Improving clinical decisionmaking as a means of achieving cost-effective medical care.

While there is widespread agreement that improving physician decision-making is one of the most promising ways to change practice styles and provide cost-effective care, there is little agreement on how to achieve those ends. Several approaches to improving clinical decisionmaking have been tried by hospitals, medical group practices, and HMOs over the past few years.(1) Much of the early research focused on the effects of various interventions on the utilization of laboratory tests and hospital medications.(2,3) More recently, this research has been expanded to include medical procedures? These studies have shown that most of the interventions have not been very effective. Moreover, the research indicates that the marginal success experienced in these settings is highly dependent on both the type of intervention employed and the specific decision area being targeted. For example, providing information through traditional continuing medical education programs and providing clinical guidelines without active involvement of physicians or their opinion leaders have been largely ineffective.(5,6) Similarly, reviews of practice patterns through chart reviews have had only a mixed effect on appropriateness of resource use.(2,7) However, an education program combined with peer comparison data has been shown to significantly reduce cesarean section rates.

The most promising approach to this issue appears to be some combination of:

* Timely provision of guideline and practice comparison data through the use of some type of computerized information system.

* Involvement of physicians or their opinion leaders in the development of the program and especially the guidelines.

* Reinforcement of the process through financial or other incentives.

It is clear from the research that clinical practice decisionmaking is not well understood. Many of the assumptions about the merits of alternative approaches to improving clinical decision making and cost effectiveness of care have faltered under rigorous analysis. Moreover, while some approaches work reasonably well for some decisions, such as cesarean sections, they are ineffective for others. Clearly, much research remains to be done. The following reference articles provide additional data for those who want more information about this area.

References

1. Eisenberg, J. "The Internist as Gatekeeper: Preparing the General Internist for a New Role." Annals of Internal Medicine 102(4):53743, April 1985.

2. Everett, G., and others. "Effect of Cost Education, Cost Audits, and Faculty Chart Review on the Use of Laboratory Services." Archives of Internal Medicine 143(5):942-4, May 1983.

3. Soumerai, S., and Avom, J. "Principles of Educational Outreach ('Academic Detailing') to Improve Clinical Decision Making." JAMA 263(4):549-56, Jan. 26, 1990.

4. Siu, A., and others. "Use of Hospital in a Randomized Trial of Prepaid Care." JAMA 259(9): 1343-6, March 4, 1988.

5. Davis, D., and others. "A Methodologic Review of the Continuing Medical Education Literature." Evaluation in the Health Professions 7(3):251-83, Sept. 1984.

6. Kosecoff, J., and others. "Providing Primary General Medical Care in University Hospitals: Efficiency and Cost." Annals of Internal Medicine 107(3):399-405, Sept. 1987.

7. Nyrnan, J., and others. "Changing Physician Behavior: Does Medical Review of Part B Medicare Claims Make a Difference?" Inquiry 27(2):127-37, Summer 1990.

8. Stafford, R. "Alternative Strategies for Controlling Rising Cesarean Section Rates." JAMA 263(5):683-7, Feb. 2, 1990.

Other References

Berwick, D., and Coltin, K. "Feedback Reduces Test Use in a Health Maintenance Organization." JAMA 255(11):14504, March 21, 1986.

Connelly, D., and others. "Knowledge Resource Preferences of Family Physicians." Journal of Family Practice 30(3):353-59, Aug. 1990.

Eisenberg, J., and others. "Computer-Based Audit to Detect and Correct Overutilization of Laboratory Tests." Medical Care 15(11):915-21, Nov. 1977.

Geertsma, R., and others. "How Physicians View the Process of Change in Their Behavior." Journal of Medical Education 57(10, Pt. 1):752-61, Oct. 1982.

McMahon, S., and others. "An Application of Continuing Medical Education to Decrease Excessive Lengths of Stay." Journal of Medical Education 63(5):364-71, May 1988.

Schwartz, J., and Cohen, S. "Changing Physician Behavior." In Mayfield, J., and Grady, M. Primary Care Research: An Agenda for the '90s. Washington, D.C.: Agency for Health Care Policy and Research, Public Health Service, Department of Health and Human Services, 1990.