Primary studies included in this systematic review

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36 articles (36 References) loading Revert Studify

Primary study

Unclassified

The effect on test ordering of informing physicians of the charges for outpatient diagnostic tests.

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Journal The New England journal of medicine
Year 1990
Links Pubmed DOI

This article is included in 20 Systematic reviews Systematic reviews (20 references) 1 Broad synthesis Broad syntheses (1 reference)

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We studied the effect of informing physicians of the charges for outpatient diagnostic tests on their ordering of such tests in an academic primary care medical practice. All tests were ordered at microcomputer workstations by 121 physicians. For half (the intervention group), the charge for the test being ordered and the total charge for tests for that patient on that day were displayed on the computer screen. The remaining physicians (control group) also used the computers but received no message about charges. The primary outcomes measured were the number of tests ordered and the charges for tests per patient visit. In the 14 weeks before the study, the number of tests ordered and the average charge for tests per patient visit were similar for the intervention and control groups. During the 26-week intervention period, the physicians in the intervention group ordered 14 percent fewer tests per patient visit than did those in the control group (P less than 0.005), and the charges for tests were 13 percent ($6.68 per visit) lower (P less than 0.05). The differences were greater for scheduled visits (17 percent fewer tests and 15 percent lower charges for the intervention group; P less than 0.01) than for unscheduled (urgent) visits (11 percent fewer tests and 10 percent lower charges; P greater than 0.3). During the 19 weeks after the intervention ended, the number of tests ordered by the physicians in the intervention group was only 7.7 percent lower than the number ordered by the physicians in the control group, and the charges for tests were only 3.5 percent lower (P greater than 0.3). Three measures of possible adverse outcomes--number of hospitalizations, emergency room visits, and outpatient visits during the study period and the following six months--were similar for the patients seen by the physicians in both groups. We conclude that displaying the charges for diagnostic tests significantly reduced the number and cost of tests ordered, especially for patients with scheduled visits. The effects of this intervention did not persist after it was discontinued.

Primary study

Unclassified

A diagnostic centre for general practitioners: results of individual feedback on diagnostic actions.

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Authors Pop P , Winkens RA
Journal The Journal of the Royal College of General Practitioners
Year 1990
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This article is included in 6 Systematic reviews Systematic reviews (6 references)

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A diagnostic centre, managing diagnostic tests for general practice, can improve the service provided by primary health care and the communication between general practitioners and specialists. In addition, it can evaluate the use and misuse of tests. This paper describes the work of a diagnostic centre in the Netherlands serving 80 general practitioners. Following the introduction of individual feedback to general practitioners on their use of diagnostic tests there was a decrease in the number of requests for tests.

Primary study

Unclassified

A computer-assisted quality assurance audit in a multiprovider EMS system.

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Authors Swor RA , Hoelzer M
Journal Annals of emergency medicine
Year 1990
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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Prehospital care delivered by multiple agencies and their paramedics in a suburban emergency medical services (EMS) system was compared to assess the impact of a receiving hospital quality assurance audit on paramedic and agency performance. A committee of physicians, nurses, and paramedics developed performance criteria based on a county EMS protocol. Run tapes were reviewed to assess accuracy of runsheets. Deviations were categorized and tabulated with Lotus 1-2-3 software. A profile was developed for each agency and paramedic. Results were returned to supervisors of each agency on an intermittent basis with subsequent feedback to paramedics. Four agencies and 100 paramedics were audited during the 18-month study period, with a total of 2,406 runsheets reviewed. Average deficiencies per run per quarter for all paramedics decreased from 0.47 to 0.34 (P less than .006). For one agency, deficiencies per run declined from 1.98 to 1.06, although this was not statistically significant (P = .068). During the second nine-month segment of the study, the records of 62 paramedics were reviewed. A mean deficiency per run of 0.39 +/- 0.55 was found, with four paramedics performing more than two standard deviations from the mean. This receiving hospital EMS quality assurance audit has helped document problems in agency procedure performance and individual paramedic performance. It also has improved compliance with county protocol on patients delivered to our institution.

Primary study

Unclassified

The nonvalue of retrospective peer comparison feedback in containing hospital antibiotic costs.

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Authors Parrino TA
Journal The American journal of medicine
Year 1989
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This article is included in 2 Systematic reviews Systematic reviews (2 references)

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Antibiotics have accounted for an increasing percentage of hospital pharmacy charges. Recently, an inexpensive method, automated peer comparison feedback, has been developed to influence physician use of resources. The documented success of several implementations of this strategy led to a one-year experiment to influence hospital antibiotic utilization. Each month, attending physicians in the top 50 percentiles for expenditure were notified of their status in relation to their peers. Expenditures by feedback and control groups were compared to determine whether feedback would result in reduced expenditures by individuals, or whether there would be a generalized reduction in expenditure by the entire group (Hawthorne effect). Over the year, no significant reduction in expenditure was noted. However, some important utilization patterns were identified. Although more surgical patients received antibiotics than did nonsurgical patients, surgical antibiotic costs were less. Surgical therapy was typically of shorter duration and involved the use of less expensive antibiotics. Multiple-antibiotic prescribing was less frequent on surgical services. Thirty percent of attending physicians were responsible for 80 percent of all antibiotic costs; 60 percent of those in this top group were members of the medical cohort. In conclusion: (1) As implemented in the current study, automated peer comparison feedback was not an effective method for reducing antibiotic utilization; (2) Differences in prescribing patterns between services may dictate the best strategies for improving antibiotic utilization; (3) More attention should be directed toward the relatively small "reference group" of physicians responsible for most hospital antibiotic prescribing.

Primary study

Unclassified

Computerized protocol for preventive medicine: a controlled self-audit in family practice.

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Journal Family practice
Year 1989
Links Pubmed DOI

This article is included in 15 Systematic reviews Systematic reviews (15 references) 1 Broad synthesis Broad syntheses (1 reference)

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A protocol for adult health maintenance was designed for display on a desk-top microcomputer in the general practitioner's office. Two hundred and twenty-two patients were entered into a randomized study comparing the outcome of the computerized protocol with manual records. The doctor had the option of displaying the single-screen protocol for the experimental group and acting on its prompts in the course of his normal clinical consultations. At the end of 30 months, significantly more preventive medicine items--smoking, height, blood group, tetanus and rubella immunization status and family planning--had been recorded for patients in the computerized group. For other items, requiring more frequent measurements, computerization produced an advantage only for blood pressure and breast examination, but not for weight, occult blood and serum cholesterol. Recording rates increased significantly for patients in both the control and the computerized groups for all the items. Using the computer lengthened the average consultation time from 8.5 minutes to 10 minutes. Such systems are a valuable aid to encouraging doctors to increase the amount of preventive medicine they incorporate into their routine practice.

Primary study

Unclassified

Promoting cancer screening. A randomized, controlled trial of three interventions.

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Journal Archives of internal medicine
Year 1989
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This article is included in 33 Systematic reviews Systematic reviews (33 references) 1 Broad synthesis Broad syntheses (1 reference)

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To determine effective methods of promoting routine cancer screening, we randomly assigned 62 internal medicine residents to receive cancer screening reminders (computer-generated lists of overdue tests at patients' visits), audit with feedback (monthly seminars about screening, with feedback about their performance rates), or no intervention (controls). Half of the residents in each group also were randomized to receive patient education (patients received literature and notices of overdue tests). We reviewed a sample of each physician's medical records to assess performance of seven tests during 9-month periods before and after initiating the interventions. Cancer screening reminders increased performance of six of seven tests; audit with feedback, four of seven tests; and patient education, one of two targeted breast cancer screening tests. The results indicate that the cancer screening reminders strategy was the most effective in promoting the performance of routine cancer screening tests.

Primary study

Unclassified

Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians.

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Journal The New England journal of medicine
Year 1989
Links Pubmed DOI

This article is included in 5 Systematic reviews Systematic reviews (5 references)

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Guidelines for medical practice can contribute to improved care only if they succeed in moving actual practice closer to the behaviors the guidelines recommend. To assess the effect of such guidelines, we surveyed hospitals and obstetricians in Ontario before and after the release of a widely distributed and nationally endorsed consensus statement recommending decreases in the use of cesarean sections. These surveys, along with discharge data from hospitals reflecting actual practice, revealed that most obstetricians (87 to 94 percent) were aware of the guidelines and that most (82.5 to 85 percent) agreed with them. Attitudes toward the use of cesarean section were congruent with the recommendations even before their release. One third of the hospitals and obstetricians reported changing their practice as a consequence of the guidelines, and obstetricians reported rates of cesarean section in women with a previous cesarean section that were significantly reduced, in keeping with the recommendations (from 72.2 percent to 61.1 percent; P less than 0.01). The surveys also showed, however, that knowledge of the content of the recommendations was poor (67 percent correct responses). Furthermore, data on actual practice after the publication of the guidelines showed that the rates of cesarean section were 15 to 49 percent higher than the rates reported by obstetricians, and they showed only a slight change from the previous upward trend. We conclude that guidelines for practice may predispose physicians to consider changing their behavior, but that unless there are other incentives or the removal of disincentives, guidelines may be unlikely to effect rapid change in actual practice. We believe that incentives should operate at the local level, although they may include system-wide economic changes.

Primary study

Unclassified

Alteration of physicians' orders by nonphysicians.

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Authors Finn AF , Valenstein PN , Burke MD
Journal JAMA : the journal of the American Medical Association
Year 1988
Links Pubmed

This article is included in 1 Systematic review Systematic reviews (1 reference)

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We prospectively evaluated the accuracy with which clerical and laboratory staff carried out physicians' written orders for thyroid function testing in 181 patients at two institutions. In 54% of the patients studied, support staff were found to have added or deleted one or more tests from the original written orders. When the ordering physicians were asked to identify the clinical indications for the tests they had ordered, 37% of their orders either lacked an appropriate test or included an unnecessary test request. In contrast, after clerical and laboratory staff had changed orders, only 25% of patients had inappropriate tests performed or necessary tests omitted. Clerical staff using computer-based ordering menus significantly improved the appropriateness of physicians' orders compared with clerks who lacked such guidance. Laboratory technologists who used informal, knowledge-based rules also tended to improve the appropriateness of physicians' orders. We conclude that a substantial proportion of physicians' orders for diagnostic tests may be modified during the test requisitioning process. The use of testing regimens by ward clerks and laboratory technologists may explain their ability to improve on physicians' orders.

Primary study

Unclassified

Can audit improve patient care? Effects of studying use of digoxin in general practice.

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Journal BMJ (Clinical research ed.)
Year 1988
Links Pubmed

This article is included in 4 Systematic reviews Systematic reviews (4 references)

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A survey of monitoring of digoxin treatment in five practices examined the indications for prescribing digoxin, its long term use, and how its use could be monitored. These data were used to generate a protocol for monitoring treatment with digoxin in general practice. The findings of the survey and the protocol were distributed to and discussed with all the partners in the practices participating in the study. One year later similar analysis showed that record keeping (recording of pulse rate and rhythm) had improved significantly in the group of principals carrying out the audit but not in other principals in these practices. Audit may change only the auditors.

Primary study

Unclassified

A successful program to lower cesarean-section rates.

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Authors Myers SA , Gleicher N
Journal The New England journal of medicine
Year 1988
Links Pubmed DOI

This article is included in 3 Systematic reviews Systematic reviews (3 references)

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Despite the consensus that national cesarean-section rates are excessive, they continue to rise. Currently, approximately one of every four deliveries is by cesarean section. We developed an initiative to reduce the number of cesarean deliveries to a rate of 11 percent of all deliveries at our inner-city hospital. Participation by attending physicians was voluntary and not linked to any sanction. The program included a stringent requirement for a second opinion, objective criteria for the four most common indications for cesarean section, and a detailed review of all cesarean sections and of individual physicians' rates of performing them. During the first two years of the program, the cesarean-section rate fell from 17.5 percent of 1697 deliveries in 1985 to 11.5 percent of 2301 deliveries in 1987 (P less than 0.05). The proportion of infants with five-minute Apgar scores lower than 7 increased from 3 percent in 1985 to 4.9 percent in 1987 (P less than 0.05), but neither the fetal mortality rate (11.9 per 1000) nor the neonatal mortality rate (11.2 per 1000) in 1987 differed significantly from the rates in 1985. A single maternal death, unrelated to cesarean delivery, occurred during the study. Rates of both primary and repeat cesarean sections decreased, although only the decline in the rate of primary cesarean sections, from 12 to 6.8 percent, was statistically significant (P less than 0.05). During the same period, operative vaginal deliveries (i.e., forceps deliveries and midpelvic procedures) declined from 10.4 to 4.3 percent (P less than 0.05) of total deliveries. We conclude that an initiative within an obstetrics department can reduce cesarean-section rates substantially without adverse effects on the outcome for mother or infant.