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Guideline Implementation and Evaluation

Individualized Feedback To Implement Clinical Guidelines
Grant/Contract Number: HS07715
Project Period: 01/94-12/95
Principal Investigator: E. Andrew Balas, M.D., Ph.D.
Institution: University of Missouri
Columbia, MO 65211
Purpose: To develop an expert system to generate individualized feedback for the implementation of clinical practice guidelines. The study aimed to (1) promote the development of corporate continuous quality improvement programs for the purpose of implementing practice guidelines and reducing unnecessary variation in patient care; (2) promote the translation of corporate objectives into measurable, individual quality improvement objectives for various clinical diagnoses; and (3) support the implementation of clinical practice guidelines by comparing practice patterns with specified objectives, selecting evidence, and highlighting discrepancies.

Computer-Based Access to Guidelines for Clinical Care
Grant/Contract Number: HS06575
Project Period: 07/91-01/97
Principal Investigator: G. Octo Barnett, M.D.
Institution: Massachusetts General Hospital
Boston, MA 02114
Purpose: To develop, implement, and evaluate a computer-based system that provides physicians and nurses access to clinical guidelines of care for the purpose of learning and consultation. This system will be applied to topics such as troubleshooting and management of patients with pulmonary artery catheters, prevention and management of skin breakdown, and management of patients on ventilators.

Implementation of Guidelines in a Large Group-Model HMO
Grant/Contract Number: HS07649
Project Period: 09/92-09/96
Principal Investigator: Jonathan B. Brown, Ph.D., M.P.P.
Institution: Kaiser Foundation Research Institute
Portland, OR 97227-1098
Purpose: To evaluate strategies used by a large group-model health maintenance organization to implement national clinical guidelines for the detection and treatment of hypertension and depression. Three implementation strategies (Continuous Quality Improvement, Academic Detailing, or both combined) are being evaluated by the study site, using routine organizational processes but within the framework of a quasi-experimental design that also included an untreated control group. Study aims are being compared in terms of changes in patient outcomes, the technical content of care, provider knowledge and satisfaction, patient satisfaction, and costs.

Evaluating AHCPR Urinary Incontinence Guideline Usage
Grant/Contract Number: HS08716
Project Period: 09/94-09/97
Principal Investigator: Stuart J. Cohen, Ed.D.
Institution: Bowman Gray School of Medicine
Winston Salem, NC 27157-1063
Purpose: To conduct a randomized controlled trial with 40 primary care practices to foster the adoption and implementation of the AHCPR urinary incontinence (UI) guidelines by primary care providers. The trial also seeks to determine the impact of UI guideline adoption on severity status, health status, health related quality of life and satisfaction with care of about 600 patients 60 years of age who report being symptomatic for UI. This study tracks primary care providers' attitudes, beliefs, and guideline adherence and their office staff attitudes and beliefs.

A Physician Insurer's Impact on Early Cancer Detection
Grant/Contract Number: HS06992
Project Period: 06/91-05/96
Principal Investigator: Stuart J. Cohen, Ed.D.
Institution: Bowman Gray School of Medicine
Winston Salem, NC 21757-1063
Purpose: To (1) conduct a randomized controlled study to demonstrate the effect of a physician liability insurance company in influencing physicians' behavior regarding compliance with National Cancer Institute (NCI) endorsed guidelines for cancer screening, (2) determine whether the company's evaluation activities are effective in facilitating change, and (3) determine the extent to which changes in early cancer detection diffuse to practices not receiving interventions. The study will provide information on effective processes for increasing physicians' conformity with selected NCI endorsed guidelines for the prevention and early detection of breast, cervical, skin, and prostate cancer, thereby leading to improved outcomes in cancer patients.

Impact of OB Practice Guidelines on Physician Behavior
Grant/Contract Number: HS07294
Project Period: 09/93-11/96
Principal Investigator: Ronald D. Deprez, Ph.D.
Institution: Public Health Research Institute
Portland, ME 04101
Purpose: To evaluate the impact of five obstetrical care practice guidelines implemented by the Maine Medical Liability Demonstration Project (MLDP) on physician practice patterns. The study measured changes in Caesarean section rates, diagnoses, physician behavior, and birth outcomes addressed by the guideline parameters. The study also measured reductions in defensive medicine resulting from these changes, as well as the impact of the MLDP on obstetrical malpractice incidents and claims.

A Randomized Trial of Computerized ICU Protocols
Grant/Contract Number: HS06594
Project Period: 12/91-02/97
Principal Investigator: Thomas D. East, Ph.D.
Institution: University of Utah
Salt Lake City, UT 84143
Purpose: To generate and test the efficacy of computer protocols for the management of mechanical ventilation for critically ill patients. The efficacy of the computer protocols is being tested by conducting a prospective, randomized, controlled clinical trial using 400 patients in 4-5 hospitals and examining survival, morbidity, incidence/severity of barotrauma, and resource consumption. Generalizability will be determined by (1) the time in which protocols controlled patient care, (2) the number of protocol instructions that were not followed, and (3) the number of objections to protocol logic.

Superspecialization of Medical and Surgical Subspecialists
Grant/Contract Number: HS08573
Project Period: 06/96-05/98
Principal Investigator: José J. Escarce, M.D., A.M.
University of Pennsylvania
Philadelphia, PA 19104-3246
Purpose: To examine the patterns and determinants of superspecialization among medical and surgical subspecialists. The project studies three medical and four surgical subspecialities. Using an information theory index, this study measures the degree of superspecialization. Sources of data include 1992 and 1993 Medicare physician eligibility and claims files. The results of this study should lead to a better understanding of how proposed physician workforce policies and the evolution of health care delivery toward managed care are likely to influence subspecialists' scope of practice.

Dissemination of Guidelines for Pneumonia Length of Stay
Grant/Contract Number: HS08282
Project Period: 09/96-09/99
Principal Investigator: Michael J. Fine, M.D.
Institution: University of Pittsburgh
Pittsburgh, PA 15213
Purpose: To (1) determine the effectiveness of a medical practice guideline to reduce length of stay in community-acquired pneumonia using a dissemination strategy (intervention) implemented through study hospital utilization management programs; (2) compare the medical costs of care and the outcomes of patients managed by physicians who received the intervention of patients of physicians in the usual medical care group; and (3) evaluate the process of guideline dissemination to determine the factors associated with guideline compliance. The results of this multicenter, randomized, single-blinded study should lead to a substantial reduction in unnecessary hospital care in patients with community-acquired pneumonia.

Dissemination of Prevention Guidelines to Harlem Physicians
Grant/Contract Number:HS07076
Project Period: 09/91-09/94
Principal Investigator: Donald Gemson, M.D., M.P.H.
Institution: Columbia University
New York, NY 10032
Purpose: To develop a national model for dissemination of prevention practice guidelines to hospital based residents and attending physicians that helps meet the critical need for preventive services in inner city minority communities. The study (1) described physician knowledge, attitudes, and practices with respect to health promotion and disease prevention at two inner city hospitals before the initiation of an educational program in prevention; (2) identified factors associated with physicians' knowledge, attitudes, and practices, such as personal, professional, and practice setting characteristics; (3) designed and implemented a practical and replicable hospital based educational program in health promotion and disease prevention; and (4) assessed changes in physician health promotion and disease prevention knowledge, attitudes, and practices at the two hospitals following a 5 month educational program in prevention at Harlem Hospital. Data were obtained from self administered questionnaires and patient interviews.

Evaluation of Guidelines in Large Group Practices
Grant/Contract Number: HS07652
Project Period: 12/92-11/96
Principal Investigator: Harold I. Goldberg, M.D.
Institution: Harborview Medical Center
Seattle, WA 98104
Purpose: To combine and analyze data about the outcomes of two experimental studies in the effectiveness of academic detailing and continuous quality improvement in implementing clinical practice guidelines for the primary care of depression and hypertension. Using the combined data, the study performs analyses that will help AHCPR and other researchers understand how guideline implementation methods differentially affect subgroups of providers and patients.

Legal Barriers to Insurers' Use of Practice Guidelines
Grant/Contract Number: HS08681
Project Period: 07/93-06/96
Principal Investigator: Mark A. Hall, J.D.
Institution: Wake Forest University
Winston Salem, NC 27109-7206
Purpose: To (1) understand the courts' reservation to public and private insurers' use of medical practice guidelines; (2) share the list of concerns and recommended modifications with representatives of Government, insurers, and consumers for their review and comment; and (3) disseminate the findings to guideline panels, PORTs, policymakers, physicians, lawyers, judges, and other interested parties. This project is conducting a comprehensive review of court decisions and legal, ethical, social science, and health services literature.

Dissemination of Professional Parameters of Care
Grant/Contract Number: HS07079
Project Period: 09/91-06/96
Principal Investigator: John F. Helfrick, D.D.S., M.S.
Institution: Methodist Hospital
Houston, TX 77030
Purpose: To study and improve educational methods for disseminating professional parameters for clinical care developed by the American Association of Oral and Maxillofacial Surgeons. To facilitate the study, four educational programs are planned; surveys are being distributed before, during, and after the intervention; and a review of patient records is being conducted. Analysis of the frequency of use of the specific treatments recommended within the parameters will measure the diffusion in behavior changes and the effectiveness of differing teaching methods based on those behavior changes.

Clinical Practice Guideline Implementation Demonstration
Grant/Contract Number: HS07095
Project Period: 03/93-02/97
Principal Investigator: David E. Kanouse, Ph.D.
Institution: RAND Corporation
Santa Monica, CA 90407-2138
Purpose: To conduct a randomized study to develop a rigorous, large-scale demonstration and experimental evaluation of two alternative implementation strategies in order to determine appropriate active dissemination of appropriateness review ratings that will actually influence medical practice. The strategies are being tested in a trial using 12 physician groups in 6 community hospitals and managed care organizations, settings similar to those in which the most complex medical care is delivered in the United States. Random assignment to intervention or control groups and other research designs ensures validity and universality of the results. Review of 2,400 medical records is being conducted, and background data on the physicians and hospitals are being collected.

Outcomes Dissemination: The Maine Study Group Model
Grant/Contract Number: HS06813
Project Period: 09/91-03/97
Principal Investigator: Robert B. Keller, M.D.
Institution: Maine Medical Assessment Foundation
Manchester, ME 04351
Purpose: To develop a demonstration project that will (1) show how the study group/data feedback approach produces behavior change in physicians; (2) determine via survey research the effect of the data feedback process on physician knowledge and attitudes; and (3) show that the feedback approach can be used to disseminate PORT findings, practice guidelines, and other outcome research findings to practicing physicians.

Diffusion and Adoption of Children's Vaccine Guidelines
Grant/Contract Number: HS07286
Project Period: 07/92-06/96
Principal Investigator: Thomas R. Konrad, Ph.D.
Institution: University of North Carolina
Chapel Hill, NC 27599-7590
Purpose: To more effectively disseminate and improve adoption of pediatric vaccine guidelines by (1) identifying pediatricians' and family physicians' awareness of, agreement with, adoption of, and adherence to immunizing guidelines for selected pediatric diseases; (2) identifying correlates of vaccine guideline awareness, agreement, adoption, and adherence; (3) identifying features of the immunization guidelines and routes of dissemination that influence their visibility and physician adherence; (4) identifying physician perceived barriers to the successful dissemination and implementation of vaccine guidelines; and (5) developing strategies to more effectively craft and disseminate vaccine guidelines and maximize physicians' ability to achieve high vaccine administration rates. Data are being gathered through a mail survey, followup mail survey, office records audit, focus groups, and telephone contacts.

Computer Records, Guidelines, Quality, and Efficient Care
Grant/Contract Number: HS07719
Project Period: 07/94-06/97
Principal Investigator: Clement J. McDonald, M.D.
Institution: Regenstrief Institute
Indianapolis, IN 46202-2859
Purpose: To rigorously measure the real effect of automated guidelines on physician practice problems and patient outcomes and to shed light on the practicality, costs, and benefits of practice guidelines automatically applied by a computer based patient record system. Various medical problems and their computer executable guidelines are being reviewed, including congestive heart failure, pneumonia, and urinary tract infection.

Validating Guidelines for the Care of AMI Patients
Grant/Contract Number: HS08071
Project Period: 09/94-08/98
Principal Investigator: Barbara J. McNeil, M.D., Ph.D.
Institution: Harvard Medical School
Boston, MA 02115
Purpose: To validate national guidelines for acute myocardial infarction (AMI) patients for angiography, coronary artery bypass graft (CABG) or percutaneous transluminal angioplasty (PCTA). The study will provide information regarding the extent to which adherence to guidelines affects patient outcomes and cost.

Practice Guidelines in Primary Care
Grant/Contract Number: HS07069
Project Period: 07/93-08/96
Principal Investigator: W. Scott Schroth, M.D., M.P.H.
Institution: George Washington University Medical Center
Washington, DC 20037
Purpose: To determine the impact of a clinical guideline for the treatment of acute low back pain on clinician practices, utilization of medical resources, patient satisfaction and functional outcomes with analyses of patient education, and cost. The study also evaluated alternative guideline implementation methods in a controlled comparison of primary care clinician practice groups within a health maintenance organization setting.

A Structured Criteria Review Process for Four Surgical Procedures
Grant/Contract Number: HS07080
Project Period: 09/91-09/93
Principal Investigator: J. Sanford Schwartz, M.D.
Institution: University of Pennsylvania
Philadelphia, PA 19104-6218
Purpose: To evaluate a review and dissemination process of appropriateness criteria for coronary artery bypass graft surgery, abdominal aortic aneurysm resection, cataract extraction, and carotid endarterectomy in an effort to better characterize the necessary components of a successful intervention program in the development of practice guidelines. The study tested the review process by engaging affected clinicians in a structured review of the criteria, soliciting their reactions to the criteria and identifying any modifications that would improve them, soliciting predictions of results from applying the criteria with and without any modifications, and comparing actual results with predictions.

Adoption of Cancer Pain Guidelines in Managed Care
Grant/Contract Number: HS08691
Project Period: 06/96-05/00
Principal Investigator: Mildred Z. Solomon, Ed.D.
Education Development Center, Inc.
Newton, MA 02158-1060
Purpose: To determine the effect of a two-tiered (organizational and individual) dissemination strategy on health care providers' adoption of the Agency for Health Care Policy and Research's cancer pain guideline. The study involves 1,360 cancer patients and 160 physicians and nurses from 8 clinics, randomized into 4 treatment and 4 control sites. It tests the hypothesis that compared with control group patients, treatment group patients will (1) report lower ratings of pain intensity; (2) report an enhanced quality of life, as measured by the extent to which pain interferes with sleep, work, and other aspects of daily living; (3) receive more appropriate analgesic regimens; (4) be less likely to be readmitted to the hospital for pain control; and (5) be more likely to be referred to hospice and referred there earlier.

Outcomes of Compliance with an AMI Practice Guideline
Grant/Contract Number: HS07631
Project Period: 12/93-11/97
Principal Investigator: Stephen B. Soumerai, Sc.D.
Institution: Harvard Medical School
Boston, MA 02215
Purpose: To investigate (1) whether well-documented acute myocardial infarction treatment guidelines are adopted by physicians in primary care settings; and (2) whether a retrospective cohort study using large, linked Medicare drug-claims databases can replicate the results of randomized controlled trials of beta blocker therapy on patient outcomes. The investigators are linking and analyzing three New Jersey claims databases.

Improving Compliance with Acute MI Practice Guideline
Grant/Contract Number: HS07357
Project Period: 10/93-08/97
Principal Investigator: Stephen B. Soumerai, Sc.D.
Institution: Harvard Medical School
Boston, MA 02215
Purpose: To conduct a randomized controlled study that will evaluate the effectiveness and costs of a model to disseminate practice recommendations for acute myocardial infarction. The intervention involves technical assistance to opinion leaders who will provide consultation and peer review, dissemination of an attractively designed brochure, and group performance feedback by opinion leaders to physicians and nurses. The project involves 37 hospitals in 1 state. It examines the proportion of patients who received effective therapies and the proportion of patients who received potentially harmful therapies as a result of the dissemination. In addition, the cost effectiveness of the dissemination strategy is being assessed.

Pediatric Asthma Care PORT II
Grant/Contract Number: HS08368
Project Period: 09/96-09/01
Principal Investigator: Kevin B. Weiss, M.D.
Institution:
Center for Health Services Research Chicago, IL 60612
Purpose: To test the effectiveness and cost effectiveness of recently developed practice guidelines (National Asthma Education Program) designed to reduce asthma morbidity among children. The primary outcomes to be examined in this randomized controlled clinical trial are based on symptom assessment; however, other outcomes, specifically functional status, health care utilization and patient satisfaction will be examined as well. It is anticipated that the study arms will substantially differ from usual care both marginal costs and marginal effectiveness. Additionally, this PORT-II will test educational and organizational approaches to changing practice patterns within managed care organizations.

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