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This article examines the quality of acute episodic care for five diagnostic categories amenable to one-visit diagnosis and treatment at the nation's largest chain of investor-owned ambulatory care centers. A total of 803 medical records were audited for five common conditions and measured against specific protocols. In four of the five diagnostic categories studied--pharyngitis, otitis media, vaginitis, and use of tetanus immunization--42-97% of patients received care that met or exceeded the standards set by a panel of practicing academic physicians. In follow-up of an incidental high blood pressure reading, however, study physicians met the standard only 24% of the time. Some overprescribing and overtreatment with immunizations were detected. As far as comparison is possible to other studies, results suggest that care in this setting falls within the range of experience that has been reported for other types of practices. In spite of direct economic incentives to increase volume, little evidence was found of overuse of ancillary tests or unnecessary scheduling of repeat visits.

A seminar devoted to the psychological aspects of medical care has formed the major portion of the psychiatric training of primary care internal medicine residents at the Kenmore Center of the Harvard Community Health Plan since 1973. The group includes a psychiatrist, a psychiatric nurse, staff physicians, residents, and nurse practitioners. The atmosphere is open and supportive, and discussion focuses on particular situations causing discomfort to members. Content issues include professional identity, relationships with co-workers, and difficulties in handling patients. The group teaches the value of communication and sharing and improves skills in caring for patients.

To test the validity of a nurse-administered protocol for low back pain, a prospective trial of 419 patients was undertaken in a walk-in clinic. In all, 222 patients were randomly allocated to a "nurse-protocol group" in which they were evaluated by one of five nurses using the protocol; the nurses independently managed 53 percent of the patients and referred to a physician patients with potentially complex conditions. In addition, 197 patients in a randomly allocated control group were managed by one of 32 physicians. Care in the experimental and control groups was compared by follow-up telephone contact and by a four-month chart review. There was no significant difference in symptomatic relief or the development of serious disease in the two groups. Nurse-protocol patients expressed greater satisfaction with the care they had received; patient satisfaction correlated positively with symptom relief. In over 95 percent of the patients, there were noncomplex, nonserious, nonchronic conditions as the cause of back pain. We conclude that nurse-protocol management of this generally benign condition in a primary care setting is both effective and efficient.

In an institutional quality assurance program in hypertension, performance of tests, control of blood pressure, and follow-up were monitored through a computer program that was developed to audit records in an automated record system. Two types of feedback previously shown to be effective were provided quarterly for a period of one year to experimental providers. For all hypertensives considered together, there were no differences between scores of Experimental and Control providers based on percentage of patients meeting pre-set criteria in testing--87% vs 87%--, blood pressure control--58% vs 59%--, or follow-up--79% vs 77%. Only small but significant differences occurred in the subgroup of moderate to severe hypertensives. There appear to be limitations to what can be accomplished through hypertension quality assurance interventions directed at providers of care in this institutional setting. Interventions designed to deal directly with patients whose blood pressures are uncontrolled may be more effective.

An automated surveillance system utilizing a computer-based medical record system (COSTAR) was designed to improve the follow-up of patients with newly identified elevated diastolic blood pressure. A population of patients was selected where, in the 6-month period following the initial measurement of an elevated diastolic blood pressure, there were fewer than two visits during which blood pressure was recorded. In a randomized controlled clinical trial, this poor follow-up population was divided into two groups, with computer-generated reminders being automatically generated for only patients in the experimental group. Follow-up was significantly improved in the group receiving the reminders, both in terms of rate of follow-up attempted or achieved by the responsible physician and in the repeated recording of blood pressure. We conclude that a computer-based reminder system improves follow-up of newly discovered elevation in diastolic blood pressure.

A project to improve physician performance in colorectal cancer screening was evaluated as part of an ambulatory quality assurance program. A minimum standard was adopted requiring a digital examination and stool test for occult blood at annual check-ups of patients aged 40 years and older. During a 31/2-year period, three different intervention strategies for improved compliance with the standard were sequentially implemented and assessed: educational meeting, retrospective feedback of group compliance rate, and retrospective feedback of individual compliance rate compared with that of peers. A pretest/posttest design was employed in evaluating the first two intervention strategies. Neither strategy resulted in significant improvement in compliance. Monthly feedback of individual performance ranked with that of peers was then implemented in a randomized clinical trial utilizing a crossover design. During the first 6-month period, the physicians receiving feedback (group 1) improved from 66.0% to 79.9% (P less than 0.001), while the control group (group 2) also improved, from 67.5% to 76.6% (P less than 0.001), suggesting a spillover effect. During the second 6-month period, group 2 received feedback and group 1 did not. Group 1 stabilized at approximately 80% while group 2 continued to improve from 76.6% to 84.0% (P less than 0.001). Behavior changes persisted at 6 and 12 months after intervention.