Physician practice change II: implications of the Integrated Systems Model (ISM) for the future of continuing medical education.

In a companion paper, the authors provide the development and description of the Integrated Systems Model (ISM). In this article, they describe 14 general implications of the ISM for continuing medical education (CME). They discuss how applying the ISM would change CME by describing (1) how CME and the larger health care environment would be restructured if they were based on the ISM and (2) how the ISM would impact CME under the current environment of health care in the United States.

Physician practice change I: a critical review and description of an Integrated Systems Model.

The long lag time between medical discovery and when Americans benefit from that discovery has a huge cost in terms of morbidity and mortality. Medicine needs more effective methods for moving discovery to practice. In this article, the authors first offer a critical review of the models of structure and change process gleaned from the physician change literature.

Are patients who use a generalist physician healthier than those who seek specialty care directly?

Background: American health care consumers want the option of seeing specialists whenever they wish, but given this option, do they in fact use it without consideration of their health status? This paper reports on a cross-sectional analysis that compares the demographics and health status of fee-for-service Medicare enrollees who exhibited four different patterns of physician access.

Methods: The Medicare Beneficiary Survey data from 1998 were used. Subjects ages 65 and older were categorized into one of four groups: those with no physician claim, those who saw a generalist only, those who saw a specialist only, and those who saw both.

Predictors of influenza immunization in persons over age 65.

Background: Numerous individual characteristics have been found to be associated with rates of obtaining flu shots. This study creates a predictive model that assesses the relative impact of each of these factors on increasing rates of flu shots in a population.

Methods: The Medicare beneficiary survey from 1998 and 1999 was used.

Who provides care to Medicare beneficiaries and what settings do they use?

Background: Concerns have been expressed that the physician workforce is unprepared for the explosion in the number of older persons in America. As a step toward informing these discussions, this article will describe how Medicare beneficiaries currently access physician services.

Methods: This study is a descriptive analysis of the physician services used by Medicare beneficiaries.

Curricular framework: core competencies in multicultural geriatric care.

Strategies to reduce the documented disparities in health and health care for the rapidly growing numbers of older patients from diverse ethnic populations include increased cultural competence of providers. To assist geriatric faculty in medical and other health professional schools develop cultural competence training for their ethnogeriatric programs, the University of California Academic Geriatric Resource Program partnered with the Ethnogeriatric Committee of the American Geriatrics Society to develop a curricular framework. The framework includes core competencies based on the format of the Core Competencies for the Care of Older Patients developed by the Education Committee of the American Geriatrics Society.

Implementing an incontinence management protocol in long-term care. Clinical outcomes and costs.

This article describes clinical outcomes and costs of implementing an incontinence management protocol based on the recommendations contained in the Agency for Health Care Quality and Research clinical practice guidelines on incontinence and pressure ulcer prevention. Following implementation of the protocol, 63 nursing home residents were followed for 6 months and assessed for the presence of wetness or pressure ulcers. Facility costs for incontinence management were accumulated.

A strategy for teaching students concepts of population-based health care for older persons.

The authors present a strategy for organizing and teaching the concepts of population-based health care for patients over the age of 65. The key ingredients are a case study based on a representative sample of 5,000 Medicare recipients and a student guide containing the sample group's demographics, clinical characteristics, and utilization patterns. As part of the case study, three subgroups within the sample are described: the basically healthy 50% that consume only 3% of medical resources, the most severely ill 10% that consume 70% of medical resources, and the moderately ill 40% that consume the remaining 27% of medical resources.

Improving efficiency in a residency training clinic: results from addressing a root cause of inefficiency.

Background: Since the early 1980s, primary care teaching clinics have repeatedly been reported to be inefficient. This paper describes the results of a 5-year effort to improve the efficiency of our residency teaching clinic.

Methods: This 5-year longitudinal tracking study of a clinic monitored monthly patient volume, number of providers scheduled per half day, and patient satisfaction with waiting times while interventions occurred to improve clinic efficiency.