements in evaluated clinical measures were demonstrated in the first Intervention cohort, and overall program satisfaction was 94%. Clinical measures and satisfaction were not evaluated for the second cohort. These results indicate that Healthways successfully adapted its commercial chronic care management program for a Medicare fee-for-service population and achieved high satisfaction, improved clinical measures, and financial savings.     

Scheduling Elective Admissions

Each of the several thousand hospitals in the United States is faced with the task of meeting the demands for its facilities, services, and personnel by individuals seeking satisfaction for their health care needs as well as by physicians seeking satisfaction for their professional needs. In general, these demands are not in perfect balance with the available supply at any point in time. It is the purpose of this paper to identify the specific problems created by excess demand for specific services at a specific institution—Henry Ford Hospital—and to present a scheme to minimize both the magnitude and the adverse effects of the imbalance.

Physicians who are engaged simultaneously in the clinical practice of medicine, in professional education, and in medical research must participate in meeting the health care needs both for a number of patients and for specific, unusual patients so as to satisfy their professional needs.

In general, individuals who need health care want the cost to be minimized and, so, place constraints on the amount of resources they are willing to expend for this purpose.

As a practical expediency, this discussion emphasizes the problems of excess demand for specific services of hospital beds and operating room time. It is suggested that the manner in which these specific services are utilized is fundamental to the simultaneous satisfaction of the needs of the patient and the physician and is representative of how we expect to extend this program to include other services, such as professional staff, operating room staff and inpatient nursing staff.

     

Assessing the Barriers to Engaging Challenging Populations in Disease Management Programs

Disease management has gained popularity as a way to improve health status and control of chronic illness through the use of risk stratification, targeted nurse outreach, telephonic nurse advice, and evidence-based guidelines in managing illness. Disease management programs have been successfully implemented by commercial insurers and managed care plans, as well as in Medicare and state Medicaid programs. Although evidence regarding cost savings is inconsistent, it appears that disease management programs do impact health status and quality of care, and improve self-management among the chronically ill.Disease management programs can be customized to meet the needs of vulnerable subpopulations. This article explores the barriers to dealing with chronic illness and other factors faced by disease management programs for Medicaid populations. Barriers to participation and success in disease management for Medicaid beneficiaries are apparent due to lack of access to translation and interpretation services; difficulty with community outreach; achieving buy in from providers and beneficiaries; problems with housing; difficulties accessing primary and specialty care; problems with the availability of pharmacy, durable medical equipment, and other support services; as well as difficulties with Medicaid eligibility and ‘churn’.In order to create a successful disease management program that positively impacts health status, utilization, and cost, it is necessary to consider all of these barriers when designing an intervention for Medicaid beneficiaries. Some of the innovative ways to handle the difficulties of dealing with Medicaid or other low-income populations with special healthcare needs include expanded interpretation and translation activities, extensive community outreach to patients and safety net providers such as clinics and public hospitals, providing support services related to non-medical problems experienced by enrollees, providing understandable written and verbal instructions and training related to health education and medication adherence, as well as efforts to track and maintain contact with eligible and enrolled individuals. Disease management programs can be successful in saving money and improving health in Medicaid populations. However, they must be carefully designed with the specific state Medicaid program and should target the needs of the state’s beneficiaries.