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INTRODUCTION: The objective of this project was to develop and evaluate case-based immunization education materials that use a new teaching method called Multistation Clinical Teaching Scenarios (MCTS) for use in medical school clerkships and primary care residencies. METHODS: A multidisciplinary team developed objectives, abstracted clinical cases, and created MCTS modules, which use contextual learning, problem solving, and small-group interaction. RESULTS: Mean scores increased from the 10-item pretest to the posttest by 3.2 (95% confidence interval [CI] of 2.8 to 3.6) items for measles, 3.8 (CI = 3.4 to 4.1) for influenza, and 1.8 (CI = 1.4 to 2.1) for hepatitis B (P < .01 for each). To evaluate the materials, we administered questionnaires and conducted focus groups. Most (99%) of the students and residents rated the materials highly, as did most (89%) facilitators. CONCLUSIONS: This new method has been widely tested, increases content mastery, and is well received.

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OBJECTIVE: To examine the effect of an intervention designed to reduce antihistamine prescribing costs in an HMO. DESIGN: A quasi-experimental design with clinicians at one HMO site receiving an intervention. Their prescribing behavior before and after the intervention was compared to the prescribing behavior of clinicians at other HMO sites in a non-randomized control group. SETTING: A mixed model HMO in metropolitan Washington, DC. PARTICIPANTS: Group model clinicians at a single site received the intervention; network and group model clinicians at other sites composed the control group. INTERVENTION: An education memo addressed to clinicians discussing antihistamine prescribing costs and strategies for initial use of nonprescription or less expensive prescription agents, coupled with free antihistamine sample "trial packs" for patient use. OUTCOME MEASURE: The prescribing costs of the intervention group were compared to the prescribing costs of the non-randomized control group. The intervention group was surveyed regarding their attitudes toward the intervention. RESULTS: A 2% decline in costs was noted between the baseline and intervention year for both the intervention and control groups. Though clinicians indicated they were well disposed toward the intervention, they believe patient expectations were a major obstacle to the use of cheaper agents. CONCLUSION: We conclude that an effective intervention would require the targeting of major patient-related barriers to clinician behavior change.

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The authors evaluated the effect of an educational and feedback intervention on H2-blocker prescribing patterns and determined, if such effects differed for network- versus group-model health maintenance organization (HMO) physicians and in academic versus nonacademic settings. Physicians were randomized to receive an educational memorandum alone or combined with feedback regarding their individual prescribing behavior. The memo suggested preferred use of an H2-blocker (cimetidine) that would be less expensive to the HMO. Prescribing was monitored during the 6 months before and after the intervention. The study was undertaken at the primary care practices of a mixed group- and network-model university-affiliated HMO. Thirty group-model (at two academic and four nonacademic sites) and 33 network-model (all in full-time private practice) primary care physicians participated in the study. The analysis utilized weighted and unweighted analysis of covariance of the change in physicians' cimetidine-prescribing rates between the baseline and study periods. A significant response to the intervention was noted among academic and nonacademic group-model HMO physicians, but not among network physicians (adjusted mean absolute prescribing changes of +9.9% and +8.9% versus -2.8%, P = .02). There was no difference in prescribing change based on type of intervention (education versus feedback). The authors conclude that a simple passive educational intervention can be effective at changing group-model HMO physician behavior.

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The number needed to treat is a unique and cognitively useful summary measurement for the description of medical treatments. However, the original concept lacks the means to account for multiple benefits and harms or differences in the utilities or timings of patient outcomes. The authors describe an "adjusted" number needed to treat that allows for the inclusion of multiple harms and benefits, and also adjustments for the utilities and timings of these outcomes. The expanded version offers a richer description of medical outcomes, and may be utilized as an adjunct to traditional risk-benefit, cost-effectiveness, and decision-analytic techniques.

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OBJECTIVE: To assess the utilization of diagnostic and therapeutic medical services for the management of acute low back pain in a primary care setting, and to determine whether such utilization conforms to suggested guidelines for the management of this condition. STUDY DESIGN: A retrospective chart audit of consecutive cases of acute low back pain. Specific elements of the diagnostic and therapeutic approach were judged appropriate or inappropriate based on comparison with published recommendations supported by the medical literature. SETTING: The primary care adult practice of a university-affiliated health maintenance organization. PATIENTS: One hundred eighty-three patients presenting with acute low back pain of musculoskeletal origin. MEASUREMENTS AND MAIN RESULTS: According to suggested guidelines for the care of acute low back pain, 26% of plain lumbar x-rays (10/38), 66% of computed tomography (CT) and magnetic resonance imaging (MRI) scans (12/18), and 82% (23/28) of subspecialty referrals were categorized as inappropriate. Among patients without indications for these services, 12% (10/85) had received lumbar x-rays, 7% (12/168) had received lumbar MRI or CT scans, and 14% (23/168) had received subspecialty referrals. Underutilization of these services had occurred in 71% (70/98) of patients with an indication for plain lumbar radiography, and 47% (7/15) of patients with potential indications for surgical referral or CT/MRI scanning. Neither overutilization nor underutilization had led to adverse outcomes or delays in diagnosis in this small sample. CONCLUSIONS: According to guidelines from the medical literature, the primary care physicians in this study both overutilized and underutilized diagnostic and referral services in cases of acute low back pain. It is necessary to determine whether underutilization of plain lumbar radiography adversely affects diagnostic accuracy and whether overutilization of other services improves important clinical outcomes, given the generally benign natural history of this condition.

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We present the case of a young woman with an acute exacerbation of multiple sclerosis associated with paroxysmal atrial fibrillation and electrocardiographic changes characteristic of central nervous system effects on cardiac conduction. The patient presented with ataxia, vertigo, and left facial paresthesia, and was found to have a large demyelinating lesion involving the left middle and inferior cerebellar peduncles with extension rostrally into the brain stem. Profound pulmonary edema, out of proportion with the cardiac abnormalities, also developed. This confirms that demyelinating disease, like other central nervous system abnormalities, can lead to alterations in cardiac conduction, and may induce neurogenic pulmonary edema.

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