Cost containment in primary care: Using clinical findings to improve resource use. The nonselective use of health care resources by clinicians is responsible for much of the explosive growth in health care costs. Since clinical research has not clearly identified which patients will benefit from such diagnostic or therapeutic interventions, a large number of patients receive extensive care including hospitalization to insure capture of the few who will benefit. Through this project, we plan to develop improved clinical strategies for the management of patients with two common prototypic disorders - congestive heart faiure and chronic obstructive lung disease - which will reduce the costs of care wthout adversely affecting its quality. Through a prospective study, we will identify clinical variables from the history, physical examination, and first-line laboratory tests which will distinguish those patients who require hospitalization for therapy from those who do not. We will design alternatives to reduce hospitalization care for low-risk patients including strategies which address the psychosocial and psychiatric reasons often responsible for admission. We will search for care factors which seem to cause patients' decline and design interventions to prevent clinical deterioration. Clinical information available soon after admission will be studied to discover factors which could be used to select patients for early discharge. Suggested guidelines for laboratory test use will be developed by an evaluation of current utilization patterns, clinical yield, predictive value, and the effect of test results on therapeutic decision making. The impact of using these guidelines on admission rates, costs, and quality of care will be evaluated in an intervention trial at Strong Memorial Hospital and two affiliated community hospitals as well as by concurrent comparisons with other Rochester hospitals through a community-wide hospital data base. This research should lead to clinical strategies to significantly reduce admission rates, hospital days, and costs for common conditions in primary care. Cost containment interventions based on these strategies should be more effective than promulgating arbitrary guidelines for resource use. This research should facilitate the development of a methodology which can then be focused on other common problems with high utilization of medical resources.
