 Prior studies of hospitalist services have suggestedimproved efficiency and quality of care compared with traditionalinpatient services.

 To compare outcomes of patients on a new hospitalistservice with those on traditional inpatient services and todetermine the impact of hospitalists on particular patient subgroups.

 Prospective, quasiexperimental, observational.

 The study was conducted on the general medicineservice at an academic teaching hospital, staffed by hospitalistphysicians (HP) and nonhospitalist physicians (NHP), and included1706 consecutive, directly admitted patients over 1 year.

 The 447 HP patients and 1259 NHP patients had similarrates of in-hospital mortality (1.3% vs 2.1%, respectively; 

 =.29) and 30-day readmission (7.8% vs 8.7%, respectively; 

 = .55).Mean hospital length of stay (LOS) was 1 day shorter for HPpatients in unadjusted analyses (5.5 vs 6.5 days, respectively; 

 =.009) and in multivariable analyses adjusting for clustering andpatient factors. Physician experience was not correlated (

 < .2)with LOS. In stratified analyses, differences in LOS between HPand NHP patients were greater for patients residing closer to thehospital. Mean total costs were $917 less for HP patients (

 = .04) in multivariable analyses. Decreases in costswere significant (

 = .04). Nonetheless, mean costs per daywere $122 higher (

 Patients managed by hospitalists had shorter LOSand lower costs than patients managed by nonhospitalists, but hadhigher costs per day. These results suggest that hospitalists increasethe intensity of care and may have their greatest impact on specifictypes of patients and classes of hospital costs.

Since the term hospitalist was coined 7 years ago

to describe physicians who provide inpatient carein place of primary care physicians or academic1-month-per-year attendings, several studies have comparedoutcomes of patients managed by hospitalist andnonhospitalist physicians. These comparisons have typicallyrevealed that hospitalist care reduced length ofstay (LOS) by approximately 1 day and costs by 10% to15%.

 In a recent review of the growing hospitalist movement,Wachter and Goldman concluded that "researchsupports the premise that hospitalists improve inpatientefficiency without harmful effects on quality or patientsatisfaction."

 Although multiple studies have shownreductions in hospital LOS and costs, the number ofstudies and hospitals upon which the above conclusionswere based are limited. In addition, hospitals are activelyrestructuring inpatient care services including theexpansion of hospitalist services, nurse case management,and other concurrent interventions that mayaffect LOS and costs. Evidence of the impact of hospitalistson individual hospitals is still needed.

An important determination to make is the factorsthat contribute to this shorter LOS and lower costs.Prior studies have not provided insight into the mechanismsby which hospitalist services achieved thisimproved efficiency. Some have argued that "practicemakes perfect," although the relationship betweenexperience and efficiency has not been proven.Reductions in laboratory and radiology testing or druguse may be another mechanism for reductions in costsof care. In addition, the relative impact of the cost associatedwith nursing care and excess LOS has not beenwell described. Finally, patient-specific factors have notbeen evaluated for associations with outcomes andresource utilization on hospitalist services.

Herein we report the findings from an observationalstudy of the first year of a hospitalist program at an academicmedical center, and compare outcomes andresource utilization for patients managed by hospitalistand nonhospitalist physicians. Whereas the primaryaim of the study was to add to the body of evidenceabout the effect of hospitalist programs, we also soughtto provide greater detail than prior studies on the natureof cost differences and whether differences were consistent across different cost categories (eg, nursing, laboratory).We further sought to examine whether particularpatient groups were somehow more or less affected bythe hospitalist model.

The study was conducted at the University of IowaHospitals and Clinics, an 831-bed academic teachinghospital and tertiary referral center. The general internalmedicine ward service has 4 teams consisting of 1attending physician, 1 senior resident, 1 intern, and 1or 2 medical students. Residents and students are randomlyassigned to the 4 teams. All teams admit patientsto the same hospital floors, have the same nursing staff,and work with the same social service and other hospitalpersonnel.

In July 2000, the Division of General InternalMedicine implemented a hospitalist physician (HP)service for inpatient general internal medicine. Theservice was developed to meet the professional interestsof faculty. No implicit or explicit goals for resource use,clinical outcomes, or patient satisfaction were set.During the 2000-2001 academic year, 3 "hospitalist"faculty staffed 1 of the 4 general internal medicine servicesin month-long blocks and were provided with coveragefor 2 to 3 weekends per month by 12 other generalmedicine faculty in an effort to prevent burnout. Eachhospitalist faculty staffed for 3 to 6 months.

Thirty-four faculty from various divisions in internalmedicine staffed the nonhospitalist physician (NHP)services for the same year. Of the 3 NHP services, 1 wasstaffed by 7 endocrinologists; 1 by 12 nephrologists;and 1 by a combination of 2 rheumatologists, 6 infectiousdisease specialists, and 7 general internists. TheNHP services varied in their approach to weekend coverage.Some staff attended for the entire month (n = 9;26%), others split the month in half (n = 9; 26%), andall the others had variable coverage throughout themonth (n = 16; 47%). Of the 34 nonhospitalist faculty,1 spent 3 months on the service, 5 others spent a rangeof 5 to 8 weeks, and the remainder 1 month or less onthe service.

The eligible sample included all 1887 consecutivedischarges between July 1, 2000, and June 30, 2001,from the 4 general internal medicine services. Allpatients were sequentially admitted in a quasiexperimentalmanner to one of the teaching teams in an alternatingmanner without regard to diagnosis or to complexity.The teams took "long-call" every fourth day,during which teams admitted up to 10 patientsovernight. In addition, on weekdays teams took up to 4admissions during the day on "short-call," whichoccurred 2 days before and after long-call. All admissionsto general internal medicine from university- andcommunity-based physicians were assigned to the 4teaching services, including admissions from primarycare physicians. During the study period, there was no"nonteaching" service. Patients requiring an intensivecare unit (ICU) bed were admitted to a closed medicalor cardiovascular ICU. Separate cardiology and hematology/oncology teams also existed.

Of the 1887 consecutive admissions, 1706 (90%)patients were admitted directly to the general internalmedicine service (ie, direct admissions) from either theemergency room (n = 801) or from university clinics,referring physicians' offices, or other acute care hospitals(n = 905). The remaining 181 (10%) admissionswere transferred to general internal medicine (ie, transferadmissions) from the medical ICU (n = 105) or fromsurgical or other nonmedicine services (n = 76).Because costs incurred by transfer admissions prior totheir transfer to general internal medicine could not beseparated from costs after the transfer, our primaryanalyses were conducted in the 1706 direct admissions.

All study data, including outcome variables andmeasures of resource utilization, were obtained fromthe hospital's information systems. The principal outcomevariables were hospital mortality and 30-day readmissionrate. Resource utilization was measured usinghospital LOS and hospital costs. Because of the potentialbias introduced by outlier LOS values, all patientswith a LOS of longer than 60 days were truncated at 60days. This truncation included 1 patient in the hospitalistgroup and 5 in the nonhospitalist group.

Hospital costs were measured using the TSI costaccounting system (Transition Systems, Inc, Boston,Mass). This widely used methodology determines thefixed and variable costs of all billable hospital services.This system also allocates to these services indirectcosts associated with nonbillable services giving a totalcost by category (eg, nursing, physicians, medications)and a total cost for the hospital stay. Separate analyseswere performed on nursing, laboratory, pharmacy, andradiology services, as these cost categories representedthe top 4 categories in total cost and together more than70% of all inpatient costs in our study sample. Totalcosts were reported in the analyses because of the complexitiesof determining direct and indirect costs andwhat proportion may be attributed as fixed and variable.Total costs are more generalizable to other hospitalsand systems.

International Classificationof Diseases, Ninth Revision, Clinical Modification

Demographic and clinical variables available includedage, sex, race, health insurance status, admissionsource (eg, home, nursing home), discharge destination(ie, home, home healthcare, other hospital, nursinghome, died, against medical advice, or other care facility),admission and discharge date, discharge diagnosis-relatedgroup (DRG), and principal diagnosis (asmeasured by taxonomy of the 

[ICD-9-CM] In addition, for each patient, distance fromthe hospital was determined using a function thatmathematically estimates the "straight line" distancebetween 2 coordinates (longitude and latitude).

Coordinates used in the calculation included the longitudeand latitude of the hospital and the centroid of thezip code of a patient's residence.

The primary analyses compared outcomes ofpatients discharged from the HP service with outcomesof patients discharged from the 3 NHP services.Categorical variables were analyzed using the chi-squarestatistic; continuous variables were analyzedusing the Student 

 test or Wilcoxon rank-sum, dependingon whether the data were normally distributed.Multiple linear regression was used to evaluate differencesin continuous outcome variables (ie, LOS, costs)and logistic regression for dichotomous variables (ie,death, 30-day readmission). To account for the skeweddistribution of costs and LOS, we used generalized linearmodels, assuming that the effects of the covariateswere proportional using a logarithmic link function.

 Tocontrol for potential differences in patient characteristics,the following independent variables were includedin the regression models: age, sex, type of health insurance,and admission month. Because of the potentialeffect of physician-level clustering

 on observed differences,we performed analyses using the PROC GENMODfunction with SAS software, which accounts forclustering by physician. Additional multivariable analysesof costs and LOS were performed that adjusted forprincipal diagnosis using the technique of absorption inthe PROC GLM function of SAS.

 This technique iscomputationally similar to creating indicator variablesfor individual ICD-9-CM codes, but does not allow forthe concurrent use of techniques to account for clustering.Results of these analyses yielded similar estimatesof the coefficients associated with hospitalist care, andwere not reported. No further case-mix adjustment wasperformed due to the quasirandom allocation ofpatients and the similar distribution of diagnoses basedon DRGs. No other indicators of differences in case-mixwere observed that were considered to potentially biasthe results.

Further stratified analyses were performed to determinewhether the impact of hospitalist care was similarin subgroups defined by distance from the hospital,need for postacute care nursing services, and admissionsource. Need for postacute care nursing services includedhome healthcare, intermediate nursing care, orskilled nursing care. Specific factors examined in theseanalyses were selected on the basis of discussions withhospitalists. Lastly, relationships between LOS and severalphysician characteristics, including the number ofyears since completion of residency and the number ofdays on the inpatient service during the academic year,were examined using the Pearson correlation coefficient.All analyses were performed using SAS forWindows, version 8.0 (SAS Institute, Cary, NC).

Patients admitted to HP and NHP services were nearlyidentical in mean age, sex, race, type of health insurance,admission source, discharge destination, anddistance from the home to hospital. (

). Proportionsof patients in each group were similar for 9 of the10 most common DRGs (

In-hospital mortality was similar for direct admissionpatients on HP and NHP services (1.3% vs 2.1%, respectively;

), as were 30-day readmissionrates (7.8% vs 8.7%, respectively; 

 = .55). Results weresimilar in analyses of transfer patients and in analysesof all admissions (ie, direct plus transfer admissions).Mean hospital LOS was roughly 1 day shorter inpatients on the hospitalist service for direct admissions(5.5 vs 6.5 days, respectively; 

 = .009). In contrast,relationships between LOS and the number of yearssince attending physicians' completed residency (

 = .53) and number of days on service during theacademic year (

 = .95) were not significant(data not shown).

Mean total costs for direct admissions were $917(11%) lower for patients in the HP group, although thisdifference was only of borderline statistical significance(

 = .08). The relative decline in LOS was greater thanthe relative declines in costs, such that the mean cost perhospital day was $122 higher in the HP group (

In addition to total costs, nursing, laboratory, pharmacy,and radiology costs are reported for the HP andNHP groups in Table 3. For direct admissions, meannursing costs were $604 less for the HP patients (

 =.002) and laboratory costs were $126 less (

 = .04).Differences in pharmacy and radiology costs were notsignificant.

Additional analyses were performed on the entirecohort of "all admissions" (n = 1887) and "transfers" (n= 181), as reported in Table 3. The difference in LOS,nursing costs, and costs per day persisted in the "alladmissions" cohort, but no significant differences wereobserved among the "transfer" patients.

In multivariate analyses, adjusting for age, sex,admission month, and type of insurance, the odds ofdeath for patients on the HP service were similar to thatfor patients on NHP services (odds ratio [OR] 0.65, 95%confidence interval [CI] 0.26 to 1.63; 

 = .37). AdjustedLOS was 16.2% lower (95% CI —31.2% to —1.6%; 

 = .03)for patients on the HP service,while adjusted total costs were9.7% lower (95% CI —19.3% to—0.5%; 

Exploration of Associationswith Length of Stay

In stratified analyses, differencesin LOS between patientson HP and NHP services tendedto be largest for patients residing25 miles or less from thehospital (

). Absolutedifferences in LOS were alsogreater among patients dischargedwith home nursingcare or to skilled nursing facilities(1.7 days) than those whodid not require nursing services(0.8 days). Absolute differencesin LOS between HP andNHP patients were also similarin patients admitted fromhome (1.0 days) and fromother acute care hospitals (1.2days), although only the differencesin patients admittedfrom home were statisticallysignificant. In contrast, LOSwas nearly identical in HP andNHP patients among patientsadmitted from other sources.

During the first year of anacademic hospitalist program at a large university teachinghospital, mean LOS was 1 day (16%) shorter amongpatients on the hospitalist service. Based on theseresults, we could extrapolate that the hospitalist serviceresulted in approximately 450 fewer days of care duringfiscal 2001, compared with the nonhospitalist services,before and after adjustment for potential differences incase-mix.

Articles

MANAGERIAL

Associations With Reduced Length of Stay and Costs on an Academic Hospitalist Service

 To identify gaps in current osteoarthritis (OA) carein Qu&#233;bec, Canada, and to implement and evaluate interventionsto promote appropriate use of evidence-based medicine.

 Pretest and posttest; analysis of the Qu&#233;bechealth insurance database.

 CURATA is a patient health management programutilizing an evidence-based approach for OA treatment. Evaluationof the current level of care revealed major gaps in physicians'knowledge of (1) risk factors for gastrointestinal (GI) toxicity associatedwith nonsteroidal anti-inflammatory drugs (NSAIDs); (2)NSAID-induced toxicity associated with long-term administrationand contraindications for NSAID use in patients with hypertension,cardiovascular disease, or renal insufficiency; (3) choice of cytoprotection;and (4) use of nonpharmacologic treatments for OA.The CURATA intervention consisted of educational workshops,with and without presentation of a decision tree regarding appropriateuse of pharmacologic and nonpharmacologic OA treatments.Participating physicians were asked to complete an 8-itemquestionnaire before and after the workshop, as well as 3 and 6months later, to test their immediate and remote knowledge oftreatment choices. The prescribing patterns of GPs also were evaluatedthrough analysis of the Qu&#233;bec health insurance database.

 The participating physicians were better immediateand remote risk assessors of GI bleeding and made more appropriatetreatment choices (15.2% improvement relative to mean preworkshopscore).

 These evidence-based interventions were successfulnot only in improving the physicians' knowledge regarding thediagnosis and management of OA, but also&#150;more importantly&#150;inchanging their behavior to make more appropriate therapy choicesfor their patients.

Osteoarthritis (OA) is the most prevalent jointdisorder; its primary signs and symptomsof joint pain, swelling, and stiffness reflect theloss of joint cartilage integrity.

 There is currently nocure for OA. Available treatments include a range ofpharmacologic and nonpharmacologic interventionsdesigned to reduce pain and inflammation, maintain orimprove mobility, and limit functional disability.

Osteoarthritis has been shown in a variety of US-basedstudies to be a leading contributor to the cost ofmedical appointments, over-the-counter drug use, andrestricted activity.

 Drug therapy represents a largeproportion of the direct costs, with analgesics accountingfor approximately 20% of the total. The treatment ofgastrointestinal (GI) adverse reactions related to non-selectivenonsteroidal anti-inflammatory drug (NSAID)use adds significantly to both direct and indirectcosts.

 Nonpharmacologic modalities such as physicaland occupational therapy also contribute to these costs.Indirect costs (eg, absenteeism) are responsible for themajority of the economic burden of OA.

As a result of our aging population, the increaseddemand for healthcare for this disease adds to theseconcerns. There is a critical need to develop strategiesto manage the disease more cost effectively through betterdiagnosis, safer and more effective treatment, andenhanced patient education. This paper describes aninnovative approach using patient health managementto address this need.

CURRENT TRENDS IN THE PHARMACOLOGICTREATMENT OF OSTEOARTHRITIS

Despite their side effects, conventional NSAIDs havebeen widely used and are the agents of choice in thetreatment of OA

 for patients who do not respond toacetaminophen. In Canada, the most commonly prescribedNSAIDs include diclofenac sodium, a combinationof diclofenac and misoprostol, ibuprofen, andnaproxen.

 However, current concerns about thegreater risk of GI toxicity associated with prolonged useof NSAIDs,

 including potentially fatal perforation,ulcer, and bleed (PUB),

 have led to a reexamination oftheir role in the treatment of the disease. Risk factorsfor GI toxicity include age more than 65 years, a historyof peptic ulcer or upper-GI bleeding, concomitant useof oral corticosteroids and anticoagulants, comorbiditiessuch as cardiac conditions, and renal dysfunction.

 For patients with GI risk factors,coprescription of a gastroprotective (GPA) agent hasbeen advised. More recently, with the introduction ofthe cyclooxygenase-2 (COX-2) inhibitors, it has beenrecommended that patients who require chronic analgesiaand who are at risk for GI adverse events withNSAIDs receive first-line alternative therapy with acetaminophen;if they do not respond, they should receivea COX-2 inhibitor.

The COX-2 inhibitors have recently emerged as analternative class of anti-inflammatory drugs with efficacyin reducing pain and inflammation equivalent to thatof NSAIDs 

 and a clearly reduced potential for upper-GI injury relative to NSAIDs.

 TraditionalNSAIDs inhibit both the COX-1 and COX-2 forms of thecyclooxygenase enzyme. Prostaglandins involved in theprotection of the GI mucosa are produced by COX-1,whereas those that mediate inflammation and painare induced by COX-2.

 The COX-2 inhibitors rofecoxiband celecoxib (coxibs) selectively inhibit COX-2,with little effect on COX-1.

 However, they are notfree of side effects: dyspepsia has been reported withcoxib use, but at a lower frequency than withNSAIDs.

A retrospective cohort study conducted in Qu&#233;becbetween April and November 2000 reported that coxibswere more frequently prescribed than acetaminophenor NSAIDs to elderly (&#8805;65 years) patients with musculoskeletaldiseases. The study also found that elderlypatients with a history of GI events were more frequentlygiven a coxib or acetaminophen as opposed toNSAIDs. The study also reported that coxibs were 47%less likely to be prescribed with a GPA than wereNSAIDs.

The R&#233;gie de l'assurance maladie du Qu&#233;bec (RAMQ)applies and administers the provincial health insuranceplan established by the Health Insurance Act. The publicprescription drug insurance plan, instituted in 1997,guarantees basic coverage for all Qu&#233;bec residents fordrugs purchased in Qu&#233;bec and listed on the provincialformulary (liste de m&#233;dicaments). Adults with access toa private insurance plan through their workplace (4.2million individuals; 57% of the population) must pay toreceive coverage for themselves and their dependents.All others are covered by the provincial plan, includingthose receiving employment assistance and persons age65 years and over.

 Celecoxib became eligible forreimbursement by RAMQ in October 1999, followed inApril 2000 by rofecoxib. In the first half of 2000, nopublished guidelines or consensus existed for the utilizationof these new anti-inflammatory drugs. Clinicalexperience was still developing.

In the planning stage of this study, we conducted aliterature review to profile and identify the care gaps inNSAID and coxib utilization in Qu&#233;bec.

A study conducted in 1997 by the Qu&#233;bec College ofPhysicians using administrative data obtained fromRAMQ revealed inappropriate utilization of NSAIDs.The study found that general practitioners (GPs) oftenignored drug interactions, dosages, and adverse eventsin prescribing NSAIDs and did not prescribe GPAs asadvised by the guidelines.

 In a second study,Choquette et al surveyed the NSAID prescription patternsof all GPs in the province of Qu&#233;bec (D.Choquette, MD unpublished data, 1999). The results ofthis self-reported questionnaire, based on 2328 participants(30% response rate), corroborated the finding ofthe Qu&#233;bec College of Physicians and demonstrated alack of understanding of the indications, contraindications,dosage, and duration of NSAID treatment.

A recent study by Rahme et al concluded that the useof NSAIDs significantly increased the risk of GI adverseevents by 2.48-fold, requiring an additional cost of 0.66Canadian dollars per patient-day of treatment withNSAIDs.

 conducted a blinded, office-basedstudy using simulated patients, in which 2 clinical cases(chronic hip pain due to early OA and NSAID-inducedgastropathy) were used to assess the management decisionsof 112 physicians for elderly patients with arthritis.In 41.7% of office visits, unnecessary prescriptionsfor NSAIDs or other drugs were given. Gastropathyrelated to NSAID use was properly diagnosed in 93.4% ofcases, but acceptably managed in only 77.4% of cases.The risk for suboptimal management of NSAID-relatedadverse events was increased 16.6-fold with an incorrectdiagnosis versus a correct diagnosis.

These studies revealed significant gaps between optimaland actual practice. The results raise questionsabout the appropriateness of NSAID use in the elderlypopulation at large and concerns that current prescribingpatterns are contributing to GI morbidity in the elderly,with the associated avoidable health costs.Selective utilization of coxibs in the elderly is perhaps abetter medical practice. Their acquisition cost is muchhigher than that of NSAIDs. However, the cost of treatmentwith an NSAID plus a proton pump inhibitor inCanada is greater than the cost of a COX-2 inhibitoralone.

 In a public healthcare system such as that ofQu&#233;bec, the widespread utilization of coxibs andNSAIDs plus proton pump inhibitors, combined withtheir high acquisition costs, makes them affordable onlyat the expense of other healthcare services. Therefore,programs that promote appropriate utilization of thecoxibs and NSAIDs are needed.

CURATA (Concertation pour une UtilisationRaisonn&#233;e des Anti-inflammatoires dans le Traitementde l'Arthrose [An Integrated Approach to Improving theAppropriate Utilization of Anti-Inflammatory/AnalgesicMedications in the Treatment of Osteoarthritis inQu&#233;bec]) is a patient health management programdeveloped by the Association of Rheumatologists andMerck Frosst Canada in 2000. It was developed toaddress the gaps in OA care and implement effectiveinterventions to promote evidence-based medicationprescription for OA patients, with the goal of optimizingthe management of OA. Its objectives are toimprove the quality of life of OA patientsand to encourage the appropriate utilizationof NSAIDs and coxibs in the treatment of thedisease.

The patient health management approachseeks to optimally manage disease throughimprovement of practice patterns andpatient outcomes. It is a patient-centeredapproach in which best practices are comparedwith current practices, and modificationsare introduced to improve therapeuticresults in the most cost-effective manner. Itsgoal is to bring the greatest health benefit tothe largest number of people at the best cost.To be optimally effective, patient healthmanagement mobilizes a wide range ofhealthcare stakeholders: governments, third-partypayers, university researchers, healthcharities, community specialists, familyphysicians, nurses, pharmacists, special-interestgroups, pharmaceutical companies,and above all, patients. These partnershipswill ensure the broadest application of theprogram and its interventions.

The key to success of this process is continuousmeasurement and feedback of outcomes obtained fromthe broadest application of evidence-based therapies.

A community-based approach to research providesthe greatest opportunity for highly committed stakeholdersto identify the gaps in care and to work aspartners to define best practices to achieve optimal outcomesat the lowest possible cost. Another view mightbe that partnership-directed, evidence-based diseasemanagement represents healthcare improvement fromthe ground up, as opposed to the top down. The functionalprocesses are illustrated in 

The Continuing Medical Education Department ofthe University of Montr&#233;al, in collaboration with delegatesof the Association of Rheumatologists, developedthe CURATA educational tools. The partners in the programinclude representatives from government, academia,charitable organizations, and the pharmaceuticalindustry (

The program activities were coordinated by using amodified structure similar to that utilized by theNational Institutes of Health to conduct a large-scalestudy.

The primary objectives of the CURATA program wereto (1) improve the GP's ability to identify OA patientsthrough appropriate questioning and musculoskeletalexamination and (2) to enhance the GP's ability to selectappropriate pharmacologic and nonpharmacologic therapyaccording to a defined decision tree. The underlyinghypothesis was that an integrated program involvingprofessionals and patients whose goals were to enhancethe appropriate use of NSAIDs and GPAs would facilitatebridging the gap that exists between the current state ofcare and optimal practice.

In the first phase of the program, the current level ofcare was evaluated in an effort to identify potential discrepancieswith optimal evidence-based treatment.Studies identified in this stage of the program aredescribed in the section titled Profile of NSAID Use inQu&#233;bec. In summary, there were major gaps in physicians'knowledge of (1) risk factors for GI toxicity associatedwith NSAIDs; (2) NSAID-induced toxicityassociated with long-term administration and contraindicationsfor NSAID use in patients with hypertension,cardiovascular disease, or renal insufficiency; (3)choice of cytoprotection; and (4) use of nonpharmacologictreatments for OA.

In the second phase, interventions were introduced.To provide guidelines for the appropriate utilization ofNSAIDs and coxibs as well as GPAs, the CURATAdevelopment committee created a decision tree withan algorithm for optimizing OA treatment approaches(

 To maximize adoption of this decisiontree, the committee developed a workshop including 3clinical cases on the diagnosis and treatment of OA. Ithas been demonstrated that small-group, interactive,case-based workshops ideally facilitate the disseminationof such material and provide a forum for peer discussionand emulation of the desire to excel.

For each clinical case, a participant worked individuallyto answer questions, then shared his or her answerswith all others in a small group. The group produced asummary of individual responses on transparency for discussionin a plenary session. In this session, expertsshared their experience with all participants. This formatallowed participants to reflect on their own processes ofdata interpretation in making clinical decisions and toexamine those of experts. The workshop was accreditedby the College of Family Physicians of Canada and provided1.5 hours of MAINPRO-C credit to its participants.

A large group session was held for pharmacists andother health professionals. A patient follow-up sheetwas created for pharmacists, which included questionsregarding patients' use of homeopathic and other alternativemedicine products. A series of 5 brochuresdetailing the various joints affected by OA was developedfor patients. In addition, there was a brief presentationby a physiotherapist and an occupationaltherapist to describe their role in patient managementof OA. A multidisciplinary panel including a physician,pharmacist, physiotherapist, and occupational therapistthen discussed a case study.

Evaluation of the Educational Intervention

To assess the impact of CURATA, 2 measurementswere undertaken: one to evaluate the impact on medicationprescription and the other to determine theimmediate and remote impact on retention of knowledgeregarding treatment selection for OA. AlthoughCURATA was implemented throughout the province ofQu&#233;bec, the evaluation was undertaken in 8 cities.

. The interventionwas comprised of the workshop and a decision treein the form of a laminated sheet. There were 4 interventiontypes: workshop and tree, workshop only, decisiontree only, and control group; each type wasassigned to 2 cities.

Records of all patients age 65 years or older who hadfilled a prescription for a coxib, NSAID, or acetaminophenbetween May 2000 and June 2001 (the date whenthe data were requested) from an eligible GP (GP with&#8805;2 NSAID prescriptions) were retrieved from the RAMQdatabase. Only new prescriptions preceded by a diagnosisof OA in the previous 3 years were considered. Ingeneral, prescriptions for a chronic condition are writtenwith the possibility of 3 refills. New prescriptionswere either a new treatment or a continued treatmentfilled for the first time (nonrenewal). Because a prescriptioncould have been written before the workshoptook place and refilled later, refills were not assessed. A0/1 score was given to every filled prescription accordingto the instruction on the decision tree. All acetaminophenprescriptions were given a score of 1, andall patients were presumed to have used acetaminophenbefore NSAIDs or coxibs prescriptions.

Mean scores were calculated for each GP in thepreintervention and postintervention periods. Theanalyses were done both by "intent-to-treat" (includingall GPs who practice in 1 of the 8 cities) and "per protocol"(including only GPs who attended the workshopsin the intervention groups) and were compared with thescores of all GPs in the control group.

Details of the methodology adopted in this study andthe results have been published.

In the intent-to-treat analysis, the study demonstratedan adjusted significant improvement on mean scoresof 8% (

 = .003) between the control group and theworkshop and workshop and tree groups combined. Nosignificant improvement was reported in the tree groupversus the control group. A per protocol analysisrevealed a 12% (

In summary, the intervention had a positive impact onthese physicians' prescription patterns for OA. In view ofthe widespread use of coxibs, nonselective NSAIDs, andacetaminophen, and given that more than 50% of theseprescriptions were for the treatment of OA, the positiveimpact should reflect considerable cost savings.

Immediate and Remote Impact on Retention ofKnowledge.

 The GPs were asked to fill a questionnaireconsisting of 8 multiple-choice questions before (pretest)and after (posttest) the workshop, as well as 3 and 6months later. (For a copy of this questionnaire, pleasecontact the author.) Each question was scored 1 or 0according to whether or not the checked answer agreedwith the workshop content. Overall pretest and posttestscores for each GP were calculated and compared byusing a paired 

 test. Questions were divided into 2 types,those concerning patients with no GI risk factors andthose concerning patients with GI risk factors. Of 52 GPsinvited to the workshop, 26 completed the questionnaire.Nonparametric tests were used to compare the medianpretest and posttest scores for the 2 types of questions.Overall median scores (pretest, posttest, and 

 value)were 2.0, 3.5, and <.0001, respectively, for questionsdescribing patients with no GI risk factors (4 questions)and 3.0, 3.5, and <.01, respectively, for questions describingpatients with GI risk factors (4 questions). At the 6-month evaluation, the knowledge improvement wassustained; scores were similar to those seen on theimmediate posttest. Thus, physicians who attended theworkshop were, in fact, better assessors of GI bleeding,both immediately afterwards and 6 months later; andthey selected a more appropriate therapeutic regimen.

On completion of this workshop, the GPs were ableto adopt a structured approach to the assessment ofjoint pain, identify the principal signs of OA on clinicalexamination, use a decision tree to manage patientswith OA, and select an anti-inflammatory medicationappropriate to the patient's clinical condition.

In light of these encouraging results, 50 small-groupsessions and 2 large-group sessions were held, with atotal of 1000 physicians attending. The decision treewas disseminated to 7500 physicians in June 2001. Weanticipate that the positive effect of CURATA will beeven greater once the intervention for pharmacists andother health professionals is implemented.

CURATA: A Patient Health Management Program for the Treatment of Osteoarthritis in Qu"bec: An Integrated Approach to Improving the Appropriate Utilization of Anti-Inflammatory/Analgesic Medications

 To improve quality of dementia care in a KaiserPermanente service area through rigorous dissemination of practiceguidelines and social worker support for physicians andpatients.

 Pre-post design with practice behavior changeassessed by medical record review, and provider and caregiver satisfactionwith care assessed by surveys.

 A diagnostic guideline and later a managementguideline were adopted for use by Kaiser Permanente physicians inmetropolitan Los Angeles. Physicians received training based onthe guidelines, and social workers provided ancillary support.Eighty-three community-dwelling dementia patients and their caregiverswere referred to the project by primary care physicians andthen were assessed and followed by social workers. Data wereabstracted from medical records to determine whether these interventionsled to improved quality of care as indicated by adherenceto key care processes derived from the adopted dementia guidelines.Chi-square and t tests were applied to compare guidelineadherence and satisfaction rates before and after the interventions.

 Compared with baseline, higher rates of provider andcaregiver satisfaction with Kaiser's system of dementia care werefound at the postintervention follow-up. There also were significantlyhigher rates of adherence to several practiceguidelineâ€“based quality measures: assessment of cognitive status;referrals to the Alzheimer's Association; and assessments of activitiesof daily living, decision-making capacity, depression, and wanderingrisk.

 Quality of primary care for people with dementiacan be improved through guideline implementation with caremanagement support by social workers.

Healthcare organizations are being challenged tocare for the growing number of older adults withchronic health conditions. Dementing diseases,such as Alzheimer's disease, vascular dementia, andother associated disorders, present particular challengesbecause there are strong social and behavioralcomponents to disease management. Physicians play acentral role in assessment, diagnosis, and treatment;but much of the management for noninstitutionalizedindividuals is done by families with the support of socialwork care managers and community resource organizations.Furthermore, primary care physicians are dailyfaced with a broad range of disorders and are challengedby dementia patients, who may compensate for cognitivelosses with retained social skills during the briefoffice visit.

Research suggests that Alzheimer's disease is neitherwell recognized nor systematically diagnosed.

 physicians diagnoseas few as 50% of dementia cases. Focus groups of primarycare physicians from 3 geographic areas found significantbarriers to the recognition and formal diagnosisof dementia. Physicians reported difficulty in recognizingpossible dementia. Many reported that they reliedon families to bring the disease to their attention. Therealso was a prevalent viewpoint that a formal diagnosticevaluation (including a comprehensive clinical historyand mental status examination, laboratory referrals torule out treatable conditions, and other procedures) isnot always necessary.

Yet delay in diagnosis also means delay in treatment.The last 10 years have seen approval of several medicationseffective in slowing progression of Alzheimer's disease,the most common type of dementia in people withmild or moderate cognitive impairment.

 Furthermore,people with undiagnosed dementia and their familiesare less likely to gain access to supportive services thatcan ameliorate caregiver burden and perhaps delayinstitutionalization.

Clinical practice guidelines have been developed andpromoted as tools for improving dementia care.

However, practitioners often are not familiar with theseguidelines; and even when disseminated broadly, theguidelines are not implemented uniformly.

Managed care organizations offer some unique possibilitiesfor quality improvement in dementia care. Theyprovide the communication lines for dissemination ofguidelines. Their accreditation is dependent on adoptionand implementation of guidelines-based qualityimprovement projects.

 Capitated payments can beused creatively to bring in the services of less expensiveprofessionals that may reduce costs or hold them steadywhile improving quality. A number of pilot projectshave been initiated to improve care for people withdementia in managed care settings 

; one such project,involving a large managed care plan in Los Angeles, isdescribed here.

Overview of Project and Description ofIntervention

In 1995, Kaiser Permanente's Metropolitan LosAngeles Service Area entered into a partnership with theAlzheimer's Association of Los Angeles to assess andimprove the quality of care provided to people withdementia. The Metropolitan Los Angeles Service Area ofKaiser Permanente serves a densely urban and ethnicallydiverse region. It includes 2 major medical centers andseveral satellite clinics. Based on extrapolated demographicestimates,

 up to 5000 people with dementiamay be served by Kaiser Permanente in this region.

The goal of the Dementia Care Project was to improvethe quality of care for people with dementia whileincreasing provider and consumer satisfaction. Thestudy used a longitudinal preintervention/postinterventiondesign, with evaluation data collected by medicalrecord review, caregiver interview, and provider survey.A consensus-based diagnostic practice guideline wasdeveloped by a multidisciplinary panel of KaiserPermanente practitioners and representatives of theAlzheimer's Association's Medical and ScientificAdvisory Board. The disciplines of neurology, psychiatry,geriatrics, family practice, psychology, and socialwork all were represented in the development group.This guideline sought to improve consistency in thediagnostic assessments done at Kaiser Permanente inthis region. The project later adopted a managementguideline published by Cummings et al.

 To implementthese guidelines as part of the Dementia Care Project,the following steps were taken:

 Promotion by Kaiser Permanente's clinical leadership through letters to providers and presentations at meetings.

 Broad dissemination of a laminated pocket version of the diagnostic guideline to all primary care physicians in this service area.

 Annual in-service training for primary care providers that was notable for its inclusion of physician leaders and caregivers as speakers, as well as the participation of a theater troupe that enacted a physician visit and the administration of a mental status examination. The theater troupe was used to increase physician empathy for presenting families. It also was assumed that the novelty of this form of teaching would enhance learning.

 Broad dissemination of a provider "tool kit" that contained the 2 guidelines and a variety of forms and tests of mental status and depression to support physicians as they followed guideline recommendations.

 presentoutlines of the diagnostic and management guidelines used by the Dementia Care Project.

The Dementia Care Projectrelied heavily on social work caremanagers to support this guideline basedquality initiative. Two full-timeprofessionals were trained bythe Alzheimer's Association with a24-hour intensive course followedby 7 months of mentoring via caseconferences. Patients were referredto the social workers by their primarycare physicians. The socialwork care managers provided arange of services in support ofphysicians, including administrationof mental status exams, follow-upwith families on thepsychosocial aspects of care, homevisits, intervention with familiesregarding behavior managementissues, and facilitation of connectionto physicians for treatment ofcomorbid conditions. The caremanagers also provided guideline recommendedservices for familycaregivers, including assessmentsof patients, linkage to services withinKaiser Permanente and in thecommunity, caregiver supportgroups, family education, and ongoingcare management.

In order to participate in theDementia Care Project, the personwith dementia needed to have a primarycare physician in the designatedKaiser Permanente servicearea, have a guideline-based dementiadiagnosis, dwell in the community(not in an institution), and havean involved, nonpaid caregiver. Participants also neededto be referred for participation by their primary carephysicians. Data were collected on 83 persons withdementia and their caregivers. The dementia patientsranged in age from 63 to 93 years (mean age = 80 years).They were 52% male and ethnically diverse (55% AfricanAmerican, 21% Caucasian, 3% Latino, 1% Asian, and 19%other or not specified). This ethnic diversity reflects themembership of Kaiser Permanente in this geographicregion. Initial Folstein Mini-Mental Status Examinationscores

 recorded after the program intervention beganwere available for more than 90% of the patients andranged from 2 to 29 with a mean score of 17. Of the 83participating caregivers, 63% were spouses; 16%, daughters;11%, sons; and 10%, other. Their mean age was 66years. The ethnic breakdown of caregivers was 52%African American, 23% Caucasian, 4% Latino, 4% Asian,1% Native American, and 16% other or not specified.

The study was primarily focused on improving thequality of care for people with dementia in this targetedregion. The following indicators of improved qualitywere drawn from the practice guidelines:

 Conducting a cognitive assessment with the Folstein Mini-Mental Status Examination.

, Venereal Disease Research Laboratory/rapid plasma reagin [test forsyphilis], thyroid-stimulating hormone, complete blood count, and selected blood chemistries).

 Referral to the Alzheimer's Association and to the Safe Return Program (for wandering risk) of theAlzheimer's Association.

 Conducting assessments that included activities of daily living, decision-making capacity, depression,and wandering risk.

These care processes were selected as study outcomesin part because they were guidelines targeted by theintervention. In addition, they have been identified andused with some frequency in studies of the quality of carefor dementia.

 It was predicted that each of these practiceswould increase as a result of project participation.

Kaiser Permanente physicians were surveyed abouttheir diagnostic practices, referral behaviors, perceptionsof services provided to patients with dementia, useof educational materials, and overall satisfaction withthe care of patients with dementia and their families.Satisfaction was assessed with a single question: "Howsatisfied are you with the treatment and support thatKaiser Permanente provides to patients with dementiaand their caregivers?" Similarly, participating caregiverswere surveyed regarding their satisfaction withdementia-related services at Kaiser Permanentethrough a series of questions including:

 "Overall, how satisfied have you been with the dementia-related service you and the patient havereceived at Kaiser Permanente?"

 "How satisfied have you been with the sensitivity and respect shown to you and the patient at KaiserPermanente?"

 "Have Kaiser Permanente physicians and staff given you educational materials about dementia?"

Caregivers also were questioned regarding referrals they were given both within the organization and tocommunity services.

The study design and consent forms were reviewedand approved by the Kaiser Permanente institutionalreview board. All study participants gave informed consentfor the study. Three different sources of data wereused to assess the impact of the project on providerpractices and satisfaction with care:

 Medical records, including primary care providerand social work files, were abstracted to assesswhether the quality indicators derived from theguidelines were being practiced. Preinterventionadherence and postintervention adherence tothese guidelines were measured and compared.

 Surveys of primary care physicians, administeredbefore the program was implemented and again 3years later, were used to assess self-reported practicebehaviors and provider satisfaction withKaiser Permanente's system of care for people withdementia.

 Interviews were conducted with caregivers atbaseline and between 3 and 6 months after theprogram was implemented to assess change in satisfactionwith dementia care.

 Medical recordsincluding social work files were audited to examine thesystem of care before and after implementation of theDementia Care Project. Project coinvestigators designedand applied a structured chart abstraction form toreview the records of the 83 program participants. First,abstractors identified the first mention of dementia ormemory problems by medical staff after January 1998,the date on which the Dementia Care Project interventionwas initiated. After this index visit, abstractorsrecorded dates of documentation of the mental statusexam, assessments, and results of laboratory tests. Theabstractors also documented referrals to staff socialworkers and to outside resources such as theAlzheimer's Association.

Next, 42 of the 83 participants were randomlyselected for a study of preintervention versus postinterventioncare. Resource limitations dictated theneed for this more restricted sample. Records for thissubset of subjects were abstracted over 3 years priorto the onset of the intervention in January 1998 toevaluate differences in rates of adherence to the guidelines before the intervention compared with after theintervention.

Preintervention and Postintervention PhysicianSurveys.

 With cover letters from the chiefs of internalmedicine and family practice, a total of 307 surveyswere mailed to primary care providers in theMetropolitan Los Angeles Service Area prior to projectimplementation; 112 surveys were returned, for a 36%response rate. Three years after the project was initiated,345 surveys were sent to primary care providers inthe same service area; 126 were returned, for a 37%response rate. (Because identifiers were not linked tothe surveys, it was not possible to determine the percentageof follow-up surveys received from the originalpreintervention sample.) As an incentive for participation,physicians who completed the follow-up surveywere entered into a lottery for a complementary dinnerfor 2 people.

 Caregivers of patients witha diagnosis of dementia who were enrolled in the projectparticipated in 2 structured telephone interviews.The first interview was conducted by a trained intervieweror the social work care manager at the time ofenrollment of the caregiver and patient in theDementia Care Project. A trained interviewer also conductedthe postintervention interview 3 to 6 monthsafter the caregiver and patient began receiving servicesfrom the social worker. All 83 participating caregiverscompleted the baseline and postinterventioninterviews.

 tests were applied to compareguideline adherence rates prior to the intervention withthose after the intervention, based on the medicalrecord reviews and on the physician surveys. Chi-squareand 

 tests were used to compare caregiver satisfactionwith care before and after the project intervention.

There was an increase in the reporting of Mini MentalStatus Examination scores from 16% prior to the projectto 93% after the project (chi-square, 

 < .001) amongthe subset of 42 pre- and postintervention chartsreviewed. The first postintervention mental status examdocumented in records was most frequently administeredby a neurologist (27%), followed by a primary carephysician (23%) and then by a social worker (20%). Thepercentages of patients who obtained each of the followingguideline-supported laboratory tests during thepostintervention period were: thyroid-stimulating hormone,84.3%; Venereal Disease Research Laboratory/rapid plasma reagin, 67.5%; B

, 69.9%; completeblood count, 94.0%; electrolytes, 84.3%; blood ureanitrogen, 81.9%; calcium, 75.9%; creatinine, 81.9%; andglucose, 89.2%.

Documentation of referrals to the Alzheimer'sAssociation increased from 3% prior to the project to76% afterwards (chi-square, 

 < .001), and referrals tothe Alzheimer's Association's Safe Return programincreased from 0 to 29% (chi-square, 

 < .001). Projectsocial workers made most of the referrals to theAlzheimer's Association (34%), followed in frequency byother staff social workers (19%).

Interventions to Improve Quality of Care: The Kaiser Permanente"Alzheimer's Association Dementia Care Project

Inflammatory bowel disease is a complicated condition, includingCrohn's disease, ulcerative colitis, microscopic colitis, and indeterminatecolitis, that affects the intestine and several extraintestinalsites. There has been much debate regarding whether Crohn's diseaseand ulcerative colitis are distinct entities or if they exist alonga continuum of the same disease process. In this article, the pathogenicmechanisms and clinical manifestations of inflammatorybowel disease are reviewed, as well as treatment options. BecauseCrohn's disease and ulcerative colitis are chronic diseases, theyhave an important economic effect on our healthcare system andthe United States as a whole. Some newer and more expensivetreatment options may provide overall cost savings in select patientpopulations because of decreased use of healthcare resources.

Inflammatory bowel disease (IBD) includes Crohn'sdisease (CD), ulcerative colitis (UC), microscopiccolitis, and indeterminate colitis. Microscopic colitis,which includes collagenous and lymphocytic colitis,is characterized by a chronic lymphocytic infiltrate inthe absence of any endoscopic or radiographic abnormalities.

 Histologically, collagenous colitis is distinguishedfrom lymphocytic colitis by the presence of athickened subepithelial collagen band.

 Most IBD can becategorized as CD or UC. However, 8% to 13% of casesof IBD cannot be clearly categorized into CD or UC andare said to represent indeterminate colitis.

There has been much debate regarding whether CDand UC are distinct entities or if they exist along a continuumof the same disease process. Crohn's disease ischaracterized by transmural inflammation involvingany part of the gastrointestinal tract, with skip lesionsoften present.

 The inflammation in UC involves onlythe mucosa and submucosa of the colon and extendsproximally from the rectum in a continuous fashion.

Because CD and UC are chronic diseases, they havean important economic effect on both the healthcaresystem and the United States as a whole. The direct cost(medical care, medications, tests, and procedures) ofCD in the United States in 1990 was $6561 per patient,and the direct cost of UC was $1488 per patient.

 Inaddition to these direct costs, there are indirect costs,such as absence from work, decreased earnings, prematuredeath, and changes in quality of life. After adjustingfor productivity losses, the annual cost for CD and UCin the United States has been estimated at $1.8 to $2.6billion.

 During the past decade, some expensive treatmentoptions have been developed. One study 

 lookedat the effect of infliximab use on resource utilization inpatients with CD and found that treatment with infliximab(especially among those with fistulas) resulted indecreased use of surgical services and fewer hospitalizations.Consequently, some of our newer and moreexpensive treatment options may provide overall costsavings in select patient populations because ofdecreased use of healthcare resources.

One to two million people in the United States haveIBD. In the United States, the incidence of CD is 3.6 to8.8 cases per 100 000 people, and the incidence of UCis 3 to 15 cases per 100 000 people.

 In contrast to UC,which shows a slight male predominance, CD appears tobe slightly more common among women.

 There is abimodal distribution in the population. Most individualsare diagnosed during a first peak between ages 15 and40 years, with a second peak occurring in individualsolder than 60 years,

 demonstrating that CD and UCcan affect people of all ages. Because physicians oftendo not consider IBD in the differential diagnosis in olderpatients, this group of patients may be misdiagnosed ashaving ischemic colitis or diverticulitis. Therefore, cliniciansshould consider IBD as a diagnosis in patients ofall ages.

All the races and ethnic groups in the world have CDand UC. The highest prevalence is seen in NorthAmerica and Europe.

 Whites are affected more oftenthan African Americans, who are affected more oftenthan Asians and Hispanics. There appears to be a gradientof increasing risk that correlates with how far onelives from the equator.

During the past few decades, this racial gap has beenclosing, as there has been an increasing incidence ofIBD in Asians and African Americans.

 The incidenceof UC in Seoul, Korea, has increased 10-fold since themid 1980s, and South Asians who have migrated todeveloped countries are at increased risk for developingIBD.

 Among children living in the southeasternUnited States, CD and UC were found to be equallycommon among African Americans and whites.

 Thesepopulation findings indicate a dynamic distribution ofIBD among ethnic and racial groups, and the migrationfindings underscore the importance of environmentalfactors in the risk of IBD.

The pathogenesis of IBD is multifactorial. Affectedindividuals often have a genetic predisposition to developCD or UC. After disruption of the gastrointestinalmucosal barrier, a luminal antigen causes ongoing activationof the mucosal immune system, which leads totissue damage and the clinical features of IBD. The

 shows a schematic view of the pathogenesis ofCD and UC.

Studies have shown evidence for a genetic predispositionto IBD. First-degree relatives of patients with IBDhave a 4- to 20-fold increased risk and a 7% absoluterisk.

August 2004

Associations With Reduced Length of Stay and Costs on an Academic Hospitalist Service

CURATA: A Patient Health Management Program for the Treatment of Osteoarthritis in Qu"bec: An Integrated Approach to Improving the Appropriate Utilization of Anti-Inflammatory/Analgesic Medications

Interventions to Improve Quality of Care: The Kaiser Permanente"Alzheimer's Association Dementia Care Project

Inflammatory Bowel Disease

Communicating Effectively and Managing Care

Evaluating Patient Compliance With Nurse Advice Line Recommendations and the Impact on Healthcare Costs