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OCR Page 1 of 63QUALITY AND COST OF DISEASE MANAGEMENT
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management program, but developmental costs would have to be spread over a larger program
and several years to be adequately addressed. In addition, the development of the communication
skills curriculum would be spread over several diseases. Even with conservative assumptions, the
development costs would have a small effect on the cost-effectiveness ratio spread over more
diseases, patients, and years of program operation.
Effects of the Program at the Community Level
Only a fraction of the physicians in the intervention communities participated in the program. About
200 physicians in the Intervention communities accounted for over 85 percent of all the patients
with any service claims for asthma. However, the program reached only 65 of these physicians,
and they were the ones with fewer emergency visits for asthma per 1,000 patients at the baseline.
Their patients experienced relatively less severe illness when compared with the patients of
untrained physicians in both the intervention and comparison communities. Thus, there was a bias
against favorable outcomes for trained physicians.
Despite this bias and the relatively small number of physicians trained, the program had an effect
on the use of emergency services and drugs at the community level. Since the effect on
emergency service visits was spread among all (trained and untrained) physicians in the
intervention communities, we did not observe large, consistent changes at the community level for
emergency visits. However. the effect on visits was large in the first quarter, when the program was
heavily marketed to all 200 physicians by mail, faxing, and phone calls.
There is an explanation for the sustained effect at the community level on drug use but not on
emergency service visits. Trained physicians retained a direct link with and control over drug
prescribing. For every asthma patient with a service claim, there are roughly two others without a
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