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Information for technical efficacy would include signal-to-noise ratios order yasmin 3.03mg online, image resolution buy cheap yasmin 3.03 mg online, and freedom from arti- facts. The second step in this hierarchy is to determine if the image pre- dicts the truth. This is the accuracy of an imaging study and is generally studied by comparing the test results to a reference standard and defining the sensitivity and the specificity of the imaging test. The third step is to incorporate the physician into the evaluation of the imaging intervention Chapter 1 Principles of Evidence-Based Imaging 13 Table 1. Imaging Effectiveness Hierarchy Technical efficacy: production of an image or information Measures: signal-to-noise ratio, resolution, absence of artifacts Accuracy efficacy: ability of test to differentiate between disease and nondisease Measures: sensitivity, specificity, receiver operator characteristic curves Diagnostic-thinking efficacy: impact of test on likelihood of diagnosis in a patient Measures: pre- and posttest probability, diagnostic certainty Treatment efficacy: potential of test to change therapy for a patient Measures: treatment plan, operative or medical treatment frequency Outcome efficacy: effect of use of test on patient health Measures: mortality, quality adjusted life years, health status Societal efficacy: appropriateness of test from perspective of society Measures: cost-effectiveness analysis, cost-utility analysis Source: Adapted from Fryback and Thornbury (38). Finally, to be of value to the patient, an imaging procedure must not only affect management but also improve outcome. Patient outcome efficacy is the deter- mination of the effect of a given imaging intervention on the length and quality of life of a patient. A final efficacy level is that of society, which examines the question of not simply the health of a single patient, but that of the health of society as a whole, encompassing the effect of a given inter- vention on all patients and including the concepts of cost and cost- effectiveness (38). Some additional research studies in imaging, such as clinical prediction rules, do not fit readily into this hierarchy. Clinical prediction rules are used to define a population in whom imaging is appropriate or can safely be avoided. Clinical prediction rules can also be used in combination with CEA as a way of deciding between competing imaging strategies (39). Ideally, information would be available to address the effectiveness of a diagnostic test on all levels of the hierarchy. Commonly in imaging, however, the only reliable information that is available is that of diagnos- tic accuracy.

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To some physicians discount yasmin 3.03 mg with mastercard, the hospital represented direct competition in that physical exams and urgent care patients were being diverted away from their practices buy discount yasmin 3.03 mg online. Most staff doctors, however, expe- rienced a more visceral reaction: this slick marketing approach felt sleazy, commercial, and inappropriate, and the culture of medicine was simply not ready for it. Meanwhile, hospitals everywhere were lining up to learn how to replicate this organization’s dubious success. In response to overwhelm- ing demand, Fyfe assisted the American Marketing Association in the for- mation of a healthcare section. She also formed and became president of the Northern California Health Care Marketing Association. Fyfe received one of the first Modern Healthcare "up and comer" awards and was pre- sented with a cash prize by the HealthCare Forum for her article on CliniCare. Over time her contributions have made healthcare organiza- tions smarter about their business decisions, more cautious about adver- tising, and more sensitive to the needs of their customers. Today she works closely with her primary strate- gic partner in the marketing enterprise—the physician. CHAPTER 2 THE CHALLENGE OF HEALTHCARE MARKETING he marketing of healthcare goods and services is not comparable to the marketing that takes place in any other industry. The extent to which healthcare is different from other industries, and the implications of this for marketing, cannot be overemphasized. This situation requires a spe- cialized approach to the marketing endeavor in healthcare, along with a need to develop healthcare-specific techniques to complement marketing techniques adopted from other industries. The conditions that historically surrounded healthcare mitigated the need for and interest in marketing for the majority of organizations involved in patient care. The slow acceptance of marketing in healthcare described in Chapter 1 reflects a number of characteristics of the healthcare industry as well as the attributes of healthcare organizations, products and services, professionals, and consumers.

On the acute low back pain side buy discount yasmin 3.03mg, primary care providers and physical therapists at Site D focused on standardizing their approach to con- servative treatment generic yasmin 3.03mg free shipping, with specific attention to patient referrals to physical therapy. The occupational medicine clinic also began to use the guideline, and providers found it helped them manage care for low back pain patients. They also planned to introduce the guideline at the emergency department, which was staffed by contract physi- cians. These providers resisted use of the guideline, however, and the emergency department still had not yet begun to work with it as of the end of the demonstration. The primary care providers resisted use of the low back pain documentation form, so the site decided to postpone use of the form pending development of an electronic ver- sion of the guideline and of the form. It took nearly six months to complete the electronic form and integrate it into the site’s clinical care software. The site began testing the new electronic form at one TMC a year after it began working with the low back pain guideline. Implementation Actions by the Demonstration Sites 61 Trends in low back pain encounters reported by the site indicated that establishment of the gatekeeper function for chronic low back pain patients shifted encounters from the TMCs to the physical medicine clinic and reduced encounters in orthopedics and neuro- surgery. These data did not make the distinction between patients referred during the six-week period of acute low back pain and those referred after they were considered to have chronic low back pain. The Implementation Process and Activities To carry out their respective strategies, the sites (1) introduced the guideline algorithm and supporting toolkit items to providers and staff, (2) sought to make changes to administrative procedures, (3) identified one standardized diagnostic code for low back pain, (4) provided patient education and self-management, and (5) monitored selected indicators. We synthesize the experiences of the four sites in each of these implementation steps and discuss the various ap- proaches and activities they undertook. All the sites began their im- plementation activities by holding education sessions for primary care providers to introduce them to the evidence-based practices specified in the low back pain guideline. These initial sessions typically reached approximately 60 percent of the relevant providers, with absences reported to be due to deployments and work schedule conflicts. MEDCOM was securing CME credits for training on DoD/VA clinical guidelines but had not completed that process at the time of the ini- tial education sessions. Some sites indicated that the absence of CME credit hindered participation in the training sessions.