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Women from diverse backgrounds generally agree on the quality of obstetric care they receive in the hospital

Regardless of sociodemographic differences, women admitted to a hospital for labor and delivery generally agree in their assessment of the quality of obstetric care they receive, concludes a study supported in part by the Agency for Health Care Policy and Research (National Research Service Award training grant T32 HS00059). Sociodemographic differences accounted for only 2 to 3 percent of the variation in women's obstetric care assessments. Also, hospital characteristics had a very small influence on patients' evaluations of obstetric care.

Although differences were small, women generally rated obstetric care higher in nonteaching hospitals (teaching hospitals are often staffed by unfamiliar physicians and residents), those with fewer beds, fewer deliveries, lower cesarean delivery rates, fewer Medicaid-insured patients, and higher rates of vaginal births after previous C-section deliveries. Women's assessments of care were strongly correlated with several other general measures of patient-perceived quality, such as how much women felt they were helped by the hospitalization or their perception of the hospital's reputation in the community. Thus, assessments of individual aspects of care, such as nursing or physician care, were influenced by general perceptions of the hospital, according to Beth S. Finkelstein, Ph.D., of the Cleveland Veterans Affairs Medical Center and her colleagues at Case Western Reserve University.

The researchers conducted a community-based survey of 16,051 women discharged after labor and delivery from 18 hospitals during a 3-year period, one of the largest evaluations to date. The women completed a questionnaire assessing hospital obstetric care, which included five scales assessing different aspects of the process of care—for example, physician care or discharge preparation. The women's care assessments were then correlated with patient and hospital characteristics.

More details are in "Patient and hospital characteristics associated with patient assessments of hospital obstetrical care," by Dr. Finkelstein, Jagdip Singh, Ph.D., J.B. Silvers, Ph.D., and others, in Medical Care 36(8), pp. AS68-AS78, 1998.

Many low-income women are satisfied with Norplant contraception

Low-income women who do not feel coerced into using Norplant—a contraceptive implant that lasts for 5 years—seem to be satisfied with this method of birth control. Satisfaction is greatest among women who are told about potentially serious side effects and about other birth control options.

Norplant has been criticized from the beginning as placing population control policies over the health care needs of low-income women. However, Florida's public family planning system made an effort to educate low-income women about the risks of serious side effects, the need for a trained professional to remove the implant, and other birth control options. As a result, 92 percent of Norplant users interviewed were satisfied with this method of birth control, says a study supported in part by the Agency for Health Care Policy and Research (HS07965).

Led by Leslie L. Clarke, Ph.D., of the University of Florida, researchers interviewed 1,152 Norplant users and 1,268 nonusers who attended family planning clinics in four Florida counties. The researchers correlated women's sociodemographic and medical characteristics with Norplant selection and satisfaction. Women who experienced side effects (for example, blood loss, pain, hair loss or growth, and moodiness) and those who felt pressure to select this method were less likely than others to be satisfied with Norplant.

Women who were Medicaid clients, planned to have children in 5 or more years, lived in Palm Beach County, were using drugs, and were offered Norplant were more likely than other women to select Norplant. Those younger than 17 and those who learned about Norplant from a friend were twice as apt as others to select Norplant over other contraceptive methods. Florida was the first State to offer Norplant through its publicly funded family planning clinics.

For more details, see "Norplant selection among low-income women," by Dr. Clarke, Karla Schmitt, M.S.N., M.P.H., Christine A. Bono, M.A., and others, in the August 1998 American Journal of Public Health 88(8), pp. 1175-1181.

Treatment costs are nearly five times as high for infants weighing closer to 2 pounds than 3 pounds at birth

Large improvements in neonatal technology in the last 2 decades have significantly improved survival prospects of very low birthweight (VLBW) infants, but costs are high. For instance, a recent study supported by the Agency for Health Care Policy and Research (HS065667) shows that it costs almost five times as much, on average, to produce a first-year infant survivor weighing less than 750 grams or 1.7 pounds at birth than one weighing 1,250 grams to 1,499 grams or 2.8 to 3.3 pounds ($273,900 vs. $58,000). Any prenatal intervention that results in a normal birth instead of a VLBW saves $59,700 in medical costs during the first year of the infant's life, concludes RAND researcher, Jeannette Rogowski, Ph.D.

Dr. Rogowski used California Medicaid claims data to measure first-year treatment costs for all VLBW (less than 1,500g or 3.3 pounds) single babies born alive in California during 1986 and 1987 who were eligible for Medicaid during that time. Results showed that treatment costs per first-year survivor produced were twice as high ($273,900) for surviving infants weighing less than 750g as for those weighing 750 grams to 999 grams ($138,800) and were almost twice as high as for the 1,000-gram to 1,249-gram group ($75,100).

Public policies such as recent Medicaid expansions, which are aimed at improving birth outcomes by providing insurance coverage for pregnant women and children, are in part an effort to decrease infant mortality rates. By decreasing the likelihood of premature births, these policies can potentially be very cost effective. A weight increase of 250 grams at birth saves an average of $12,000 to $16,000 in first year medical costs, and a 500-gram increase generates $28,000 in savings.

For details, see "Cost-effectiveness of care for very low birth weight infants," by Dr. Rogowski, in the July 1998 Pediatrics 102(1), pp. 35-43.

Newborn screening for cystic fibrosis has little effect on future reproductive decisions of parents with a CF child

Cystic fibrosis (CF) is a hereditary disease that affects the pancreas and lungs in ways that lead to malnutrition and frequent respiratory infections. With new treatments, more children with CF are surviving into early adulthood. However, the benefit of newborn CF screening remains controversial. The largest study to date shows that neonatal CF screening does not significantly affect decisions of parents who already have a child with CF to have more children. Most families whose first-born child had CF continued to have children, and only a few used prenatal diagnosis in future pregnancies, finds a study supported by the Agency for Health Care Policy and Research (HS08570).

Nevertheless, this genetic information was valuable to some families and should still be considered a limited secondary benefit in national policy decisions about CF newborn screening, conclude Benjamin S. Wilfond, M.D., of the University of Arizona, and his colleagues. As part of the Wisconsin Cystic Fibrosis Neonatal Screening Project, they identified 135 families as having a child with CF from 1985 to 1994. These families were provided information about the genetics of CF at the time of diagnosis and during followup visits, and they were offered the option of referral to genetics counselors for information about prenatal diagnosis for future pregnancies and implications for extended family members.

When surveyed in 1994, 70 percent of couples with a first CF child had conceived more children. There were 43 subsequent pregnancies in 31 families. Prenatal diagnosis was used by 26 percent of the families for 21 percent of the pregnancies. There were three pregnancies with CF detected, all of which were carried to term.

See "Cystic fibrosis newborn screening: Impact on reproductive behavior and implications for genetic counseling," by Elaine H. Mischler, M.D., Dr. Wilfond, Norman Fost, M.D., M.P.H., and others, in Pediatrics 102(1), pp. 44-52, 1998.

Providing high school students with access to condoms does not increase teen sex

Teenagers who have access to condoms in their high school classrooms are no more sexually active than those who don't. However, male students who are sexually active and have access to condoms at school are more likely to use them when they have sex and male virgins are more apt to use condoms for first-time sex, concludes a study supported by the Agency for Health Care Policy and Research (HS08055).

These findings support the arguments of proponents who believe that such school programs can reduce the number of pregnancies and sexually transmitted diseases among teenagers. They also refute objections that such programs increase sexual intercourse among teenagers. By early 1995, at least 431 schools in 50 U.S. school districts had established such programs.

Mark A. Schuster, M.D., Ph.D., of RAND and the University of California, Los Angeles, and his colleagues evaluated a program at a Los Angeles County high school in which plastic packets of condoms were placed in baskets in four classrooms and outside the nurse's office of a Los Angeles County high school. Each package contained two condoms, an instruction sheet, and a card warning that "Condoms are not 100 percent effective in preventing AIDS/HIV, sexually transmitted diseases, or pregnancy during sexual intercourse. Abstinence is! Not all teenagers are sexually active. Think before you act! The consequences may be for a lifetime." Students completed anonymous surveys of their sexual behavior before program inception and 1 year later.

The proportion of male teens who reported using condoms every time they engaged in vaginal intercourse during the prior year increased significantly from 37 percent prior to the program's inception to 50 percent 1 year later. Also, the number of male virgins who reported condom use at a recently initiated first vaginal intercourse increased from 65 percent to 80 percent. However, female high school students, who may find it more difficult to discuss condom use with their partners, showed no significant change in their condom use.

For more information, see "Impact of a high school condom availability program on sexual attitudes and behaviors," by Dr. Schuster, Robert M. Bell, Ph.D., Sandra H. Berry, M.A., and David E. Kanouse, Ph.D., in Family Planning Perspectives 30(2), pp. 67-72, 88, 1998.

Editor's Note: See also "Students' acquisition and use of school condoms in a high school condom availability program," by the same authors, in Pediatrics 100(4), pp. 689-694, 1997).

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Long-term Care

Nursing staff levels at U.S. nursing homes continue to be lower than recommended

Poor quality of care in nursing homes has been a concern for some time, with low nurse staffing levels identified as one factor that may contribute to poor quality of care. Although overall nurse staffing levels increased among certified nursing facilities in the United States from 1991 through 1995, they varied substantially across regions and States. They also remained below nurse staffing levels recommended by the Institute of Medicine, finds a study supported in part by the Agency for Health Care Policy and Research (HS07574).

Average registered nurse (RN), licensed vocational nurse (LVN), and licensed practical nurse (LPN) combined staffing levels were 72 minutes per day per resident (or 24 minutes per 8-hour shift) in nursing homes in the United States in 1995. The majority of nursing care was provided by nursing assistants. The average staffing levels for RNs and LVNs increased somewhat over the 5 years, but total nurse staffing levels only increased by 7 percent during that time. Nursing homes in Western regions had significantly higher levels of nurse staffing than other regions. States that had nursing homes with higher resident case mix levels had higher RN and LVN/LPN hours. States with higher percentages of large facilities had lower RN and LVN/LPN levels, and States with higher percentages of for-profit facilities had lower RN levels.

Variation in staff levels, even after accounting for differences in case mix, are troubling, since they indicate inequities for residents, explains Charlene Harrington, Ph.D., of the University of California, San Francisco. Dr. Harrington and her colleagues call for studies to define acceptable staffing standards for long-term-care facilities. Their findings are based on analysis of data for all certified nursing homes in the United States listed in the Federal On-Line Survey Certification and Reporting System.

For more details, see "Nursing facility staffing in the states: The 1991 to 1995 period," by Dr. Harrington, Helen Carrillo, M.S., Joseph Mullan, Ph.D., and James H. Swan, Ph.D., in the September 1998 Medical Care Research and Review 55(3), pp. 334-363.

Nursing home characteristics have inconsistent effects on patient outcomes

A recent study correlating nursing home characteristics with the outcomes of chronically ill long-term nursing home residents has found an inconsistent relationship between the two. Although many patient attributes, such as diagnosis, were associated with survival chances and functional decline, few facility characteristics were. No one or two facility characteristics could be pinpointed as consistently improving or adversely affecting all four patient outcome measures: survival rate and functional, mental, and incontinence status. Facility characteristics examined included proportion of Medicaid residents with great service needs, nurse staffing levels, use of restraints, and profit or non-profit status.

In contrast to previous studies of nursing home residents receiving short-term (usually 6 months or less) posthospital rehabilitative care, this study of nursing home stays up to 3 years in duration found no evidence that better health outcomes (with the exception of mental status) were associated with greater RN staff levels or that poorer outcomes were associated with for-profit facilities. Previous research has raised concerns over the higher prevalence rates of decubitus ulcers and restraint use in for-profit facilities. These recent findings suggest that regulation of nursing home structural attributes cannot ensure the provision of high-quality nursing home care.

Greater precision in measurement of health outcomes may be needed to identify broad relationships among structure, process, and outcome variables, suggests Francis G. Caro, Ph.D., of the University of Massachusetts. With support from the Agency for Health Care Policy and Research (HS07585), the researchers used Massachusetts Medicaid data on residents from over 500 nursing homes to create individual resident histories ranging from 3 months to 3 years and analyzed resident and nursing home attributes associated with patient outcomes.

See "A longitudinal analysis of nursing home outcomes," by Frank Porell, Ph.D., Dr. Caro, Ajith Silva, Ph.D., and Mark Monane, M.D., M.S., in the October 1998 Health Services Research 33(4), pp. 835-865.

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HIV/AIDS Research

Many HIV-infected Americans are not receiving medical care regularly

According to a major new study sponsored by the Agency for Health Care Policy and Research and led by RAND, the Santa Monica, CA-based research group, roughly 335,000 adults in the United States infected by HIV see a doctor on a regular basis. However, in conjunction with the estimate by the Centers for Disease Control and Prevention (CDC) that 650,000 to 900,000 Americans have HIV, the virus that causes AIDS, the study also implies that a significant proportion of HIV-infected adults do not receive medical care on a regular basis. Furthermore, most infected adults who do not receive medical care on a regular basis are in the early stages of the disease.

These findings are from the HIV Cost and Service Utilization Study (HCSUS), which provides the first comprehensive picture on a national scale of who gets care for HIV illness, the kinds of health services used, the costs of these services, and who pays for them. The study also found that HIV care amounted to $6.7 billion in 1996, or an average of $20,000 per HIV patient, which is less than what is commonly believed and represents less than 1 percent of all direct personal health expenditures in the United States.

Study findings also indicate that 85 percent of patients treated for the virus used at least one HIV medication, and 79 percent used an antiretroviral drug during the 6 months prior to being interviewed. The pattern of use of protease inhibitors and non-nucleoside reverse transcriptase inhibitors (recently developed drugs that are highly effective in suppressing HIV infection) changed rapidly in 1996. At the beginning of the year, 16 percent of patients had used one of the newer drugs; by December of 1996, that proportion had shot up to 55 percent.

The study found that 231,400 people received medical care for HIV infection in January and February 1996. From this, the researchers estimated that 292,000 to 372,000 adults with known HIV infection saw a doctor at least once during any 6-month period (the definition of regular medical care) in 1996, with the best point estimate being 335,000. Other findings include that:

  • 59 percent of adults under care because of the virus meet the CDC definition of AIDS—the most advanced stage of HIV disease. They represent about 85 percent of all adults thought to be living with "full-blown" AIDS.
  • The demographic and socioeconomic characteristics of the population under care for HIV infection are strikingly different from those of the U.S. population as a whole. Americans under care for HIV are disproportionately male, black, unemployed, poor, and do not have private health insurance to pay for medical care.
  • 30 percent of patients received care at major teaching hospitals; the balance received their care from office-based physicians and community hospitals and clinics. One-third made at least one visit to an emergency room, and 20 percent were hospitalized every 6 months. Their stays accounted for about 1 percent of all hospital days in the United States.
  • Hospital care accounted for 43 percent of patients' direct medical care costs, medications for 39 percent, emergency department care for 2 percent, and other outpatient care and associated costs for 15 percent.
  • 77 percent of HIV-infected patients were men, and 89 percent were less than 50 years of age. About half were non-Hispanic whites, one-third were non-Hispanic blacks, and one-sixth were Hispanics. Women with HIV were more likely than men to be young, black, less educated, unemployed, impoverished, and underinsured. But they were also less likely to have "full-blown" AIDS.
  • The percentage of HIV patients who depend exclusively on Medicaid (29 percent) is three times greater than the percentage of Medicaid patients in the general population. A surprisingly large 19 percent of the population had coverage through Medicare.
  • Nearly half of the patients were men who said they had sex with other men but no injection drug use; 24 percent reported injection drug use with or without other risk behaviors; 18 percent said they only engaged in heterosexual sex; and 9 percent reported no known risk factors.

The findings are based on data from the opening round of HCSUS interviews with 2,864 patients randomly selected to accurately represent the study's "reference population"—adults with known HIV infection who received medical care during the first 2 months of 1996 in the contiguous 48 States. The sample did not include adults treated only at military, prison, and emergency room facilities.

As pointed out by the authors of the study, it is deeply disturbing that up to two-thirds of people with HIV infection are not getting regular care and even fewer are getting the new multi-drug therapy. The study's lead author is Samuel A. Bozzette, M.D., Ph.D., an infectious disease specialist and HIV expert who serves as co-director of HCSUS. The other HCSUS co-director is Martin F. Shapiro, M.D., Ph.D., of the University of California, Los Angeles.

As noted by Dr. Bozzette, the data presented in this study explode the widespread belief that care for people infected with HIV is extraordinarily costly. Although it is a large and growing burden on the public sector, HIV care is less expensive than care for many other serious diseases. The real crisis in paying for HIV care is not its cost, but rather how to finance it, he concludes. Dr. Bozzette is affiliated with the University of California, San Diego, and the Veterans Affairs San Diego Healthcare System.

In the future, HCSUS will address many other topics, including disparities in access to care, the impact of variation in insurance coverage, the extent of mental health and substance abuse disorders, oral health, rural care, and the extent to which HIV is becoming resistant to antiretroviral drugs.

AHCPR's sister agency, the Health Resources and Services Administration (HRSA), is a primary sponsor of HCSUS. In addition to AHCPR and HRSA, other HHS components contributing to HCSUS include the Office of the Assistant Secretary for Planning and Evaluation, the National Institute for Mental Health, the National Institute on Drug Abuse, the National Institute on Aging, and the Office of Research on Minority Health of the National Institutes of Health. Additional support was provided by the Robert Wood Johnson Foundation, Merck and Company, Glaxo-Wellcome, Inc., and Quest Diagnostics.

For more information about the study, see "The care of HIV-infected adults in the United States," by Dr. Bozzette, Sandra H. Berry, M.A., Naihua Duan, Ph.D., and others, in the December 24, 1998, issue of the New England Journal of Medicine 339, pp. 1897-1904.

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Special Populations

Researchers identify the conditions that place homeless adults at the greatest risk of death

Homeless individuals typically suffer from substance abuse, psychiatric disorders, and/or major medical illnesses. A new study shows that certain medical conditions in particular place the homeless at greatest risk of death. For homeless adults living in Boston, these conditions are AIDS and HIV, renal disease, a history of cold-related injury, liver disease, and cardiac arrhythmia. Alcohol and substance abuse only slightly increased risk of death among the Boston homeless but may in fact have contributed to many of their medical problems. Clinicians who see homeless people with these risk factors should be alert to the need for aggressive intervention and close medical followup, recommends Stephen W. Hwang, M.D., M.P.H., of St. Michael's Hospital, Toronto.

In a study supported in part by the Agency for Health Care Policy and Research (National Research Service Award training grant T32 HS00020), the researchers conducted a case-control study of 558 adults who were seen by a health care program for the homeless in Boston and who died sometime between 1988 and 1993. They compared them with age-matched homeless people (controls) seen by the program who were alive at the end of 1993. Based on retrospective review of their medical records, the researchers calculated odds ratios for death.

Homeless people diagnosed with AIDS had an odds ratio (OR) for death of 55.8 (equal odds is 1). Those with symptomatic HIV infection had an OR of 17.7; asymptomatic HIV infection (OR, 4.1); renal disease (OR, 18.4); history of cold-related injury such as frostbite or hypothermia (OR, 8.0); liver disease (OR, 3.8); and cardiac arrhythmia (OR, 3.3). The risk of death was about twice as high among individuals with a history of abusing alcohol or cocaine and three times as high for those with a history of opiate abuse or injection drug use.

See "Risk factors for death in homeless adults in Boston," by Dr. Hwang, Joan M. Lebow, M.D., Michael F. Bierer, M.D., M.P.H., and others, in the July 13, 1998, Archives of Internal Medicine 158, pp. 1454-1460.

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Managed Care/Primary Care

Informal consultation among physicians may increase with growth in group practices and managed care

Informal or "curbside" consultation has long been an important part of medical practice. And it still is, according to a new study involving Massachusetts physicians. However, informal consultation varies by physician specialty, practice setting, and payment arrangements (capitation) between physicians and insurance companies. For instance, physicians working in a group practice or a health maintenance organization (HMO) rather than solo practice, those working in a hospital or community health center rather than a private office, and those who receive some income from capitation arrangements, are more likely to use informal consultation. This suggests that use of informal consultation may increase with current trends toward group practice and managed care, according to the researchers.

For this study, the researchers surveyed a State-wide sample of physicians in five specialties (705 responded) to learn how they used informal consultation and how they valued it. They found that generalist physicians requested more consultations than specialists (median of three vs. one per week) and were asked to provide fewer of them (two vs. five per week). Physicians in an HMO, multispecialty group, or single-specialty group requested more informal consultations than those in solo practice (82 percent, 40 percent, and 28 percent more, respectively) and were more often asked to provide them (43 percent, 63 percent, and 14 percent more, respectively).

Physicians with at least 30 percent of their income from capitation requested 38 percent more informal consultations and were asked to provide 46 percent more informal consultations than those with little or no income from capitation. Overall, physicians perceived informal consultation as more of a tool for gathering information than a means of avoiding fees, excess appointments, barriers to referral, or malpractice litigation. This study was supported in part by the Agency for Health Care Policy and Research (National Research Service Award training grant T32 HS00020).

More details are in "Physicians' experiences and beliefs regarding informal consultation," by Nancy L. Keating, M.D., M.P.H., Alan M. Zaslavsky, Ph.D., and John Z. Ayanian, M.D., M.P.P., in the September 9, 1998, Journal of the American Medical Association 280(10), pp. 900-904.

Guidelines mailed to physicians on proper use of hypnotic sedatives can reduce inappropriate prescribing

Most State Medicaid agencies mail drug prescribing guidelines to physicians to reduce inappropriate (and costly) prescribing of medications. This approach substantially reduced the use of certain benzodiazepine sedative hypnotics (triazolam, temazepam, estazolam, quazepam, and flurazepam) among Washington Medicaid patients who used them once a day for a year. These benzodiazepines are approved only for insomnia and should be used for less than 4 weeks.

Targeted patients and their physicians were mailed guidelines on the use of sedative hypnotics, a prescriber profile detailing sedative hypnotic prescribing, and a patient profile. Within 3 months of receiving the drug utilization review package, this group of physicians reduced use of targeted medications by 28 percent compared with a 9 percent drop among those not targeted by the drug use review. The average reduction in use of the targeted medications was about half a tablet per day during the 3-month period of observation. This reduction is likely to have decreased the risk of fractures associated with benzodiazepine use, concludes first author David H. Smith, Ph.D., of the University of Washington, Seattle.

This study adds to recent evidence that mailed drug use reviews can have a desirable impact on patient drug use. About 9 percent of intervention patients switched to other nontargeted benzodiazepines. However, switching to another benzodiazepine is not necessarily a desirable outcome. Not only can these drugs increase the likelihood of hip fractures in the elderly, they also have been associated with central nervous system disturbances and may mask untreated medical problems causing insomnia. This study was supported in part by a National Research Service Award (NRSA) training grant (T32 HS00034) from the Agency for Health Care Policy and Research.

See "A randomized controlled trial of a drug use review intervention for sedative hypnotic medications," by Dr. Smith, Dale B. Christensen, Ph.D., Andy Stergachis, Ph.D., and Garth Holmes, R.P.H., M.A., in Medical Care 36(7), pp. 1013-1021, 1998.

Quality improvement teams can address quality of care in primary care clinics, even in times of great turmoil

Recent efforts have been made to apply continuous quality improvement (CQI) in medical settings. A group of researchers led by Leif I. Solberg, M.D., of HealthPartners Research Foundation, and supported by the Agency for Health Care Policy and Research (HS08091), studied primary care clinics participating in the first randomized controlled trial to evaluate the effectiveness of CQI in primary care—Project IMPROVE. The 4-year project randomly assigned 22 clinics to a CQI intervention beginning in September 1994; 22 other clinics were assigned to a control group and received no intervention.

The intervention consisted of a program of leadership facilitation, training, consultation, and networking. Each of these program elements was designed to facilitate a CQI process focused on eight adult preventive services such as mammograms, influenza shots, and hypertension screening. The goal was to improve preventive services at primary care clinics, for example, by sending reminder letters to patients who had not had recent mammograms. Two studies of the IMPROVE project are summarized here.

Fischer, L.R., Solberg, L.I., and Kottke, T.E. (1998, July). "Quality improvement in primary care clinics." Joint Commission Journal on Quality Improvement 24(7), pp. 361-370.

The researchers conducted case studies in six intervention clinics where they observed CQI team meetings; interviewed team members, IMPROVE consultants, and clinic personnel; and examined documentation from the project. They found that changes in staff procedures, equipment, location, and administrative structures created by mergers and acquisitions both complicated the QI process and motivated participation in improvement. Smaller clinics seemed to have more difficulty with the QI process because of limited resources and lack of compatibility between the QI approach and their clinic organization.

Nevertheless, project IMPROVE increased awareness of preventive services among patients and clinic staff and prompted application of the CQI method to other areas such as pediatrics or urgent care. The increased emphasis on prevention was noticeable on entering the clinics, most of which displayed posters and brochures on improvement in their preventive services. The researchers conclude that CQI initiatives can help clinics adapt to a changing health care environment and create functioning teams or groups to address a variety of organizational problems and tasks. However, the process should be flexible to accommodate varying organizational structures and cultures.

Solberg, L.I., Kottke, T.E., and Brekke, M.L. (1998). "Will primary care clinics organize themselves to improve the delivery of preventive services? A randomized controlled trial." Preventive Medicine 27, pp. 623-631.

The researchers surveyed all 44 clinics prior to and after the CQI intervention and found, at the end of the trial, that intervention clinics had twice as many improvement processes for preventive services as compared with control clinics or their own clinics prior to the intervention. The improved processes primarily involved use of guidelines, screening patients for needed services, and summarizing those needs on chart forms. The mean number of systems processes was nearly the same at baseline for intervention and control clinics (11.2 vs. 12.1) but changed after the intervention (25.8 vs. 11.3).

In addition, all 22 intervention clinics identified teams that appeared to follow the seven-step improvement process, which begins by identifying the problem and alternative solutions and ends with evaluation of the new process. The researchers conclude that with training and assistance, interested primary care clinics can establish functioning CQI teams that will increase the number of functional prevention system processes in their clinics.

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