Appropriate VTE prophylaxis is associated with lower direct medical costs.

PURPOSE: To calculate and compare the direct medical costs of guideline-recommended prophylaxis with prophylaxis that does not fully adhere with guideline recommendations in a large, real-world population. METHODS: Discharge records were retrieved from the US Premier Perspective™ database (January 2003-December 2003) for patients aged≥40 years with a primary diagnosis of cancer, chronic heart failure, lung disease, or severe infectious disease who received some form of thromboprophylaxis. Univariate analysis and multivariate regression modeling were performed to compare direct medical costs between discharges who received appropriate prophylaxis (correct type, dose, and duration based on sixth edition American College of Chest Physicians [ACCP] recommendations) and partial prophylaxis (not in full accordance with ACCP recommendations). Market segmentation analysis was used to compare costs stratified by hospital and patient characteristics. RESULTS: Of the 683 005 discharges included, 148,171 (21.7%) received appropriate prophylaxis and 534,834 (78.3%) received partial prophylaxis. The total direct unadjusted costs were $15,439 in the appropriate prophylaxis group and $17,763 in the partial prophylaxis group. After adjustment, mean adjusted total costs per discharge were lower for those receiving appropriate prophylaxis ($11,713; 95% confidence interval [CI], $11,675-$11,753) compared with partial prophylaxis ($13,369; 95% CI, $13,332-$13 406; P<0.01). Appropriate prophylaxis appeared to be associated with numerically lower unadjusted costs than partial prophylaxis, regardless of hospital size, rural/urban location, teaching status, and patient age and gender. CONCLUSION: This large, real-world analysis suggests that appropriate prophylaxis, in adherence with ACCP guidelines, is potentially cost-saving compared with partial prophylaxis in at-risk medical patients.

Warfarin therapy in patients with venous thromboembolism: patterns of use and predictors of clinical outcomes.

INTRODUCTION: Few studies have investigated current practices in the USA relating to warfarin use and monitoring, or the effects of warfarin discontinuation on risk of venous thromboembolism (VTE) and bleeding complications. This study investigated the effect of warfarin discontinuation on rates of VTE recurrence in a real-world setting. METHODS: Integrated Healthcare Information Services database records from January 2003 to September 2007 from patients aged at least 18 years, hospitalized for VTE, and with at least two prescriptions or 60 days of warfarin treatment were reviewed, with warfarin discontinuation and international normalized ratio (INR) data collated. RESULTS: A total of 1027 of 8380 (12.3%) patients discontinued warfarin within 3 months. Overall, 1656 (19.8%) patients had no INR monitoring, with 38.1% of INR values being inside the therapeutic range (INR 2-3). Recurrent VTE was observed in 915 (10.9%) patients. Significant predictors of recurrent VTE (at any time) included discontinuation of warfarin within 3 months, time from index VTE to warfarin initiation, previous VTE-related hospitalization, and duration of index hospitalization. CONCLUSION: This study found that in a real-world population, less than 50% of warfarin patients achieved INR values within the therapeutic range. Warfarin discontinuation within 3 months was associated with a higher rate of recurrent VTE.

Propensity score matching in the evaluation of drug therapy management programs: an illustrative analysis of a program for patients with hepatitis C virus.

This retrospective cohort analysis demonstrates the application of propensity score methods in the Be In Charge (BIC) program, a drug therapy management program for patients with hepatitis C. Data were drawn from BIC participant records and program utilization and from a longitudinal database of administrative claims for pharmacy and medical services. Eligible patients must have received peginterferon alfa-2b (PEG-IFN alfa-2b) and ribavirin, but analyses evaluated only PEG-IFN alfa-2b use; BIC enrollees were matched with patients not enrolled in BIC (controls). Adherence was measured on the basis of the number of injections dispensed and the proportion of patients for whom an average of at least 1 injection per week was dispensed during follow-up. BIC subjects refilled 1.2 more injections than did controls (P < .001) within 12 weeks, 2.7 more (P < .001) within 24 weeks, and 6.7 more (P < .001) within 48 weeks. BIC enrollees were more likely than controls to refill the indicated dose (1 injection per week) within 12 weeks (72% vs 64%, P < .001), 24 weeks (52% vs 41%, P < .001), and 48 weeks (22% vs 13%, P = .002) of initiation. These data suggest that the BIC program may significantly improve adherence to PEG-IFN alfa-2b.

Hospital-based costs associated with venous thromboembolism prophylaxis regimens.

Clinically and economically, venous thromboembolic (VTE) disease represents a significant burden to the US healthcare system. This analysis compares the total direct medical costs associated with VTE prophylaxis with enoxaparin and unfractionated heparin (UFH). Hospital discharge and billing records were extracted from the Premier Perspective database (January 2002-December 2006). The primary outcome was the total direct medical costs for discharges that were at risk of VTE and received enoxaparin or UFH. A total of 894,364 discharge records met the study inclusion criteria, of which 39.4% received enoxaparin and 60.6% received UFH. After adjustment for pre-defined covariates, mean total direct medical costs per discharge for the UFH group were $6,443, $1,080 more than those for the enoxaparin group ($5,363; P < .0001). In conclusion, enoxaparin prophylaxis is a cost-saving therapy, when compared with UFH, for the prevention of VTE in patients with a diverse range of medical conditions conferring VTE risk.

Are surgical patients at risk of venous thromboembolism currently meeting the Surgical Care Improvement Project performance measure for appropriate and timely prophylaxis?

The US Surgical Care Improvement Project (SCIP) has approved two performance measures to improve venous thromboembolism (VTE) prevention. SCIP-VTE-2 measures the proportion of surgery patients who received appropriate VTE prophylaxis within 24 h prior to surgery to 24 h after surgery. This study assesses the current rate of achievement of SCIP-VTE-2 criteria using a retrospective data set of real-world surgical patients. The Premier Perspective database, which contains real-world data from >400 US hospitals, was queried (January 2004-December 2006) for in-patient hospital transactional billing records of surgical patients aged >or=18 years. The primary outcome was the proportion of patients achieving SCIP-VTE-2 requirements for appropriate and timely prophylaxis as per the SCIP-VTE-2 algorithm. Of the 149,785 patients included, 56.2% received appropriate prophylaxis and 52.7% achieved the SCIP-VTE-2 performance measure for both appropriate and timely prophylaxis. To conclude, this study highlights that VTE prophylaxis currently only meets SCIP-VTE-2 requirements in approximately half of real-world surgical patients. The use of retrospective analyses such as this hospital billing data analysis may assist hospitals in measuring their current and future performance in VTE prevention.

Patterns and predictors of discontinuation of rhythm-control drug therapy in patients with newly diagnosed atrial fibrillation.

STUDY OBJECTIVE: To assess patterns and predictors of discontinuation of rhythm-control drug therapy in managed care patients with newly diagnosed atrial fibrillation and the direct medical costs of atrial fibrillation in these patients. DESIGN: Retrospective cohort study. DATA SOURCE: PharMetrics Patient-Centric Database. PATIENTS: A total of 3549 adults with a new diagnosis of atrial fibrillation between April 1, 2002, and March 31, 2006, and who had at least one claim for rhythm-control drug therapy within 6 months of the initial diagnosis. MEASUREMENTS AND MAIN RESULTS: Discontinuation (defined as a gap in rhythm-control drug therapy coverage [days' supply] > or = 30 days) was assessed after the initiation of rhythm-control therapy. Among the 3549 patients included in the analysis, 2688 (75.7%) discontinued initial rhythm-control therapy in the first 12 months, with a median time to discontinuation of 89 days. Significant predictors of rhythm-control therapy discontinuation included cardiac arrest (odds ratio [OR] 2.24, 95% confidence interval [CI] 1.04-4.83), history of coronary artery bypass graft surgery (OR 2.03, 95% CI 1.02-4.05), valvular heart disease (OR 1.67, 95% CI 1.33-2.09), ischemic heart disease (OR 1.44, 95% CI 1.13-1.82), and severity of illness (Charlson Comorbidity Index score; OR 1.09, 95% CI 1.01-1.17). Over 12 months, 661 (18.6%) of the 3549 patients had a hospital stay and 285 (8.0%) had an emergency department visit that were related to atrial fibrillation. Total annual atrial fibrillation-related costs/patient were $6165: $3872 for inpatient costs, $1503 for outpatient costs, and $790 for pharmacy costs. CONCLUSION: Initial rhythm-control drug therapy is associated with a high rate of discontinuation, especially early in therapy. Such rates of discontinuation will likely have an impact on the effectiveness of disease management and the quality of care in patients with atrial fibrillation.

Rates of venous thromboembolism occurrence in medical patients among the insured population.

The burden of venous thromboembolism (VTE) remains high in the United States (US). This study assesses the rate of VTE prophylaxis in a large real-world population of medically ill patients and identifies factors which confer VTE risk to this population. Discharges from the PharMetrics database were included if they were aged > or =40 years and had a hospitalisation claim (Jan 2001-Dec 2005) for cancer, congestive heart failure (CHF), severe infectious disease (SID), or lung disease. Discharges with incomplete records in the prior year to the index hospitalisation claim date were excluded. VTE rate, type (deep venous thrombosis [DVT] or pulmonary embolism [PE]), and time to VTE were compared between groups. Multivariate logistic regression analysis was used to identify independent predictors of VTE occurrence. A total of 158,325 patients were included in the study. Cancer patients had the highest incidence of VTE (7.6%), with the average for all patients being 5.6% (1.5% PE). VTE occurred most frequently post discharge, with the median time being 74 days. Post-discharge prophylaxis was provided to 13.1% of CHF patients and < 5% of all other patients. Independent predictors of VTE included a pre-index VTE (odds ratio [OR] 9.06, 95% confidence interval [CI] 8.28-9.91) and a primary diagnosis of cancer compared with a diagnosis of SID (OR 1.34, 95% CI 1.24-1.46). In conclusion, commercially insured medical patients in the US are at high risk of VTE following hospital discharge. One-quarter of medical patients who developed a VTE are at high risk of developing the more severe form of the disease, namely PE, with independent predictors of VTE in the post-discharge period including previous VTE and cancer.

Cost of atrial fibrillation in United States managed care organizations.

INTRODUCTION: Atrial fibrillation (AF) has been shown to be associated with high healthcare costs; however, limited data are available from large-scale studies quantifying the overall cost burden of AF in the USA. We therefore aimed to provide an up to date estimate of the overall per-patient costs of AF in managed care organizations across the USA. METHODS: This retrospective cohort study used claims data from the Integrated Healthcare Information Systems National Managed Care Benchmark Database from January 2005 to December 2006. Patients included in the analysis were aged > or =20 years and had at least two outpatient AF-related claims without hospitalization, or a hospitalization with a primary or secondary discharge diagnosis of AF in 2005. AF-related inpatient and outpatient costs over 12 months from the initial outpatient claim or first hospitalization were examined. For secondary AF hospitalizations, incremental costs associated with AF were measured by comparing costs for patients with AF with a group of matched controls hospitalized without AF. RESULTS: In total, 35,255 patients diagnosed as having AF (5008 with a primary AF diagnosis, 10,776 with a secondary AF diagnosis, 19,471 with outpatient-managed AF), and 20,571 controls without AF, were included in the analysis. Over 12 months, for primary AF hospitalization patients, inpatient costs were $11,306.53 and outpatient costs were $2826.78 (total $14,133.30) per patient. For hospitalized patients with secondary AF, incremental AF-related inpatient costs were $5181.19 and outpatient costs were $1376.33 (total $6557.52). For AF patients with outpatient management in 2005, 12-month AF-related costs were $2177.30 ($175.47 for AF hospitalizations in 2006 and $2001.85 for outpatient costs). CONCLUSIONS: Overall costs of AF in the US managed care organizations are high. Costs are primarily due to inpatient expenses. Improved disease management strategies to reduce AF-related hospitalizations and decrease the overall cost burden of AF are needed.

Cost of hospital admission for antiarrhythmic drug initiation in atrial fibrillation.

BACKGROUND: Initiation of some rhythm-control therapies for atrial fibrillation (AF) requires an inpatient hospital stay and telemetry monitoring, adding to the cost burden of AF. However, specific cost data for inpatient initiation of AF therapies are lacking. OBJECTIVE: To examine costs associated with initiating sotalol or dofetilide in the inpatient setting in the US. METHODS: This retrospective cohort study used data from billing/discharge records in the Premier Perspective Database for adults with a primary diagnosis of AF, hospitalized between January 2002 and September 2007. Patients had to have received 4 or more sotalol doses or 5 or more dofetilide doses starting within 2 days of admission (with >/=1 dose within 3 days of discharge). Patients admitted solely for AF drug initiation were identified by excluding patients who were admitted on an emergency basis, received care in the emergency department, or underwent major surgical procedures. The primary outcome was direct medical costs for in-hospital services during the stay. RESULTS: Among 7290 patients included in the analysis (4847 sotalol, 2443 dofetilide), mean total inpatient costs per patient were $3278 in the sotalol group and $3610 in the dofetilide group. The greatest costs were for room/board ($1874 sotalol, $1985 dofetilide) and cardiology/electrocardiograms ($394 sotalol, $443 dofetilide). Pharmacy costs were $230 and $201 per patient in the sotalol and dofetilide groups, respectively. CONCLUSIONS: The admission of patients for in-hospital initiation of AF rhythm-control therapy represents a high cost burden in the US.

Rates of symptomatic venous thromboembolism in US surgical patients: a retrospective administrative database study.

US national performance measures may reduce the burden of venous thromboembolism (VTE) in surgical patients. To characterize the VTE rate in US surgical patients, and identify real-world independent VTE risk-factors, a national managed-care database was analyzed. 172,320 eligible surgical discharges (23.9% orthopedic, 76.1% abdominal surgery) from the PharMetrics database (January 2001-December 2005) were evaluated. The rate of thromboprophylaxis was low in orthopedic (40.5%) and abdominal (1.8%) surgery discharges, with the event rates of symptomatic VTE in these groups being 4.7% and 3.1%, respectively. The median time to VTE was 51 days: the majority of VTE events occurred post-discharge. Independent predictors of VTE included prior VTE (odds ratio [OR] 10.2; 95% CI: 9.2-11.4), and orthopedic versus abdominal surgery (OR 1.4; 95% CI: 1.4-1.6). Patients undergoing orthopedic or abdominal surgery remain at-risk for VTE. Implementation of national performance measures may help reduce the burden of VTE.

Utility of bortezomib retreatment in relapsed or refractory multiple myeloma patients: a multicenter case series.

Bortezomib therapy has become an important part of the standard of care for patients with relapsed multiple myeloma, and preliminary clinical evidence suggests that bortezomib retreatment in patients previously treated with the drug may prolong disease control. This retrospective study was designed to clarify the utility of bortezomib as a repeat therapy. We reviewed records from 3 major cancer centers that had participated in the phase II (SUMMIT or CREST) or phase III (APEX) registration studies to identify patients who were subsequently retreated off protocol with bortezomib-based therapy. We found 22 patients who received bortezomib retreatment following a 60 or more day gap between bortezomib treatments. Twelve patients had intervening therapy between initial bortezomib treatment and bortezomib retreatment. During retreatment, 14 of 22 patients received bortezomib in combination with another antineoplastic agent. The overall response rate for bortezomib retreatment was 50% (9% complete responses). The median length of retreatment was 5.1 months in responding patients and 2.4 months in nonresponding patients. Therapy was terminated due to unmanageable toxicity in 2 patients during retreatment, compared with 6 patients during initial treatment. During retreatment, no patients required dose reduction due to peripheral neuropathy, compared to 4 patients during their initial treatment. Thus, bortezomib retreatment appears to be safe and effective. Favorable observed response rates with bortezomib retreatment suggest that it may be a viable option for relapsed or refractory multiple myeloma, even in patients previously exposed to bortezomib.

Therapeutic goal attainment in patients with hypertension and dyslipidemia.

BACKGROUND: Recent guidelines emphasize the need to assess and treat overall risk for cardiovascular disease through the concomitant management of multiple risk factors. We sought to ascertain treatment patterns and attainment of therapeutic goals in patients with isolated and concomitant hypertension and dyslipidemia, both with and without diabetes mellitus (DM) and symptomatic cardiovascular disease. METHODS: Inception cohorts of more than 41,000 newly diagnosed hypertension and dyslipidemia patients from 6 medical centers of the south-central Veterans Affairs health care system were evaluated. Treatment patterns and goal attainment for low-density lipoprotein cholesterol (LDL-C; Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults guidelines: <160, <130, or

Predictors of adherence with antihypertensive and lipid-lowering therapy.

BACKGROUND: Patients with comorbid hypertension and dyslipidemia are at high risk for cardiovascular disease, which can be considerably mitigated by treatment. Adherence with prescribed drug therapy is, therefore, especially important in these patients. This study was undertaken to describe the patterns and predictors of adherence with concomitant antihypertensive (AH) and lipid-lowering (LL) therapy. METHODS: This retrospective cohort study examined 8406 enrollees in a US managed care plan who initiated treatment with AH and LL therapy within a 90-day period. Adherence was measured as the proportion of days covered in each 3-month interval following initiation of concomitant therapy (mean follow-up, 12.9 months). Patients were considered adherent if they had filled prescriptions sufficient to cover at least 80% of days with both classes of medications. A multivariate regression model evaluated potential predictors of adherence. RESULTS: The percentage of patients adherent with both AH and LL therapy declined sharply following treatment initiation, with 44.7%, 35.9%, and 35.8% of patients adherent at 3, 6, and 12 months, respectively. After adjustment for age, sex, and other potential predictors, patients were more likely to be adherent if they initiated AH and LL therapy together, had a history of coronary heart disease or congestive heart failure, or took fewer other medications. CONCLUSIONS: Adherence with concomitant AH and LL therapy is poor, with only 1 in 3 patients adherent with both medications at 6 months. Physicians may be able to significantly improve adherence by initiating AH and LL therapy concomitantly and by reducing pill burden.

Prevalence of comorbid hypertension and dyslipidemia and associated cardiovascular disease.

OBJECTIVES: To estimate the prevalence of concurrent hypertension and dyslipidemia among a general veteran population and separately among patients with diabetes mellitus, and to compare the prevalence of cardiovascular disease among groups with isolated versus concurrent hypertension and dyslipidemia. STUDY DESIGN: Retrospective cohort study. PATIENTS AND METHODS: This study was conducted in 6 medical centers of the Department of Veterans Affairs and included 371221 patients seen for any reason from October 1, 1998, to September 30, 2001. The proportion of patients with isolated or concurrent hypertension and dyslipidemia was estimated based on diagnostic, pharmacy, laboratory, and vital sign information, and the age-adjusted proportions of individuals with cardiovascular disease were compared between groups. RESULTS: We found that 57.8% of all patients had hypertension or dyslipidemia; 30.7% had both. Sixteen percent of all patients had diabetes mellitus, and 66.3% of these patients had concomitant hypertension and dyslipidemia. The prevalence of coronary artery disease was often more than doubled among patients with concomitant conditions compared with patients with either condition alone. The prevalence of stroke and peripheral arterial disease similarly increased among patients with both conditions. The prevalence of these cardiovascular diseases was highest among patients with diabetes mellitus. CONCLUSION: The prevalence of cardiovascular disease was high among this population of older, predominately male US veterans.

Incremental effectiveness of amlodipine besylate in the treatment of hypertension with single and multiple medication regimens.

BACKGROUND: The objective of this retrospective observational analysis is to examine the clinical effectiveness of amlodipine besylate as monotherapy or in combination with other antihypertensive drugs (AHDs) in systolic blood pressure (BP) control and BP goal attainment, according to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 6, JNC 7, and American Diabetes Association (ADA)recommendations, within a multicenter ambulatory care setting. METHODS: Hypertensive adults (n = 1175) were identified during a 4-year period (1998 to 2001) from a large commercially available electronic medical record (EMR) database. Patients were required to have initiated therapy with amlodipine and have at least one BP measurement within 6 months before, and 12 months after, the medication start date. Patients were divided into cohorts based on the number of AHDs used before, and continued through, the initiation of amlodipine. Mean change in systolic BP was compared from pre- to post-amlodipine, and adjusted change in systolic BP was calculated using multivariate regression. The percentage of patients attaining BP goal was also calculated. RESULTS: In the order of increasing number of AHDs before initiation of amlodipine (0, 1, 2, > or = 3 previous AHDs): adjusted systolic BP change in mm Hg was -16.1 (95% confidence interval [CI]: -17.9, -14.3), -17.6 (95% CI: -19.6, -15.5), -16.7 (95% CI: -19.0, -14.5), and -15.7 (95% CI: -18.7, -12.8), respectively; BP goal attainment was 39%, 45%, 41%, and 45%, respectively. Amlodipine initiation in all regimens showed statistically significant incremental systolic BP reduction and BP goal attainment from baseline (P < .001). CONCLUSIONS: This study suggests that amlodipine besylate is effective alone or as an add-on therapy to diverse classes of agents.

Economic consequences of renal dysfunction among cardiopulmonary bypass surgery patients: a hospital-based perspective.

BACKGROUND: Renal dysfunction is common after cardiopulmonary bypass procedures and is associated with higher mortality rates and longer lengths of stay. However, less is known about the actual cost of care for these patients. We sought to quantify the hospital costs attributed to renal dysfunction in cardiopulmonary bypass patients at a large academic referral center. METHODS: All patients undergoing cardiopulmonary bypass procedures were identified through administrative databases for a 3-year study period. Renal failure was defined using laboratory values from the hospitalization. Total direct costs and costs by hospital department were determined using the hospital cost-accounting system. A multivariate linear model was developed to determine total direct hospital costs after cardiopulmonary bypass procedures after adjusting for relevant clinical and demographic variables. RESULTS: Nine percent of the study population developed new-onset renal dysfunction, and 18% of patients overall undergoing cardiopulmonary bypass experienced renal dysfunction during the hospitalization. Direct costs were 42% higher for patients with renal dysfunction, an average of 5807 US dollars per case. Higher costs were noted in intensive care unit use and pharmacy, laboratory, and radiology services. CONCLUSIONS: Renal dysfunction increases the direct hospital costs of care, even after adjustment for age, sex, race, and comorbidities. Nationwide, we estimate that renal dysfunction may add up to 643 million US dollars in hospital costs for caring for cardiopulmonary bypass patients. Interventions designed to reduce the incidence and severity of renal dysfunction may significantly reduce hospital costs for these patients.

Rapid antibiotic delivery and appropriate antibiotic selection reduce length of hospital stay of patients with community-acquired pneumonia: link between quality of care and resource utilization.

OBJECTIVES: To measure quality-of-care variables relevant to the treatment of community-acquired pneumonia and to determine their relative contribution to variation in length of hospital stay (LOS). METHODS: One hundred cases of pneumonia requiring hospitalization from each of 7 institutions (2 community and 5 university teaching hospitals) were randomly selected (total sample, 700 cases). Demographic and clinical variables were abstracted using a standardized data instrument. Three quality-of-care measures were analyzed: (1) site of initial antibiotic treatment (emergency department vs floor), (2) door-to-needle time, and (3) appropriateness of antibiotic selection. Appropriate antibiotic selection was defined by the 1998 Infectious Disease Society of America guidelines for the treatment of hospitalized pneumonia cases. Regression modeling was used to determine associations between LOS and our quality-of-care (process) variables. RESULTS: The mean +/- SD LOS for this sample was 7.0 +/- 4.1 days. Prolonged LOS, defined as greater than or equal to the 75th percentile of the LOS distribution, was the dependent variable in our regression analysis and was greater than or equal to 9.0 days. After clinical and demographic variables were adjusted for, logistic regression modeling revealed that all 3 quality-of-care measures were associated with prolonged LOS: (1) initial antibiotic treatment in the emergency department (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.19-0.48); (2) appropriate antibiotic selection (OR, 0.55; 95% CI, 0.35-0.88); and (3) door-to-needle time (OR, 1.75 per 8 hours; 95% CI, 1.34-2.29). In a secondary analysis, we examined the clinical and demographic characteristics of the patients who were treated more rapidly in the emergency department compared with those who were treated on the inpatient floor. No clinically meaningful differences were observed between these groups. CONCLUSIONS: Unlike clinical and demographic variables, process-of-care variables are modifiable and amenable to quality improvement. We observed that rapid antibiotic initiation and appropriate antibiotic selection in the emergency department have a statistically significant association with shorter LOS. These findings suggest quality improvement targeted at these processes of care may improve resource utilization and reduce LOS for patients with community-acquired pneumonia.

A practice-profiling system for residents.

Providers are increasingly evaluated and measured as part of quality, credentialling, and reimbursement programs, an approach often used by managed care organizations. However, these evaluations are rarely used in residency training, meaning that physicians entering practice have little experience or understanding of these measures. To address this issue, in 1998 the authors successfully developed a three-part practice-profiling system for internal medicine residents at their institution that includes measures of patient satisfaction, disease-management profiles for diabetes and hypertension, and an Internet-based faculty-evaluation program. The patient-satisfaction profile utilizes a ten-question patient survey that emphasizes physician-patient communication issues. The diabetes and hypertension disease-management profiles use the resident's own patients to profile process and outcome measures for common chronic ambulatory conditions. The faculty-evaluation profile is conducted over the Internet, and allows the resident to compare faculty evaluations with those of his or her peer group. Residents receive the profiles as a packet in a scheduled session with a faculty supervisor twice each year. A total of 120 residents are profiled annually for the above measures. Residents rated the program very highly, and found the profiling program to be instructive and effective feedback. As payers and regulators increasingly use physician profiling, residents will benefit from learning the strengths and weaknesses of profiling systems early in their training.