Interventions improve primary care processes but not necessarily outcomes
ACP J Club. 1996 Jan-Feb;124:23. doi:10.7326/ACPJC-1996-124-1-023
Yano EM, Fink A, Hirsch SH, Robbins AS, Rubenstein LV. Helping practices reach primary care goals: lessons from the literature. Arch Intern Med. 1995 Jun 12; 155:1146-56.
To summarize programs designed to enhance the quality and economy of primary care.
MEDLINE (1980 to 1992) searches were done using the terms ambulatory care, ambulatory care facilities, primary health care, professional education, quality of health care, outcome and process assessment (health care), continuity of patient care, costs and cost analysis, efficiency, and activities of daily living.
Studies were selected if they met ≥ 5 of 9 predetermined quality standards (data collection and validity, research question, program description, statistics, sample selection and size, follow-up, and biases).
Data extracted included study design and quality, primary care goal, intervention, and effect of the intervention.
1785 articles were identified, and 32 (26 randomized trials) met the criteria. More than half of the 5000 care providers were residents or housestaff. Primary care goals for which interventions showed improvements were reduction of physician-ordered services (10 of 10 studies), preventive care (computerized chart reminders, feedback and audit or checklists, smoking cessation [counseling reminders], and screening protocols) (7 of 10 studies), management and coordination (nursing protocols, multidisciplinary teams, and funds to improve group practices) (11 of 13 studies), appropriate use of services (4 of 5 studies), efficiency (2 of 3 studies), patient and general satisfaction (2 of 4 studies), access (2 of 4 studies), care shift from inpatient to outpatient settings (1 of 2 studies), costs and charges (2 of 5 studies), patient physical function (1 of 3 studies), and technical process (multidisciplinary teams and feedback) (2 of 16 studies). Interventions showed no improvement for continuity of care (4 studies), morbidity (4 studies), physical environment (2 studies), mortality (1 study), and humanistic processes (physician-patient relationships and patient and family psychosocial needs) (1 study).
Interventions to improve the quality and economy of primary care (especially computer-generated reminders, audit and feedback, social-influence-based methods, and shifting specific function to nonphysicians) show substantial improvements (> 50% of studies were positive) in physician-ordered services, preventive care, management and coordination, use of services, efficiency, satisfaction, access, and shift from inpatient to outpatient settings. Interventions are less successful for improving continuity of care, morbidity, physical environment, mortality, humanistic process, costs and charges, physical function, and technical process.
Source of funding: Department of Veterans Affairs.
For article reprint: Dr. E.M. Yano, Evaluation and Decision Support Service, Sepulveda Veterans Affairs Medical Center, 16111 Plummer Street, Sepulveda, CA 91343, USA. FAX 818-895-5838.
No one who has slept through hours of traditional CME lectures on a sub-specialized topic would argue with the findings of Davis and colleagues. Davidoff (1) has also questioned the efficacy of this mode of education. The most effective educational strategies are closely intertwined with clinical practice.
The reason that traditional CME is becoming irrelevant has to do with what our practices are becoming. The "new" practice of primary care is evolving away from an industrial model that rewards production of patient visits. The patient-centered approach acknowledges that what patients actually want is less computed tomography and more answers and education from their providers. Some patients are getting their health care information directly from the Internet. Today, providers need patient care information just to stay ahead of their patients! This re-engineering can take many lessons from the evolution of the information economy out of a manufacturing base.
Yano and colleagues defined access in terms of the ease with which patients could speak to or get an appointment with their care providers. In fact, a nurse's telephone call can be exactly what the patient means by "access." We will have to drop the 1950s model of a patient traveling to meet face-to-face with a physician as the sine qua non of health care. The new model of health care and CME is still being formed.
We can be sure of one thing: The paradigm of providers memorizing protocols can now be safely buried along with bleeding as a treatment for illness. We do not need to memorize protocols, we need to be reminded when to use them. Computer reminders were a common and successful method of achieving the goals of each of these articles. Another source of studies of the effects of information services and utilization management on patient care is the Columbia Registry of Information and Utilization Management Trials (2).
Davis and colleagues specifically excluded "administrative interventions," such as computer-based patient records or the problem-based format for records. According to Weed's (3) then-futuristic, computer-based, problem-oriented system, medical records should guide and teach. Barnett (4) argues that the most powerful use of information technology in undergraduate medical education will come when computer-based patient records are tightly integrated into educational resources and the student can learn at the instant the information is needed. The same can be said of postgraduate education. Perhaps how-to sessions on computer-based, problem-oriented patient records now should be a topic in primary care CME. The health care education equivalent of just-in-time manufacturing may be just around the corner.
As we continue to study the best ways to implement these changes, the humanistic aspect cannot be lost or made secondary. As managed care and economic realities force computers into patient care, we should be studying how best to bring them into the examination room without sacrificing the quality of the physician-patient relationship. Perhaps what we do best in providing health care is humanistic information processing. If so, we may see computerization continue to improve what we do and, eventually, improve outcomes.
Bruce Slater, MD
George Washington UniversityHerndon, Virginia, USA