Polypharmacy management in Medicare managed care: changes in prescribing by primary care physicians resulting from a program promoting medication reviews.

OBJECTIVE: To examine the effects of medication reviews by primary care physicians on prescriptions written for elderly members of a Medicare managed care organization who were at risk for polypharmacy. STUDY DESIGN: Prospective study with follow-up survey. PATIENTS AND METHODS: We conducted a study in 1995 to demonstrate the prevalence of polypharmacy (defined as receiving 5 or more prescription medications during the 3-month study period) among elderly members of our managed care organization. Two years later, elderly members identified as being at risk for polypharmacy were sent a letter encouraging them to schedule a medication review with their primary care physician. Each primary care physician was provided with clinical practice guidelines on polypharmacy and patient-specific medication management reports. Patients and physicians were subsequently mailed a survey to assess the impact of the medication review program on prescribing practices. RESULTS: Of 37,372 elderly members screened, 5737 (15%) were at risk for polypharmacy. Of these, 2615 (46%) responded to the follow-up survey. Of the survey respondents, 1087 (42%) had gone to their primary care physician for a medication review. During the review, 96% of patients discussed their prescription medications and 72% discussed nonprescription medications they were taking. Twenty percent reported that their physician discontinued medications, 29% reported that the physician changed the dose of a medication, and 17% informed their physician about a new prescription or nonprescription medication they were taking. Of the 275 primary care physicians surveyed, 56 (20%) returned the questionnaire. Of these, 61% reported that the medication review program was "very" or "somewhat useful." Thirty-five percent reported discontinuing unnecessary medications, and 23% reported decreasing the frequency of dosing. Overall, 45% of physicians reported making at least one change in their prescribing to a member at risk for polypharmacy. CONCLUSIONS: Our program promoting medication reviews between primary care physicians and their elderly patients resulted in significant changes in prescribing by physicians. This type of program is likely to decrease the risk of polypharmacy among older members of a Medicare managed care organization.

Aspirin treatment after myocardial infarction: are health maintenance organization members, women, and the elderly undertreated?

In April 1996, we surveyed 539 patients who had suffered a myocardial infarction in 1995 to determine whether the prescription and use of aspirin after myocardial infarction differs by patient age, sex, and type of health insurance. Patients who were insured through one of four health maintenance organizations in major metropolitan areas or by an indemnity plan in 40 states completed the survey. Among the 502 patients with no contraindications to use, 93.8% were prescribed aspirin. Among patients with a prescription and no subsequent contraindications to use, 96.4% were taking aspirin when surveyed. Among aspirin users, 96.5% reported taking aspirin daily. Controlling for other characteristics, 75-year-old patients were 5 percentage points less likely to receive a prescription for aspirin than were 50-year-old patients (P = 0.05). Although not significant at conventional levels, point estimates revealed a prescription rate for women that was 6 percentage points higher than that for men (P = 0.054) and a rate for health maintenance organization members that was 4 percentage points lower than that for patients with indemnity insurance (P = 0.10). Aspirin use was lower among older patients (P = 0.02) but did not differ by gender or type of insurance plan. Health maintenance organization members were just as likely to receive a prescription from a specialist as were those with indemnity insurance (P = 0.92). Based on these results, the rate of aspirin treatment after myocardial infarction may be much higher than previous studies indicate. Concerns that managed care patients and women may be undertreated are not supported by our findings. Although older patients are at risk for undertreatment, this risk is low. Once aspirin is prescribed, selfreported patient compliance with a daily regimen of aspirin is high.

Disease management interventions to improve outcomes in congestive heart failure.

This study is part of a planned 24-month, multicenter, longitudinal comparison of a comprehensive congestive heart failure (CHF) disease management program and was designed to determine effectiveness after 12 months of implementation. The impact of interventions such as telemonitoring of patients, post-hospitalization follow-up, and provider education on selected primary outcomes (hospital admission and readmission rates, length of stay, total hospital days, and emergency room utilization) in a managed care setting was evaluated. Subjects in the study included all participants in the managed care plan, as well as 149 selected program participants. The effects of the program were analyzed for pure CHF and CHF-related diagnoses, with outcomes for the third quarter of 1996 (postintervention follow-up) being compared with those for the third quarter of 1995 (preintervention baseline). Overall, the data demonstrated significantly reduced admission and readmission rates for patients with the pure CHF diagnosis. Among the entire CHF patient population, the third quarter admission rate declined 63% (P = 0.00002), and the 30-day and 90-day readmission rates declined 75% (P = 0.02) and 74% (P = 0.004), respectively. Among program participants with pure CHF diagnoses, the 30-day readmission rate was reduced to 0, and an 83% reduction occurred for both the third quarter admission (P = 0.008) and 90-day readmission (P = 0.06) rates. In addition, the average length of stay for patients with CHF-related diagnoses was significantly reduced among both plan participants (P = 0.03) and program participants (P = 0.001). Reductions were also seen in total hospital days and emergency room utilization. These data thus indicate that a comprehensive disease management program can reduce healthcare utilization not only among CHF patients in the program but also among the entire managed care plan population.

Development and modification of a required family medicine clerkship.

A new required clinical clerkship in family medicine at Duke University School of Medicine is described in terms of planning, implementation, and modification in response to students' evaluations. Seventy-five percent of the eight-week course involves direct clinical experience both in academic practices and community sites, and 25 percent is spent in small group seminars and workshops. Evaluations by students have been highest for the clinical experience, the clinical competence of the faculty, the teaching effectiveness of the faculty and house staff, and the overall learning experience. The ratings have been lowest for seminars, workshops, and required written projects. Several modifications made in the clerkship over a three-year period have raised the students' ratings to near their ratings of the five traditional clerkships. The data demonstrate that family medicine can be taught effectively as a core clinical rotation and can broaden the general education of medical students.

Free visits: a strategy to retain patients and improve continuity in a residency program.

All family practice residencies attempt to offer continuity experience to residents and patients as part of their model practices. However, every year one third of the most experienced resident providers leave the practice to be replaced by new, inexperienced residents. This study reports a randomized controlled trial in which a sample of reassigned patients was offered a free visit with their new physician. The free visit was a scheduled appointment with the patient's newly assigned physician during a two-month period for the purpose of meeting the new physician. The offer of a free visit succeeded in helping patients make the initial office contact with their new physician. However, during six months of follow-up the free visit offer did not have an impact on visit frequency or primary provider continuity. In this study the reassignment of patients to new physician providers did not affect overall visit frequency, but did have a negative impact on primary provider continuity.

Negotiation: a fundamental process in family medicine.

Negotiation, a common term in American society, is a process that can be especially useful to family medicine as a specialty that interfaces with many other clinical areas. The basic concepts of the negotiation process, including Maslow's need theory, terminology, and the three phases of the process (ie, planning, implementation, and follow-up), are applied to family medicine. A case study of a successful curriculum negotiation between family medicine and pediatrics is presented, and the use of need theory in the planning phase and during the strategic approach is analyzed. The negotiation process is also applied to faculty contracts, practice management training for residents, clinical teaching, and interdisciplinary relationships as indications of its broad usefulness within family medicine.

Clinical practice plans in family practice residency programs.

This paper examines clinical practice plans (CPPs), systems for remunerating physician faculty based on their clinical productivity, in family practice residency programs. A stratified random sample of residency directors responded to a CPP survey. CPPs were found significantly more frequently in residencies (usually operated by universities) either with CPPs in their parent institutions or with high patient volume. Residencies operated by community hospitals were more likely to distribute CPP benefits to faculty based on individual clinical activity, whereas residencies operated by universities were more likely to distribute equal benefits to all faculty or to include academic as well as clinical activities in the benefit determination. While most residency directors felt that CPPs brought financial benefits to a residency and to individual faculty, many directors who did not have CPPs feared that such a plan would create conflicts between patient care and teaching. A case report tracing the evolution of a CPP in one university-administered residency is presented.

Hospital privileges of family physicians in North Carolina.

Ninety-eight percent of the North Carolina hospitals studied grant some or all of their family physician staff general medicine privileges, while 80 percent grant some or all family physician staff coronary unit privileges. Sixty-eight percent of the hospitals grant some or all family physicians general pediatrics privileges, while 72 percent grant newborn nursery privileges. Routine obstetrics privileges are present in 67 percent of the hospitals. Only 24 percent of the hospitals grant some or all the family physicians operative surgical privileges. There is a significant difference between urban and rural hospitals in first assistant surgery privileges. Of the 38 hospitals granting first assistant privileges, 35 are rural. Family physicians in smaller hospitals, especially those having fewer than 100 beds, are less likely to be required to seek consultations. Hospitals were asked to note what privileges a new board certified family physician staff member might expect to receive. There was little change from the current pattern. This study suggests that the opportunity for extensive hospital practice by family physicians currently exists in North Carolina.

Teaching physicians to teach: a three-year report.

To meet the needs for an expanded preceptor faculty, the Department of Family Medicine at the College of Medicine and Dentistry of New Jersey-Rutgers Medical School has for three years conducted yearly training programs designed to prepare practicing family physicians for the teaching role. Thirty-six physicians have completed the program, which consists of four group seminars and three individual learning site visits spent in the office of an experienced preceptor while a fourth year student is present. Many lessons were learned in the course of these yearly programs which may be useful to others who plan to undertake similar faculty development activities. Therefore, detailed, practical, experiential information is presented regarding recruitment, orientation, the educational program of seminars and individual learning experiences, evaluation, and required resources. Some problems proved to be particularly difficult, such as the uneven quality of the individual learning visits and the attrition of some participants from the program. Feedback from participating physicians has been extremely positive.

Teaching geriatric care: report on an experimental second-year elective.

To help fill the growing need for medical school instruction in geriatric care, the Departments of Family Medicine and Community Medicine at the College of Medicine and Dentistry of New Jersey-Rutgers Medical School, in cooperation with Roosevelt Hospital, a nearby county-supported chronic disease facility, joined to develop an experimental second-year elective, given for the first time in the fall of 1976. The curriculum involved 11 three-hour sessions covering a variety of medical and socioeconomic topics. Enrollment was limited to 12 students. Reaction was positive on the part of students, patients, and faculty, especially with respect to student attitudes toward the elderly. Improvements are suggested in six major areas.

House call patterns of New Jersey family physicians.

House call attitudes and practice patterns of New Jersey family physicians were studied in order to assist residency programs in curriculum development. House calls were offered by 82 percent of the 290 physicians in the sample; no difference was noted between rural and urban or between younger and older physicians. The average number of house calls per week was 6.05, of which 4.71 and 1.34 were scheduled and emergency respectively. Patients who were elderly, home-bound, had suffered a stroke, had cancer or congestive heart failure made up the majority of those receiving house calls. This survey also showed that many of the physicians who stated that they do not "offer" house calls to their patients, did in fact perform them. These study results support the thesis that family practice residencies should develop criteria and a protocol for house calls. Among the results which may be expected following such an innovation are increased satisfaction for patients and physicians alike.