Billi J E, Duran-Arenas L, Wise C G, Bernard A M, McQuillan M, Stross J K
Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.
J Gen Intern Med. 1992 Jul-Aug;7(4):411-7. doi: 10.1007/BF02599158.
To assess the impact of a low-cost education and feedback intervention designed to change physicians' utilization behavior on general medicine services.
Prospective, nonequivalent control group study of 1,432 admissions on four general medicine services over 12 months. Two services were randomly selected to receive the intervention. The other two served as controls. Admissions alternated between control and intervention services each day. Results were casemix-adjusted using diagnosis-related groups (DRGs). Three internists blinded to patient study group assignment assessed quality of care using a structured implicit instrument.
Four general medicine services at a university hospital.
A brief orientation, a pamphlet of cost strategies and common charges, detailed interim bills, and information about projected length of stay and usual hospital reimbursement for each patient.
PATIENTS/PARTICIPANTS: Each service was staffed by a full-time internal medicine faculty member, one third-year and two first-year internal medicine houseofficers, three medical students, and a clinical pharmacist. Physicians were assigned to services for one-month periods by a physician unaware of the study design. To prevent crossover, houseofficers assigned to a service returned to the same service for all subsequent general medical inpatient assignments.
Geometric mean length of stay was 0.44 days (7.8%) shorter for the intervention services than for the control services (p less than 0.01), and geometric mean charges were $341 (7.1%) less (p less than 0.01). Effects persisted despite using a more precise cost estimate or casemix adjustment. Intervention houseofficers demonstrated superior cost-related attitudes but no difference in knowledge of charges. Audits of quality of care detected no significant difference between groups.
This low-intensity intervention reduced length of stay and charges, even under the cost-constrained context of the prospective payment system.
评估一项旨在改变医生对普通内科服务利用行为的低成本教育与反馈干预措施的影响。
对12个月内四个普通内科服务科室的1432例住院病例进行前瞻性、非等效对照组研究。随机选择两个科室接受干预，另外两个科室作为对照。每天对照科室和干预科室的住院病例交替安排。结果采用诊断相关分组（DRG）进行病例组合调整。三名对患者研究组分配情况不知情的内科医生使用结构化隐性工具评估医疗质量。
一所大学医院的四个普通内科服务科室。
一次简短的培训、一份成本策略和常见收费手册、详细的中期账单，以及每位患者的预计住院时长和通常医院报销信息。
患者/参与者：每个科室配备一名全职内科教员、一名三年级和两名一年级内科住院医师、三名医学生和一名临床药剂师。由一名不了解研究设计的医生为医生们分配为期一个月的科室工作。为防止交叉，分配到某科室的住院医师在所有后续普通内科住院患者任务中都回到同一科室。
干预科室的几何平均住院时长比对照科室短0.44天（7.8%）（p<0.01），几何平均费用少341美元（7.1%）（p<0.01）。尽管使用了更精确的成本估算或病例组合调整，效果依然存在。干预科室的住院医师表现出更优的成本相关态度，但在收费知识方面没有差异。医疗质量审核未发现两组之间存在显著差异。
即使在前瞻性支付系统成本受限的情况下，这种低强度干预仍能缩短住院时长并降低费用。
