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