The Ambulatory Care Medical Audit Demonstration Project: Research Design

The authors describe the design of and statistical analyses involved in the Ambulatory Care Medical Audit Demonstration Project, which tested feasibility, cost, and effectiveness of cycles that met quality assurance requirements in eight pediatric and eight general medicine group practices at four teaching hospitals and six health centers. The authors used a concurrent crossover design using randomized cycles of quality assurance so that a practice was a control site for one guideline and an experimental site for another. For 12 months before and 18 months during and after quality assurance experimental interventions, the authors measured practitioner conformance to review criteria for patient-care guidelines believed to improve outcomes, including four internal medicine patient-care guidelines (ie, follow-up of low hematocrit, cancer screening for women, follow-up of high serum glucose, and monitoring of patients treated with digoxin) and four pediatric patient-care guidelines (ie, follow-up of positive urine cultures, screening for disease and immunizing infants, management of acute gastroenteritis, and management of acute ear infection). The authors distinguished review criteria whose performance depended on personal efforts of practitioners from those that concerned performance dependent on the practice's system for reporting test results and calling patients to return for care.