Assessment of American College of Rheumatology quality criteria for rheumatoid arthritis in a pre-quality criteria patient cohort.

OBJECTIVE: To evaluate the American College of Rheumatology (ACR) starter set of quality measures for rheumatoid arthritis (RA) in an actual patient cohort that preceded publication of the quality measures. METHODS: We retrospectively applied the 2006 ACR quality criteria to a prospectively studied cohort of 568 patients with RA treated by 1,932 unique physicians including 255 different rheumatologists between the years 1999 and 2003. Data on performance were obtained from self-report surveys and medical record review within 12 months. RESULTS: At least 1 joint examination was performed in 98% of patients. Patient and physician global assessments were reported for 79% and 74% of patients, respectively. A total of 85% of patients received disease-modifying antirheumatic drugs (DMARDs). DMARD adjustments were made for 50% of patients in whom increasing disease activity was noted at least once and for 64% of patients in whom increasing disease activity was noted during 2 (of 4) 3-month periods within the year. Compared with self-report surveys, medical records substantially underreported performance on quality measures. CONCLUSION: The ACR-endorsed quality measures for RA can be assessed using available data sources. When both self-report and medical record data are used, adherence rates, designed to serve as minimum standards of care, were moderate or high for most measures. Prior to using indicators to compare quality across groups, specific strategies for operationalizing measures and for using accurate data sources to assess adherence to the measures should be defined.

Application of explicit process of care measurement to rheumatoid arthritis: Moving from evidence to practice.

OBJECTIVE: To construct quality measures with measurement validity and meaning for clinicians. METHODS: We conducted a prospective cohort study of rates of change in disease-modifying antirheumatic drug (DMARD) and/or systemic corticosteroid drug or dose for 568 patients with rheumatoid arthritis (RA) across 6,159 clinical encounters within 12 months to examine how changes in clinical specifications change adherence. RESULTS: Rates of DMARD change were sensitive to specifications regarding the intensity of disease activity (severe or moderate), duration of specified disease activity, and length of the observation period. Over 12 months, the proportions of 377 patients with severe disease activity observed for 1-month, 2-month, and 3-month time blocks who had a change in DMARD drug or dose were 36%, 57%, and 74%, respectively. Over 12 months, a change in DMARD drug or dose was observed for 44%, 50%, and 68% of 377 patients with severe disease within 3 months, 6 months, and 12 months, respectively, of the patient meeting criteria for severe disease activity. A change in DMARD drug or dose was observed for 21%, 23%, and 34% of 149 patients with moderate disease activity within 3, 6, and 12 months, respectively, of the patient meeting criteria for moderate disease activity. CONCLUSION: Rates of pharmacologic interventions for patients with moderate and severe RA disease activity vary substantially by intensity and duration of disease activity and by duration of period for observing change. Lack of precision in explicit process criteria could substantially mislead comparisons of quality of care across comparison groups.

Do malpractice concerns, payment mechanisms, and attitudes influence test-ordering decisions?

Greater understanding is needed of nonclinical factors that determine neurologists' decisions to order tests. The authors surveyed 595 US neurologists and utilized demographic information, attitude scales, and clinical scenarios to evaluate the influence of nonclinical factors on test-ordering decisions. Greater test reliance, higher malpractice concerns, and receiving reimbursement for testing were all associated with a higher likelihood of test ordering. These findings have implications for training needs and suggest malpractice worries may inflate health care costs.

What factors influence physicians' decisions to switch from intravenous to oral antibiotics for community-acquired pneumonia?

OBJECTIVE: One of the major factors influencing length of stay for patients with community-acquired pneumonia is the timing of conversion from intravenous to oral antibiotics. We measured physician attitudes and beliefs about the antibiotic switch decision and assessed physician characteristics associated with practice beliefs. DESIGN: Written survey assessing attitudes about the antibiotic conversion decision. SETTING: Seven teaching and non-teaching hospitals in Pittsburgh, Pa. PARTICIPANTS: Three hundred forty-five generalist and specialist attending physicians who manage pneumonia in 7 hospitals. MEASUREMENTS AND RESULTS: Factors rated as "very important" to the antibiotic conversion decision were: absence of suppurative infection (93%), ability to maintain oral intake (79%), respiratory rate at baseline (64%), no positive blood cultures (63%), normal temperature (62%), oxygenation at baseline (55%), and mental status at baseline (50%). The median thresholds at which physicians believed a typical patient could be converted to oral therapy were: temperature < or =100 degrees F (37.8 degrees C), respiratory rate < or =20 breaths/minute, heart rate < or =100 beats/minute, systolic blood pressure > or =100 mm Hg, and room air oxygen saturation > or =90%. Fifty-eight percent of physicians felt that "patients should be afebrile for 24 hours before conversion to oral antibiotics," and 19% said, "patients should receive a standard duration of intravenous antibiotics." In univariate analyses, pulmonary and infectious diseases physicians were the most predisposed towards early conversion to oral antibiotics, and other medical specialists were the least predisposed, with generalists being intermediate (P <.019). In multivariate analyses, practice beliefs were associated with age, inpatient care activities, attitudes about guidelines, and agreeableness on a personality inventory scale. CONCLUSIONS: Physicians believed that patients could be switched to oral antibiotics once vital signs and mental status had stabilized and oral intake was possible. However, there was considerable variation in several antibiotic practice beliefs. Guidelines and pathways to streamline antibiotic therapy should include educational strategies to address some of these differences in attitudes.

Is gender a factor in psychiatrists' evaluation and treatment of patients with major depression?

BACKGROUND: Gender differences in clinical assessment and treatment have been reported in several areas of medicine. We examine whether differences exist in the routine outpatient psychiatric management of men and women with major depression. METHODS: Psychiatrists practicing in the community completed case forms on a systematic sample of their adult outpatients with major depression. Comparisons are presented between male (n=261) and female (n=472) patients focusing on their background characteristics, clinical presentation, assessment, and treatment. Significant gender disparities in assessment and treatment are also examined with respect to the gender of the treating psychiatrist. RESULTS: Although male and female patients had generally similar clinical profiles, a significantly greater proportion of males than females had psychomotor retardation and substance use disorders. No significant gender differences were observed in the assessment of depressive symptoms, psychiatric comorbidities, and treatment with antidepressant medications or psychotherapy. However, a significantly smaller percentage of depressed women than men received assessments of sexual function and medication-related sexual side effects. Female patients were also less likely to have discussed their treatment preferences with their psychiatrists. LIMITATIONS: Only a minority (33.2%) of psychiatrists invited to participate contributed patients to this study. The results are based on structured assessments completed by practicing psychiatrists rather than patient self-assessments or independent research assessments. CONCLUSIONS: Although we find overall little evidence of gender bias in the clinical management of major depression, both male and female psychiatrists need to further explore sexual function and treatment preferences in female patients.

From understanding health care provider behavior to improving health care: the QUERI framework for quality improvement. Quality Enhancement Research Initiative.

Basic science and health care research provide the evidence base for the scientific practice of medicine. Over the past 2 decades, as increasingly refined tools for improving health and health care have been developed, the health care community has attempted to bridge the gap between available tools and actual health care practices. This gap can be bridged only by influencing health care provider behavior. The VA Quality Enhancement Research Initiative (QUERI) is a program designed to systematically translate research findings into better health care practices, and thus better health outcomes for enrolled veterans. Integrating provider behavior research considerations and findings into each step of the QUERI process will enhance the effectiveness of the initiative. This article presents a provider behavior research framework for planning, implementing, and evaluating quality improvement interventions within QUERI.

Associations between primary care physician satisfaction and self-reported aspects of utilization management.

OBJECTIVE: To evaluate the association between physician-reported utilization management (UM) techniques in capitated physician groups and physician satisfaction with capitated care. STUDY SETTING: 1,138 primary care physicians from 89 California capitated physician groups in 1995. STUDY DESIGN: Eighty percent of physicians (N = 910) responded to a mail survey regarding the UM policies in their groups and their satisfaction with the care they deliver. Physician-reported UM strategies measured included group-mandated preauthorization (number of referrals requiring preauthorization, referral denial rate, and referral turnaround time), group-provided explicit practice guidelines, and group-delivered educational programs regarding capitated care. We also measured two key dimensions of satisfaction with capitated care (multi-item scales): (1) satisfaction with capitated care autonomy and quality, and (2) satisfaction with administrative burden for capitated patients. EXTRACTION METHODS: We constructed two multivariate linear regression models to examine associations between physician-reported UM strategies and physician satisfaction, controlling for demographic and practice characteristics and adjusting for clustering. PRINCIPAL FINDINGS: Physician-reported denial rate and turnaround time were significantly negatively associated with capitated care satisfaction. Physicians who reported that their groups provided more guidelines were more satisfied on both dimensions, while physicians who reported that their groups sponsored more educational programs were more satisfied with administrative burden. The number of clinical decisions requiring preauthorization was not significantly associated with either dimension of satisfaction. CONCLUSIONS: Physicians who reported that their groups used UM methods that directly affected their autonomy (high denial rates and long turnaround times) were less satisfied with care for capitated patients. However, a preauthorization policy for referrals or tests was not, in and of itself, associated with satisfaction. Indirect control mechanisms such as guidelines and education were positively associated with satisfaction.

The appropriateness of recommendations for hysterectomy.

OBJECTIVE: To evaluate the appropriateness of recommendations for hysterectomies done for nonemergency and non-oncologic indications. METHODS: We assessed the appropriateness of recommendations for hysterectomy for 497 women who had the operation between August 1993 and July 1995 in one of nine capitated medical groups in Southern California. Appropriateness was assessed using two sets of criteria, the first developed by a multispecialty expert physician panel using the RAND/University of California-Los Angeles appropriateness method, and the second consisting of the ACOG criteria sets for hysterectomies. The main outcome measure was the appropriateness of recommendation for hysterectomy, based on expert panel ratings and ACOG criteria sets. RESULTS: The most common indications for hysterectomy were leiomyomata (60% of hysterectomies), pelvic relaxation (11%), pain (9%), and bleeding (8%). Three hundred sixty-seven (70%) of the hysterectomies did not meet the level of care recommended by the expert panel and were judged to be recommended inappropriately. ACOG criteria sets were applicable to 71 women, and 54 (76%) did not meet ACOG criteria for hysterectomy. The most common reasons recommendations for hysterectomies considered inappropriate were lack of adequate diagnostic evaluation and failure to try alternative treatments before hysterectomy. CONCLUSION: Hysterectomy is often recommended for indications judged inappropriate. Patients and physicians should work together to ensure that proper diagnostic evaluation has been done and appropriate treatments considered before hysterectomy is recommended.

Quality of life among women undergoing hysterectomies.

OBJECTIVE: To measure the association between gynecologic conditions and quality of life in women before hysterectomy. METHODS: We retrospectively identified 482 women who had hysterectomies for nononcologic and nonemergency indications in one of nine capitated medical groups in Southern California between 1993 and 1995. Their symptoms and quality of life before hysterectomy were assessed by medical record review and telephone interview. Women were placed into four symptom-based groups (pain, bleeding, pelvic discomfort, and asymptomatic groups) and compared across six quality-of-life scales. RESULTS: Women with primary pain conditions reported the highest average role impairment compared with women with primary bleeding, pelvic discomfort, or asymptomatic conditions (8.6 days/month versus 5.0, 2.5, and 1.9 days/month, respectively; P < .05). On the five 0 to 100-point quality-of-life scales, women with primary pain conditions, compared with women with bleeding, pelvic discomfort, or asymptomatic conditions, had the highest mean levels of sexual impairment (71.5 versus 54.1, 29.6, and 17.9, respectively; P < .05) and mood impairment (55.2 versus 45.2, 34.6, and 38.1, respectively; P < .05), the poorest perception of general health (74.4 versus 60.7, 44.1, and 49.4, respectively; P < .05), and the greatest increase in severity of symptoms before hysterectomy (77.2 versus 68.7, 61.5, and 57.1, respectively; P < .05). CONCLUSION: Women's primary symptoms before hysterectomy are associated differentially with varying levels of impairment. Standardized measurement of quality of life among women with gynecologic complaints that lead to hysterectomy might help in the development of treatment guidelines and in the assessment of appropriateness and outcomes of care for those women.

Primary care physicians' satisfaction with quality of care in California capitated medical groups.

CONTEXT: Managed care and capitation have placed new responsibilities on primary care physicians, including formally acting as "gatekeepers" for specialty services and tests. Previous studies have not examined whether primary care physicians who provide services to patients under many coverage arrangements feel differently about caring for patients covered under capitation vs those covered through more traditional forms of insurance. An understanding of whether California primary care physicians feel that they deliver a different level of quality to capitated patients could help signal whether variations in care for patients with different coverage forms are evolving. OBJECTIVE: To evaluate whether primary care physicians in California capitated groups report different satisfaction levels with quality of care for patients in their overall practice than for patients covered by capitated contracts and to examine whether physicians' satisfaction with capitated care quality is influenced by the characteristics of the practice setting. DESIGN: Cross-sectional questionnaire. SETTING: A total of 89 California physician groups with capitated contracts. PARTICIPANTS: A total of 910 primary care physicians (80% response rate). MAIN OUTCOME MEASURE: Satisfaction with 4 aspects of quality of care provided to patients covered by capitated contracts vs patients overall. RESULTS: Physicians reported lower satisfaction with all 4 aspects of care for patients covered by capitated contracts than for patients in their overall practice: 71% were very or somewhat satisfied with relationships with capitated patients (compared with 88% for overall practice), 64% were very or somewhat satisfied with the quality of care they provided to capitated patients (compared with 88% for overall practice), 51% were very or somewhat satisfied with their ability to treat capitated patients according to their own best judgment (compared with 79% for overall practice), and 50% were very or somewhat satisfied with their ability to obtain specialty referrals (compared with 59% for overall practice) (P< or =.001 for all comparisons). Being in a medical group practice (vs an independent practice association) and having a larger percentage of capitated patients were independently associated by multivariate analysis with higher levels of satisfaction with capitated quality of care (P< or =.005). CONCLUSION: These California primary care physicians were less satisfied with the quality of care they deliver to patients covered by capitated contracts than with the quality of care they deliver to patients covered by other payment sources. However, those in medical group practices and with a higher percentage of capitated patients were more satisfied with capitated care. National expansion of capitation should be accompanied by efforts to ensure that the satisfaction of practicing physicians with the care they deliver does not decline.

Variations in cataract extraction rates in Medicare prepaid and fee-for-service settings.

OBJECTIVE: To compare rates of cataract extraction in 2 prepaid health settings and in traditional fee-for-service (FFS) settings. DESIGN: A cross-sectional analysis using 1993 health maintenance organization (HMO) Medicare claims and encounter files, the Health Care Financing Administration (HCFA) 5% Medicare Part B provider/supplier file, and the HCFA October 1992 100% Medicare population file. SETTING: Southern California Medicare FFS settings and the staff-model and independent practice association (IPA) plans of a large California HMO. PATIENTS: 1993 Medicare beneficiaries aged 65 years and older. The study included 43387 staff-model HMO enrollees, 19050 IPA enrollees, and 47 150 FFS beneficiaries (a 5% sample of all Southern California FFS beneficiaries). MAIN OUTCOME MEASURE: Age and risk-factor adjusted rates of cataract extraction per 1000 beneficiary-years. RESULTS: After controlling for age, sex, and diabetes mellitus status, FFS beneficiaries were twice as likely to undergo cataract extraction as were prepaid beneficiaries (P<.01). Female FFS beneficiaries were nearly twice as likely to undergo the procedure as were male FFS beneficiaries (P<.001); there were no extraction rate differences by sex in the prepaid settings. CONCLUSION: Because of the potential implications for vision care in the elderly, the significantly different rates of cataract extraction in FFS and prepaid settings warrant further clinical investigation to determine whether there is overuse in FFS vs underuse in prepaid settings. Such investigations must assess the appropriateness of cataract surgery by evaluating its use relative to clinical need.

Can a specialty society educate its members to think differently about clinical decisions? Results of a randomized trial.

OBJECTIVE: Measure the effect of specialty society-developed continuing medical education (CME) on clinical decision making. DESIGN: Randomized controlled trial. SETTING: National sample of neurologists. PARTICIPANTS: Of 492 neurologists randomly selected from an ongoing American Academy of Neurology CME program, 248 were randomized to receive a mailed CME course, and 244 did not receive it. INTERVENTION: A mailed educational course on movement disorders, developed by the specialty society, containing information on diseases and practice recommendations with illustrative case presentations. MEASUREMENTS AND MAIN RESULTS: We assessed adherence to 16 practice recommendations on disease detection, diagnostic test use, and treatments by mailed survey sent to all subjects 4.5 months after the intervention group received the course (73% response rate). The survey contained detailed clinical scenarios to measure self-reported clinical decision making and short open-ended questions to measure factual knowledge. More intervention participants (up to 2.6 times more) than control subjects reported clinical decision making adherent to 9 of the 16 recommendations (p < .05). For 4 of the other 7 recommendations, adherence exceeded 85% in both groups. Within the intervention group, neurologists who read the educational course were 2 to 6 times more likely to be adherent than neurologists who did not. The intervention group had better factual knowledge than control subjects in six of seven areas (p < .01). CONCLUSIONS: This educational course improved neurologists' reported decision making. Specialty society-developed CME that utilizes a similar format may enhance the effectiveness of mailed CME information to improve physicians' approach to clinical decisions.

Quality assurance in capitated physician groups. Where is the emphasis?

OBJECTIVE: To describe quality assurance (QA) programs implemented by capitated physician groups; to measure their relative emphasis on monitoring of overuse compared with underuse and monitoring and improving preventive services compared with chronic disease care; and to examine how group characteristics influence QA activity. DESIGN: Cross-sectional questionnaire. SETTING: A large network-model health maintenance organization in California (133 contracting physician groups). PARTICIPANTS: Ninety-four physician groups (71%) caring for 2.9 million capitated patients. MAIN OUTCOME MEASURES: Self-reported use of quality monitoring and improvement methods. RESULTS: All capitated physician groups conducted some QA. Groups' QA programs monitored areas subject to overuse, such as cesarean delivery and angioplasty rates, more than areas subject to underuse, such as childhood immunization rates and performance of retinal examinations for diabetic patients (64% vs 43%, P<.001). They monitored underuse of preventive services more than follow-up services for chronic diseases (54% vs 31%, P<.001). Groups also used reminders for preventive services more than they monitored follow-up services for chronic diseases (26% vs 15%, P<.01). Physician group characteristics independently associated with higher overall QA activity were greater number of years in existence, higher profitability, and capitated care penetration. CONCLUSION: Capitation places a large share of responsibility for QA in the hands of physician groups, but not all aspects of QA are being equally addressed. The emphasis on overuse may result from financial incentives inherent in capitation, while the focus on preventive services may stem from lack of adequate quality measurement tools for monitoring chronic disease care. Further research efforts should address how capitated physician groups might expand their QA programs to include monitoring of underuse, especially for patients with chronic disease.

Use of clinical practice guidelines in managed care physician groups.

There is increasing interest in the use of clinical guidelines as a tool to improve the quality and cost-effectiveness of health care. Yet, relatively little data are available regarding the use of guidelines by health care provider organizations. We developed a written descriptive survey investigating the development, implementation, and evaluation of clinical guidelines that was administered to medical directors or their designees from physician medical groups and independent practice associations. Eighty-seven percent of physician organizations were reported to be developing or implementing clinical guidelines. The reasons most often cited for developing clinical guidelines were quality improvement and cost containment. Local expert opinion or judgment was rated as the most important influence in the development of clinical guidelines, followed by medical and scientific literature and externally developed guidelines. Feedback of information was the most popular method of increasing compliance with clinical guidelines, although 19% of physician organizations reported imposing sanctions on physicians who did not use guidelines. Most of the physician organizations surveyed have embraced clinical guidelines. Local development or adaptation of clinical guidelines may be common. There has been disproportionately little attention paid to guideline implementation and to evaluation of guideline effects relative to their development.

Diagnostic reasoning in neurology.

Studies examining physicians' clinical decisions have demonstrated considerable variation in decisions and practices and identified numerous challenges to effective, efficient, and accurate decision making. Although use of the decision aids and tools described in this article may help overcome many of these challenges, greater self-awareness of the diagnostic reasoning process and the factors influencing decisions also should help improve clinical decisions and reduce variation, irrespective of the use of these tools. Continued research into the determinants and nature of the diagnostic reasoning process will provide additional insights that can be used to develop and apply improved decision aids and corrective procedures to overcome persistent problems.

Managed care and capitation in California: how do physicians at financial risk control their own utilization?

OBJECTIVE: To describe the structure and range of utilization management methods initiated by physicians in response to capitation. DESIGN: Cross-sectional questionnaire. SETTING: A large network-model health maintenance organization (133 contracting physician groups) in California. PARTICIPANTS: 94 (71%) physician groups caring for 2.9 million capitated patients. MEASUREMENTS: Self-reported use of five major utilization management methods. RESULTS: All physician groups reported using gate-keeping and preauthorization for certain referrals or tests. Most also used profiling of utilization patterns (79%), guidelines (70%), and managed care education (69%). Most physician groups asked gatekeepers to submit preauthorization requests for specialty referrals and restricted patient self-referral. For example, 60% of groups required preauthorization for an internal medicine subspecialty referral, and 7% allowed patient self-referral. Most groups also asked gatekeepers to obtain preauthorization for many tests (for example, 95% for magnetic resonance imaging and 53% for pulmonary function tests). Preauthorization requests were denied infrequently (less than 10% of the time) by more than 75% of groups. Of the 54 groups reporting utilization profiles to their physicians, 61% never adjusted for case-mix among patients and more than 60% suggested practice changes to their physicians based on utilization. Fewer than 35% of the groups used written guidelines for expensive tests that required preauthorization (such as angiography). CONCLUSIONS: Physicians are responding to capitation by using utilization management techniques, some at early stages of development, that were previously used only by insurers. This physician-initiated management approach represents a fundamental transformation in the practice of medicine.

A Windows-based tool for the study of clinical decision-making.

Studies of health-provider decision-making, and of their practice patterns, play a central role in efforts to improve the quality and effectiveness of care and in decreasing costs of healthcare delivery systems. Researchers from a variety of disciplines have studied a broad range of clinical conditions, using a number of methodological approaches and measurement tools, including self-report, written clinical vignettes, simulated clinical encounters using actors as patients and analysis of medical records and administrative data. Although these provide information about the outcomes of clinical decisions, they provide little or no information about the process of the decision. Most clinicians agree that the decision process is as important as the outcome, and indeed it is not unusual to have an exemplary process but a poor outcome. Process information is therefore a crucial dimension of care evaluation. In this paper, we describe a new software product that was originally used to measure diagnostic reasoning in the basic medical science of immunology; subsequently adapted to measure key steps in the clinical decision-making process. This Windows-based software is user-friendly, inexpensive, and requires only commonly available hardware for its operation. It is very flexible, permitting the creation of unlimited numbers and types of clinical scenarios, with diagnostic and/or management approaches. Being clinically "real-world," the scenarios are familiar to the user, who is therefore likely to respond in a "real-world" fashion, with the consequent improved accuracy of data. In addition, a wide range of users may be accommodated. The clinical activities of physicians, nurses, pharmacists, and any other clinical providers may be measured and analyzed by the system. Non-clinical providers, such as managers and administrators, could also be assessed. The system has three major modes. In the Authoring Mode, the author creates a menu, which is common to a number of linked scenarios. For example, the menu for physicians might include the History, Physical examination, Laboratory tests, Radiology, Consultations, etc. The actual details of each related clinical case may then be varied. There is virtually unlimited flexibility in the design of the menu and the clinical details, depending on the needs of the author, and the type of information desired. Both diagnostic and management scenarios are easily constructed. The cost for each individual step may be assigned, using any scoring scale desired. Actual dollar costs, or a suitable point score, are equally possible. Once the menu and associated scenarios are generated, the candidate is asked to solve the clinical problem in the User Mode. The candidate obtains information by "mouse-clicking," so it is not necessary to be a computer expert to use the system. Eventually, the candidate is presented with a short vignette outlining the desired solution, which may include the authors comments, sources for further information, etc. In the Data Collection and Analysis Mode, the candidate proceeds to solve the scenario, the software captures and stores each individual information request i.e., each step in the candidates reasoning process. Thus, the reasoning process can be examined, including timing and order and types of information used; this may be done both for individual candidates, and also for groups. A "gold standard" reasoning may be predetermined by the author for comparison purposes. The software has already been used to teach immunology to medical students, and is currently being expanded to train gynecology surgeons in the use of Clinical Practice Guidelines. The software has potential applications in many aspects of the healthcare field. For educators, it could serve in traditional exit examinations for the clinical disciplines, both undergraduate and postgraduate. (abstract truncated)

Deliberations on the dissemination of PORT products: translating research findings into improved patient outcomes.

This report outlines the activities undertaken by the Inter-PORT Dissemination work group during its first 2 years of operation. The work group's initial purpose was to assist the individual PORTs in developing their plans for both disseminating research findings and evaluating the effectiveness of these strategies. However, it became quickly apparent that in a discipline little more than a decade old, a commonly understood vocabulary had yet to be adopted. Even the term "dissemination" held different meaning for different constituencies. Consequently, the work group has tried to encourage the development of both a definitional framework and a set of common data elements of importance to all dissemination programs. The work group has analogously attempted to agree on minimum standards of methodologic rigor as a starting point for coordination of evaluations across PORTs. To help determine the potential for further coordination, a matrix of each individual PORT's target audiences, intervention strategies, and evaluation designs has been constructed. Much remains to be learned before we can know with any certainty how best to translate research findings into useful behavior change and improved patient outcomes. Our goal is that the efforts of the work group will serve to catalyze this process.

Implementing clinical practice guidelines: social influence strategies and practitioner behavior change.

Clinical practice guidelines offer potentially valuable tools for rationalizing health care delivery and improving patient outcomes. Currently, major efforts are under way to develop, test, and refine guidelines for a wide variety of medical conditions and procedures. Although methods for producing guidelines are fairly well understood and continue to improve, experience suggests that guidelines rarely translate directly into changes in practice. For various reasons, including physician resistance or incomplete understanding of the need for guidelines, they have proven difficult to implement. This article describes a broad range of strategies for implementing clinical practice guidelines based on the social influences that affect health practitioner behavior. The article also examines issues surrounding the selection and use of individual strategies or combinations of strategies in specific efforts to improve the quality of health care.