title: Implementing evidence-based medicine: the role of market pressures, compensation incentives, and culture in physician organizations.
abstract: OBJECTIVE
  To assess the extent to which market pressures, compensation incentives, and physician medical group culture are associated with the use of evidence-based medicine practices in physician organizations.
  
  
  METHODS
  Cross-sectional exploratory study of 56 medical groups affiliated with 15 integrated health systems from across the United States, involving 1,797 physician respondents. Larger medical groups and multispecialty groups were overrepresented compared with the United States as a whole. Data are from two sources: (1) surveys of physicians assessing the culture of the medical groups in which they work, and (2) surveys of medical directors and other managerial key informants pertaining to care management practices, compensation methods, and the management and governance of the medical groups. Physician-level data were aggregated to the group level to attain measures of group culture and then merged with the data regarding care management, incentives, and management and governance. Stepwise multiple regression was used to examine the study hypotheses.
  
  
  RESULTS
  As hypothesized, the number of different types of compensation incentives used (cost containment, productivity, quality) was positively associated with the comprehensiveness of care management practices. The degree of salary control (ie, market-based salary grades and ranges versus the use of bookings or fees and individual negotiation) was also positively associated with the deployment of care management practices. As hypothesized, market pressures in the form of percentages of health maintenance and preferred provider organization patients seen were generally positively associated with the use of care management practices. Organizational culture had no association except that a patient-centered culture in combination with a greater number of different types of compensation incentives used was positively associated with greater use of care management practices.
  
  
  CONCLUSIONS
  Both compensation incentives and managed care market pressures were significantly associated with the use of evidence-based care management practices. The lack of association for culture may be due to the relatively amorphous nature of most physician organizations at this point.
authors.affiliation: School of Public Health, University of California, Berkeley, 94720-7360, USA. shortell@uclink4.berkeley.edu
authors.forename: S M
authors.initials: SM
authors.lastname: Shortell
authors.forename: J L
authors.initials: JL
authors.lastname: Zazzali
authors.forename: L R
authors.initials: LR
authors.lastname: Burns
authors.forename: J A
authors.initials: JA
authors.lastname: Alexander
authors.forename: R R
authors.initials: RR
authors.lastname: Gillies
authors.forename: P P
authors.initials: PP
authors.lastname: Budetti
authors.forename: T M
authors.initials: TM
authors.lastname: Waters
authors.forename: H S
authors.initials: HS
authors.lastname: Zuckerman
mesh_terms: D003430:Cross-Sectional Studies; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D004467:Economics; D019317:Evidence-Based Medicine; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008329:Managed Care Programs; D008389:Marketing of Health Services; D015279:Organizational Culture; D010816:Physician Incentive Plans; D011216:Practice Management, Medical; D011795:Surveys and Questionnaires; D014481:United States