LETTERS TO THE EDITOR
This program has grown out of a host of prior work on measuring patient outcomes, e.g. functional status, decision analysis, clinical epidemiology, and technology assessment. Small area analysis, which found wide variations in the use of medical treatments among apparently similar populations, has highlighted the importance of effectiveness research; if variations in treatment exist, do they lead to different outcomes? We do not know the answer to this for the different clinical activities which are now used to diagnose, treat or prevent the same condition. To begin to address what Schoenbaum calls the "fragmented approach to developing priorities for improving care," our agency, in collaboration with others, is sponsoring a conference in the Fall 1990 to set a national agenda for effectiveness research that will bring together many of the key players. We believe that the Medical Treatment Effectiveness Program of the Agency for Health Care Policy and Research closely resembles Schoenbaum's "collaborative model" in which multiple groups in the private and public sectors work synergistically to improve the quality of medical care.3.4 REFERENCES
1. Schoenbaum SC: When is the quality of care good enough? (editorial) Am J Public Health 1990; 80:403-404. 2. Agency for Health Care Policy and Research: Program Note: Medical Treatment Effectiveness Research. Rockville, MD: US Department of Health and Human Services, Public Health Service, March 1990. 3. Roper WL, Winkenwerder W, Hackbarth GM, Krakauer H: Effectiveness in health care: An initiative to evaluate and improve medical practice. N Engl J Med 1988; 319: 1197-1202. 4. Fitzmaurice JM, Weissman NW, Salive ME: An initiative to evaluate and improve medical practice (letter). N Engi J Med 1989; 320:1085.
AJPH October 1990, Vol. 80, No. 10
Marcel E. Salive, MD, MPH Medical Officer Katy Benjamin, MS, MSW Social Science Analyst Ira E. Raskin, PhD Acting Director, Center for Medical Effectiveness Research, Agency for Health Care Policy and Research, DHHS, USPHS, 18A-19 Parklawn Bldg, 5600 Fishers Lane, Rockville, MD 20857. 0 1990 American Journal of Public Health
On Ambulatory Care As a primary health care practitioner in a fee-for-service setting, I was particularly interested in the article on quality of ambulatory care by Retchin and Brown, and the related editorial by Schoenbaum published in the April 1990 issue. I wondered about the implicit assumption (despite the statement that HMOs employ physicians "and other providers"), that physicians alone were responsible for the care given. This may have been the case in the fee-for-service settings under study but I would be very surprised if nurse practitioners did not play a significant role as primary care providers in the participating HMOs. My experience has been that nurses are more likely to value preventive health care-and make sure it happens. Could nurse practitioners have been responsible for the better showing HMOs made in this regard? I also believe that money should have been given more weight as a barrier to preventive health care, particularly in fee-for-service settings. Patients of mine often decide to forego mammograms because they are too expensive and return for "a Pap Smear" only when they are symptomatic-for the same reason. Once the acute problem is solved or the prescription refill written, many informed people do not see the
value of paying for well child or well adult preventive health screening. The answer is to combine sick and well care when possible-but this is more effort and time than all but the most committed can sustain. Veneta Masson, RN, MA Family Nurse Practitioner, 2451 39th Place, NW, Washington, DC 20007
Response from Drs. Retchin and Brown Ms. Masson's comments about the potential role nurse practitioners may have played as primary care providers in HMOs are welcomed. We certainly agree that providers other than physicians could have been responsible for the differences seen, particularly in the area of preventive care. There could also have been administrative mechanisms (e.g., reminder systems) as well as direct incentives to providers for increasing compliance with screening and immunization guidelines. However, since our study was not designed to establish precise techniques used for improving or maintaining quality of care, we are unable to provide detailed information about these methods. We also agree that reimbursement is presently a barrier for preventive care in some settings. However, prepaid care appears to be able to bypass patient resistance by diminishing perceived barriers, most prominently by furnishing preventive medical care as a benefit to encourage enrollment. How the HMOs fulfill these multiple goals of providing "sick and well care" was not the focus of our study. Sheldon M. Retchin, MD, MSPH Associate Professor and Chairman, Division of Geriatric Medicine, Medical College of Virginia Barbara Brown, PhD Assistant Professor, Williamson Institute for Health Studies, Department of Health Administration, Medical College of Virginia, Richmond, VA 23298
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This program has grown out of a host of prior work on measuring patient outcomes, e.g. functional status, decision analysis, clinical epidemiology, and technology assessment. Small area analysis, which found wide variations in the use of medical treatments among apparently similar populations, has highlighted the importance of effectiveness research; if variations in treatment exist, do they lead to different outcomes? We do not know the answer to this for the different clinical activities which are now used to diagnose, treat or prevent the same condition. To begin to address what Schoenbaum calls the "fragmented approach to developing priorities for improving care," our agency, in collaboration with others, is sponsoring a conference in the Fall 1990 to set a national agenda for effectiveness research that will bring together many of the key players. We believe that the Medical Treatment Effectiveness Program of the Agency for Health Care Policy and Research closely resembles Schoenbaum's "collaborative model" in which multiple groups in the private and public sectors work synergistically to improve the quality of medical care.3.4 REFERENCES
1. Schoenbaum SC: When is the quality of care good enough? (editorial) Am J Public Health 1990; 80:403-404. 2. Agency for Health Care Policy and Research: Program Note: Medical Treatment Effectiveness Research. Rockville, MD: US Department of Health and Human Services, Public Health Service, March 1990. 3. Roper WL, Winkenwerder W, Hackbarth GM, Krakauer H: Effectiveness in health care: An initiative to evaluate and improve medical practice. N Engl J Med 1988; 319: 1197-1202. 4. Fitzmaurice JM, Weissman NW, Salive ME: An initiative to evaluate and improve medical practice (letter). N Engi J Med 1989; 320:1085.
AJPH October 1990, Vol. 80, No. 10
Marcel E. Salive, MD, MPH Medical Officer Katy Benjamin, MS, MSW Social Science Analyst Ira E. Raskin, PhD Acting Director, Center for Medical Effectiveness Research, Agency for Health Care Policy and Research, DHHS, USPHS, 18A-19 Parklawn Bldg, 5600 Fishers Lane, Rockville, MD 20857. 0 1990 American Journal of Public Health
On Ambulatory Care As a primary health care practitioner in a fee-for-service setting, I was particularly interested in the article on quality of ambulatory care by Retchin and Brown, and the related editorial by Schoenbaum published in the April 1990 issue. I wondered about the implicit assumption (despite the statement that HMOs employ physicians "and other providers"), that physicians alone were responsible for the care given. This may have been the case in the fee-for-service settings under study but I would be very surprised if nurse practitioners did not play a significant role as primary care providers in the participating HMOs. My experience has been that nurses are more likely to value preventive health care-and make sure it happens. Could nurse practitioners have been responsible for the better showing HMOs made in this regard? I also believe that money should have been given more weight as a barrier to preventive health care, particularly in fee-for-service settings. Patients of mine often decide to forego mammograms because they are too expensive and return for "a Pap Smear" only when they are symptomatic-for the same reason. Once the acute problem is solved or the prescription refill written, many informed people do not see the
value of paying for well child or well adult preventive health screening. The answer is to combine sick and well care when possible-but this is more effort and time than all but the most committed can sustain. Veneta Masson, RN, MA Family Nurse Practitioner, 2451 39th Place, NW, Washington, DC 20007
Response from Drs. Retchin and Brown Ms. Masson's comments about the potential role nurse practitioners may have played as primary care providers in HMOs are welcomed. We certainly agree that providers other than physicians could have been responsible for the differences seen, particularly in the area of preventive care. There could also have been administrative mechanisms (e.g., reminder systems) as well as direct incentives to providers for increasing compliance with screening and immunization guidelines. However, since our study was not designed to establish precise techniques used for improving or maintaining quality of care, we are unable to provide detailed information about these methods. We also agree that reimbursement is presently a barrier for preventive care in some settings. However, prepaid care appears to be able to bypass patient resistance by diminishing perceived barriers, most prominently by furnishing preventive medical care as a benefit to encourage enrollment. How the HMOs fulfill these multiple goals of providing "sick and well care" was not the focus of our study. Sheldon M. Retchin, MD, MSPH Associate Professor and Chairman, Division of Geriatric Medicine, Medical College of Virginia Barbara Brown, PhD Assistant Professor, Williamson Institute for Health Studies, Department of Health Administration, Medical College of Virginia, Richmond, VA 23298
1277
