[Show abstract][Hide abstract] ABSTRACT: To examine the feasibility of and satisfaction with a tailored web-based intervention designed to decrease radiologists' recommendation of inappropriate additional work-up after a screening mammogram.
We developed a web-based educational intervention designed to reduce inappropriate recall. Radiologists were randomly assigned to participate in an early intervention group or a late (control) intervention group, the latter of which served as a control for a 9-month follow-up period, after which they were invited to participate in the intervention. Intervention content was derived from our prior research and included three modules: 1) an introduction to audit statistics for mammography performance; 2) a review of data showing radiologists' inflated perceptions of medical malpractice risks related to breast imaging, and 3) a review of data on breast cancer risk among women seen in their practices. Embedded within the intervention were individualized audit data for each participating radiologists obtained from the national Breast Cancer Surveillance Consortium.
Seventy-four radiologists (37.8%; 74/196) consented to the intervention, which was completed by 67.5% (27/40) of those randomized to the early intervention group and 41.2% (14/34) of those randomized to the late (control) group. Thus, a total of 41 (55%) completed the intervention. On average, three log-ins were used to complete the program (range 1-14), which took approximately 1 hour. Ninety-five percent found the program moderately to very helpful in understanding how to calculate basic performance measures. Ninety-three percent found viewing their own performance measures moderately to very helpful, and 83% reported it being moderately to very important to learn that the breast cancer risk in their screening population program was lower than perceived. The percentage of radiologists who reported that the risk of medical malpractice influences their recall rates dropped from 36.3% preintervention to 17.8% after intervention with a similar drop in perceived influence of malpractice risk on their recommendations for breast biopsy (36.4 to 17.3%). More than 75% of radiologists answered the postintervention knowledge questions correctly, and the percent of time spent in breast imaging did not appear to influence responses. The majority (>92%) of participants correctly responded that the target recall rate in the United States is 9%. The mean self-reported recall rates were 13.0 for radiologists spending <40% time in breast imaging and 14.9% for those spending >40% time spent in breast imaging, which was highly correlated with their actual recall rates (0.991; P < .001).
Radiologists who begin an internet-based tailored intervention designed to help reduce unnecessary recall will likely complete it, although only 55% who consented to the study actually undertook the intervention. Participants found the program useful in helping them understand why their recall rates may be elevated.
[Show abstract][Hide abstract] ABSTRACT: To examine whether an intervention strategy consisting of a tailored web-based intervention, which provides individualized audit data with peer comparisons and other data that can affect recall, can assist radiologists in setting goals for reducing unnecessary recall.
In a multisite randomized controlled study, we used a tailored web-based intervention to assess radiologists' ability to set goals to improve interpretive performance. The intervention provided peer comparison audit data, profiled breast cancer risk in each radiologist's respective patient populations, and evaluated the possible impact of medical malpractice concerns. We calculated the percentage of radiologists who would consider changing their recall rates, and examined the specific goals they set to reduce recall rates. We describe characteristics of radiologists who developed realistic goals to reduce their recall rates, and their reactions to the importance of patient risk factors and medical malpractice concerns.
Forty-one of 46 radiologists (89.1%) who started the intervention completed it. Thirty-one (72.1%) indicated they would like to change their recall rates and 30 (69.8%) entered a text response about changing their rates. Sixteen of the 30 (53.3%) radiologists who included a text response set realistic goals that would likely result in reducing unnecessary recall. The actual recall rates of those who set realistic goals were not statistically different from those who did not (13.8% vs. 15.1%, respectively). The majority of selected goals involved re-reviewing cases initially interpreted as Breast Imaging Reporting and Data System category 0. More than half of radiologists who commented on the influence of patient risk (56.3%) indicated that radiologists planned to pay more attention to risk factors, and 100% of participants commented on concerns radiologists have about malpractice with the primary concern (37.5%) being fear of lawsuits.
Interventions designed to reduce unnecessary recall can succeed in assisting radiologists to develop goals that may ultimately reduce unnecessary recall.
[Show abstract][Hide abstract] ABSTRACT: To determine the extent to which third-year medical students are exposed to elements of the patient-centered medical home (PCMH) during required family medicine (FM) clerkships and how this exposure varies among a sample of medical schools.
In 2008, the authors conducted a cross-sectional survey of 104 ambulatory teaching practices that host required third-year FM clerkship students from nine U.S. medical schools. Descriptive statistics characterized learning settings and the status of PCMH features, and generalized linear mixed models examined variation among medical schools (as the 104 clinics were nested within nine medical schools).
Participating schools captured data on 104 eligible clerkship sites (44%). These practices were primarily community-based, single-specialty clinics (n = 48; 46%), and more than half (n = 55; 53%) were part of integrated health systems. Electronic health records (EHRs) were in place in 60 (58%), and no significant difference existed in EHR use according to medical school, despite up to a 10-fold variation from school to school in other PCMH features. Among sites with EHRs, 8 (14%) did not allow access to medical students. Preceptor attitudes about how practice transformation and new information technology are affecting the quality of medical education differ widely from site to site.
Primary care transformation toward the PCMH is already well under way in a national sample of FM teaching sites, and this transformation is having important effects on medical student education.
Academic medicine: journal of the Association of American Medical Colleges 06/2010; 85(6):965-73. · 2.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Access Assured is an experimental program being used by 2 academic family medicine practices to deliver primary care to an uninsured patient population using a monthly retainer payment system in addition to a sliding fee schedule for office visits. This prospective cohort study was designed to determine whether patients would join such a program, to describe the population of people who did so, and to assess the program's financial viability.
We used data abstracted from our electronic medical record system to describe the demographic characteristics and care utilization patterns of those patients enrolling during the first year of the study, between February 1, 2008, and January 31, 2009. We also compared 2 subpopulations of enrollees defined by their eligibility for office fee discounts based on income.
A total of 600 Access Assured members made 1943 office visits during the study period, receiving a total of 4538.22 relative value units of service. Based on the membership fee, office visit fee collections, and remaining accounts receivable, this resulted in an expected reimbursement rate of $42.88 per relative value units. Three hundred one of the 600 (50.2%) patients had incomes above 400% of the federal poverty level (FPL) at the time of each of their office visits and were therefore not eligible for any visit fee discount. Another 156 patients (26.0%) were eligible for a 100% discount of all visit fees based on their income below 200% of the FPL. Using a multivariable Poisson regression analysis of these 2 groups, we determined that age was a significant determinant of return visit rate, with a 0.7% increase in return visit rate for each additional year of age (P = .006). Women had a 26% higher return visit rate than men (P = .001). After accounting for age, sex, and clinic site, fee discount level based on income was not a significant independent determinant of return visit rate (P = .118).
A retainer-based program to enroll uninsured patients being used in 2 academic family medicine clinics attracted 600 patients during its first year. The program was financially viable and resulted in an expansion of our service to uninsured patients. More than half of the patients had incomes above 400% of the FPL, suggesting that the population of uninsured Oregonians may be economically more diverse than suspected.
The Journal of the American Board of Family Medicine 01/2010; 23(3):393-401. · 1.76 Impact Factor