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Health Care Delivery

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Changing the nature of a successful pilot program can limit its effectiveness as a large-scale service program

Social support service programs to improve pregnancy outcomes are increasing throughout the United States. However, a new study indicates that successful pilot programs do not always result in successful service programs. The study, supported by the Agency for Health Care Policy and Research (National Research Service Award training grant HS00032), shows that a pilot program successfully reduced the number of low birthweight (LBW) and small-for-gestational-age (SGA) infants of teenagers, but when the pilot program was expanded into a large-scale service program, it had no impact on these poor birth outcomes.

The objectives of both programs were the same: to increase the use of prenatal care and support services, reduce poor health habits, and improve pregnancy outcomes. Services for both programs were delivered through home visits to teenagers 17 years of age and younger by resource mothers who were employed full-time. However, when the pilot project became a service program, the training of resource mothers declined from 6 weeks to 3 weeks, their caseload increased from 30-35 to 50-65 teenagers each, they received much less supervision and review of problem cases, program funding was less stable, and the community instead of the health department managed the program.

These changes substantially shifted the intensity and character of the initial pilot program, which was a component of the 4-year (1980-1984) rural infant care project conducted by the Medical University of South Carolina.

Details are in "Translating research into MCH service: Comparison of a pilot project and a large-scale resource mothers program," by Mary M. Rogers, Dr.P.H., Mary D. Peoples-Sheps, Dr.P.H., and James R. Sorenson, Ph.D., in Public Health Reports 110, pp. 563-569, 1995.

Most who use the ER for nonurgent care are neither poor nor uninsured

It is commonly believed that persons who use emergency departments (EDs) for nonurgent health problems are poor, uninsured, or have no other source of health care. Not so, according to a new study. In fact, convenience rather than desperation may drive many of these ED visits. The study shows that most nonurgent ED users are white, have private insurance, are middle or high income, and have a regular private physician. Moreover, they visit physicians' offices as often as those who never visit the ED for nonurgent care.

This suggests that the reason most people use an ED for nonurgent care has less to do with lack of access to care than preference or convenience, notes Carolyn Clancy, M.D., Director of the Agency for Health Care Policy and Research's Center for Primary Care Research. Dr. Clancy, Joel W. Cohen, Ph.D., and Melissa Wilets, of AHCPR's Center for Health Insurance and Expenditures Studies, and former AHCPR staff member Peter Cunningham, Ph.D., used data from the 1987 National Medical Expenditure Survey to analyze the extent of nonurgent ED use for the U.S. population and to estimate associated expenditures.

Rates of nonurgent ED use were higher for poor and near-poor individuals (about 10 percent higher), persons who identified an ED as their usual source of care (17.3 percent higher), and blacks (10.5 percent higher). Yet over half of nonurgent ED users had some kind of private insurance, over half were middle or high income, 65.4 percent identified a physicians' office as their usual source of care, and almost 70 percent were white. Nevertheless, the researchers argue against restricting hospital EDs to true emergency or urgent care situations. This policy could cause some persons to lose access to the ED—their only source of health care—to achieve a relatively modest cost savings to the health care system (about $2 billion in 1987 dollars would be saved by shifting nonurgent ED visits to office-based settings, a very small percentage of all outpatient physician expenditures).

Details are in "The use of hospital emergency departments for nonurgent health problems: A national perspective," by Drs. Cunningham, Clancy, and Cohen, and Ms. Wilets, in the December 1995 Medical Care Research and Review 52(4), pp. 453-474.

History of malpractice claims exposure not linked with the practice of defensive medicine among OBs or family physicians

Obstetricians who have been sued for malpractice do not necessarily increase their use of prenatal diagnostic tests and resources or the rate of cesarean deliveries for low-risk patients as might be expected if they were practicing "defensive medicine" to avoid further suits. This is the conclusion of researchers at the University of Washington, Seattle, and the Washington State Physicians Insurance Exchange and Association. Data collection for this study was supported in part by the Agency for Health Care Policy and Research (HS06166).

The researchers studied the practices of a stratified, random sample of Washington State obstetricians/gynecologists and family physicians. They linked personal and county-based malpractice claims data to 1 year's data on the prenatal care and delivery methods used by the physicians in caring for their low-risk patients.

In this sample, 69 percent of urban obstetrician-gynecologists, 52 percent of rural obstetrician-gynecologists, 19 percent of urban family physicians, and 13 percent of rural family physicians had been named in an obstetric malpractice suit. Results showed that physicians who had been sued did not use significantly more prenatal resources—such as ultrasound, referrals to or consults with other doctors, or other prenatal visits, tests, or procedures—than physicians who had not been sued. In addition, those practicing in counties with higher rates of physicians who had been named in malpractice claims or suits (9 or more defendants per 100 physician-years of practice), who presumably would feel more vulnerable to malpractice suits, used the same or fewer resources and had the same or lower cesarean delivery rates as physicians practicing in counties with lower defendant rates (fewer than 9 defendants per 100 physician-years of practice).

For more information, see "Defensive medicine and obstetrics," by Laura-Mae Baldwin, M.D., M.P.H., Gary Hart, Ph.D., Michael Lloyd, A.R.M., and others, in the November 22/29, 1995, Journal of the American Medical Association 274(20), pp. 1606-1610.

Physician education program improves preventive medicine services for inner city residents

Poor inner city residents often suffer the most from potentially preventable diseases such as hypertension, diabetes, and heart disease. Physicians who care for inner city patients could help them more by improving their practice of preventive medicine, for example, by discussing with their patients smoking cessation and nutrition and weight control, increasing screening for breast cancer and other diseases, and increasing the use of adult immunizations. A physician education program could help these physicians improve their practice of preventive medicine, concludes a study supported in part by the Agency for Health Care Policy and Research (HS07076).

Donald H. Gemson, M.D., M.P.H., of Columbia University and the Harlem Center for Health Promotion, and his colleagues tested the effectiveness of a multifaceted physician prevention education program at Harlem Hospital Center in New York City, using prototype materials from the U.S. Public Health Service's "Put Prevention Into Practice" (PPIP) program. These ranged from posters and banners to pamphlets and patient minirecords for recording preventive tests, immunizations, and procedures. The PPIP and educational grand rounds presentations to resident and attending physicians at Harlem Hospital Center were implemented during a 6-month period from November 1991 through April 1992.

Results showed that physicians at Harlem Hospital Center improved their prevention practices to a greater extent than did resident and attending physicians at Kings County Hospital, a similar inner city hospital, which served as a control and thus did not receive the educational program. The Harlem physicians improved on 46 of 51 prevention practices and also showed improvement in a 32-item prevention knowledge scale. Finally, although Kings County Hospital patients reported no change in receipt of preventive services at the end of the 6 months, Harlem Hospital patients reported significantly increased counseling for exercise, practice of breast self-examination, and nutrition and weight control, and there was a trend toward increased counseling for smoking cessation.

For more information, see "Putting prevention into practice: Impact of a multifaceted physician education program on preventive services in the inner city," by Dr. Gemson, Alfred R. Ashford, M.D., Larry L. Dickey, M.D., M.P.H., and others, in the November 13, 1995, Archives of Internal Medicine 155, pp. 2210-2216.

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