AVOIDANCE OF REGRET AS A MOTIVE FOR ORDERING PROSTATIC SPECIFIC ANTIGEN TESTS. P.C. Sorum 1 , E. Mullet 2 , G. Chasseigne 3 , S. Bonnin-scaon 2 , J. Shim 4 , J. Cogneau 5 ; 1 Albany Medical Center, Schenectady, NY; 2 Ecole Pratique des Hautes Etudes; 3 Universite Â Franc Ëois-Rabelais, Tours; 4 University at Albany, Albany, NY; 5 MG France, St Avertin PURPOSE: When making management decisions, physicians try to avoid the regret that would be provoked by unwanted consequences of their actions or inactions. We explored the strength and determinants of such anticipated regret in a study of decisions to order prostatic specific antigen (PSA) tests for hypothetical patients. METHODS: 32 U.S. and 33 French primary care physicians looked at 32 patient scenarios and estimated the probability each patient had prostate cancer and the likelihood the participant would order a PSA. They were then given 12 scenarios and were told to suppose they had performed routine exams on these patients, had not ordered PSAs, and now several years later found advanced prostate cancer in these patients. They were asked to indicate how much regret they would feel that they had not ordered PSAs. The 12 hypothetical patients differed according to age (55, 65, or 75) , the request to be screened for prostate cancer (no or yes), and the shape of the prostate on the earlier rectal exam (no irregularity or some irregularity). The assessments of regret were analyzed by ANOVA (with significance set at p < .02). For each group of physicians, a correlation was calculated between the mean rating for regret and the mean likelihood of ordering a PSA. RESULTS: The regret scores were correlated with the likelihood of ordering PSAs for both the French (r = .64, p = < .005) and the Americans (r = .42, p < .02). The level of regret was higher when the patient had requested a PSA, when the shape had some irregularity, and when the patient was younger. When the patient had requested a PSA, the shape of the prostate had less effect than when the patient had not requested it. The U.S. physicians indicated a higher level of regret than did the French. A patient request had a greater impact on U.S. than on French physicians. Increasing patient age reduced regret more among the French than among the Americans. CONCLUSION: Anticipated regret over a failure to have diagnosed an aggressive prostate cancer is correlated with a policy of ordering of PSAs. The extent and determinants of this regret appear to be culturally sensitive. PURPOSE: Several studies have suggested that a central medical organizational structure can influence processes and outcomes, for example with audit and feedback, economic incentives, and implementation of guidelines. One form of organizational structure is clinical structure, the application of organizational policies which, in aggregate, allow medical organizations to improve the efficiency of care and outcomes delivered to cohorts of patients. We used literature review supplemented by clinical and administrative input to design a model of clinical structure which was tested in a 45 minute telephone survey by physician interviewers of medical directors of 56 medical organizations. METHODS: Responses were obtained from the directors of 53 medical organizations (response rate 95%) providing data from 29 medical groups (MGs) and 24 independent practice associations (IPAs) from 3 west coast states. The survey queried directors about whether their organization had in place corporate-wide policies to standardize clinical operations across the offices and providers that define their corporate entity. The survey asked about each of 30 dimensions of clinical corporate structure distributed across 183 individual survey items We considered an organization to have corporate policy (CP) if the respondent indicated CP for at least one item associated with a dimension of clinical structure. RESULTS: There was substantial variation across organizations in the extent to which the directors reported corporate policies. On average, organizations had CP for 49% of the 183 items across 30 dimensions of corporate structure. The clinical corporate policies most frequently cited by respondents pertained to the use of clinical guidelines (94%); specifications regarding the exact content of the ambulatory medical record (92%), and whether or not prospective review was required prior to specialty consultation (91%). Organizations infrequently cited having clinical corporate policies for assigning new patients to providers according to clinical need (19%), for office staff counseling patients following MD visits regarding next steps (21%), and use of multidisciplinary team meetings (25%). Of the 30 dimensions of clinical structure studied, CP was more prevalent in MGs than IPAs (p < .05) for 17 (57%) dimensions. For example, 66% of MGs and 33% of IPAs reported CP regarding written educational materials being available to patients (p < .05). CONCLUSION: While some medical organizations have developed sophisticated systems to organize the delivery of clinical care to cohorts of patients using corporate administrative policies, most have not. For most dimensions for which the literature suggests care could be improved with organizational support, most organizations, especially IPAs, do not report corporate policies in place.