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Although inpatient quality assessment efforts have advanced greatly in recent years, similar growth has not yet been experienced in ambulatory care. However, given the growth of primary care and its role in managed care systems, the need for quality assessment innovations is great and the future looks promising. The authors describe their experience in developing such an innovation in an ambulatory care setting. The goal of this article is to identify and describe how secondary data--in particular, data from reimbursement systems--may be used to develop a primary care quality of care assessment system. This investigation highlights the importance of reimbursement data in developing clinically meaningful and practical models for quality assessment.

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UNLABELLED: GOAL OF THE FRAMEWORK: The goal of the framework described in this review article is to provide a comprehensive model for the development of quality improvement programs in ambulatory-based primary care currently being tested at the University of Missouri-Columbia. This review article assesses the past and present, and speculates on the future, of quality improvement in primary care through a comprehensive review of 30 years of literature. PRINCIPLE CONCLUSIONS: (1) Although much of the past literature in the quality area has been concentrated in hospital care, there is a strong tradition in ambulatory-based primary care. (2) Past incentives promoted to a large extent hospital-based quality assurance, prospects for health reform and the result of recent quality initiatives will in the future promote improved methods for ambulatory-based quality. (3) There are unique dimensions of primary care that must be taken into account to accurately, appropriately, and comprehensively measure its quality. (4) A systematic process for the development of quality improvement that takes the perspective of those closest to the care being assessed, in this case the primary care provider, is necessary to develop a meaningful system. (5) Recommendations for further work in this arena are offered as they relate to both the health care system and providers.

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Elements of meaningful health care reform must include the ability of patients, providers, and payers to select services offering quality care at an affordable price. To achieve this goal, an appropriate definition of quality needs to be articulated and adopted; data capturing the definition needs to be collected; and appropriate measures need to be selected to analyze that data. Results need to be publically available to assist in making informed choices. The health professions need to fulfill their social contract. And, government needs to ensure that public safety and accountability are maintained and preserved. While the goals and strategies of the different players in the health care arena may be different, there is one thing in common--the needs of citizens must be met through the provision of available, accessible, quality, equitable, and cost-effective health care. These values need to be incorporated into a reform plan. Currently, our ability to comprehensively, consistently, and uniformly perform these tasks is severely limited. While many diverse factors, such as the limitation of financial support and the lack of uniform information systems, contribute to this situation, we believe it is possible through the implementation of a series of recommendations to achieve these goals. This paper outlines the current situation, reviews insights derived from the literature and past and current experiences. Recommendations are made that apply equally to health reform efforts at the state and/or federal levels.

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Prescribing medicine over the telephone was studied during a two-month period in a two-physician fee-for-service private family practice. Of 1,264 telephone calls, 392 (31.0%) resulted in a medication prescription. Of these calls, 176 (44.9%) were for refills of previously prescribed medicines. The most common drugs for new telephone prescriptions were decongestants/antihistamines/antitussives, antibiotics, and pain medications. Medicines were more likely to be prescribed via telephone for the diagnoses of upper respiratory infections, headache, low-back pain, or bronchitis. A patient was more likely than expected to get a telephone prescription for new problems when a message was left in the office for the physician by a caller other than the patient's son or daughter.

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All patient telephone calls to a two-physician private family practice were recorded for a 2-month period. There were 1264 calls, of which 539 were patient-initiated calls for specific medical problems. The 21 patients responsible for four or more of these 539 calls were labeled high utilizers. Chart comparisons were done for high-utilizer and 20 control patients. Calls of high utilizers were also compared with all other calls. High utilizers were older and showed evidence of more emotional dysfunction, more face-to-face medical contacts, more medical problems in general, and a suggestion of less social support. They did not seem to use the telephone in place of face-to-face visits, but used it in addition to an also higher rate of direct physician encounters.

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Telephone encounters received by two physicians in a private rural family practice setting were examined over a 61-day sampling period. A total of 1,264 calls were received during the study period, with 905 (71.6 percent) being received in the office setting. An average of 10.4 calls per physician were received each day, and a mean of 16.2 minutes per physician was spent each day with telephone encounters. Each call was brief, lasting 1.6 minutes (standard deviation 1.5 minutes); administrative and personal calls each lasted significantly longer than other call categories (F = 20.8, P = .0001). More chronic disease diagnoses tended to be handled during office when compared with nonoffice telephone encounters. The majority of calls (932, or 83.1 percent) did not require a face-to-face visit as judged by the physician. Of the office calls, 58.2 percent were handled by the physicians through a message system rather than a direct physician telephone call. It is estimated that uncharged care over the telephone saved patients in this practice up to $150,000 per year.

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Loss of a general surgeon in a rural community cna alter the referral patterns, the image and utilization of the local hospital, and even the market share of local primary care physicians. Prior research has not defined the necessary and/or sufficient conditions for a rural county to be able to support a local general surgeon. Based upon empirical analysis of 96 rural Missouri counties and the limited literature available on rural surgeons and physician referral rates, a first approximation of those conditions are offered. We conclude that a rural county with a hospital, a population base of more than 15,000 people, and at least 11 potential referring physicians has sufficient conditions to enable it to support a local general surgeon. Among those rural Missouri counties not meeting the above conditions but having a general surgeon in 1984, we estimate that 8 to 10 potential referring physicians appear to be the minimum necessary condition for supporting a rural general surgeon through patient referral. From those conclusions, we argue that any rural hospital currently without a surgeon should re-examine its situation. To prepare for a competitive future, such a hospital should take every opportunity to expand the referral base necessary to support a full-time local surgeon rather than place long-term reliance upon itinerant general surgeons.

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