PubMed Health⌕ Search

Biomedical subjects

S Dovey

Publications and source records attributed to S Dovey.

At least 19 recordsLinked to original sources
PubMed2001

Computerised advice on drug dosage to improve prescribing practice.

BACKGROUND: Maintaining therapeutic concentrations of toxic drugs is a complex task. Several computer systems have been designed to help doctors determine optimum drug dosage. Significant improvements in health could be achieved if computer advice was shown to be beneficial. OBJECTIVES: To assess whether computer support for drug dosage benefits patients and hence whether it should be more widely available. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (June 1996), MEDLINE (1966 to June 1996), EMBASE (1980 to June 1996), hand searched the journal Therapeutic Drug Monitoring (1979 to June 1996), reference lists of articles and contacted experts in the field. SELECTION CRITERIA: Randomised trials, interrupted time series and controlled before and after studies of computerised advice on drug dosage. The participants were health professionals responsible for patient care. The outcomes were: any objectively measured change in the behaviour of the health care provider (such as changes in the dose of drug used); any change in the health of patients, resulting from computer support (such as adverse reactions to drugs). DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Fifteen trials involving 1229 patients were included. The drugs studied were theophylline, warfarin, heparin, aminoglycosides, nitroprusside, lignocaine, oxytocin, fentanyl and midazolam. Interventions usually targeted doctors although some studies attempted to influence prescribing by pharmacists and nurses. All included studies took place on acute medical conditions in hospital settings. Although all studies used reliable outcome measures, sample size was often small and only two studies reported a sample size calculation. Computer support for drug dosage gave significant benefits reducing: 1. The time to achieve therapeutic control (standardised mean difference -0.44, 95% CI -0.70 to -0.17); 2. Toxic drug levels (risk difference -0.12, 95% CI -0.24 to -0.01); 3. Adverse reactions (risk difference -0.06, 95% CI -0.12 to 0.00); 4. Length of hospital stay (standardised mean difference -0.32, 95% CI -0.60 to -0.04). There was a tendency for computer support to result in higher doses of drugs, although this did not reach statistical significance. REVIEWER'S CONCLUSIONS: This systematic review provides evidence to support the use of computer assistance in determining drug dosage. Further clinical trials are necessary to determine whether the benefits seen in specialist applications can be realised in general use.

Drug Therapy, Computer-Assisted↗
PubMed2001

Direct graduate medical education payments to teaching hospitals by Medicare: unexplained variation and public policy contradictions.

PURPOSE: To comprehensively examine both inter- and intrastate variations in Medicare's cost-rate structure for teaching hospitals and to assess the Medicare payment system for graduate medical education (GME), as presently configured, as an instrument to promote physician workforce reform, specifically sufficient public access to primary care physician services. METHOD: Using Public Use Files of hospital cost reports from the Health Care Financing Administration for fiscal year 1997, 648 hospitals that met inclusion criteria for moderate GME volume were identified. The average and range of direct costs of resident training were computed for these teaching hospitals to illustrate differences within and between the 45 states that had at least two teaching hospitals that qualified for comparison. The cost rate upon which direct medical education (DME) payments are based was then correlated with the percentage of a state's counties that were wholly designated primary care health personnel shortage areas (PCHPSAs) in 1997 and with its primary care physician-to-population ratio, as determined from the Area Resource FILE: RESULTS: Variations in inter- and intrastate DME costs exist. In some states, the range in DME rates substantially exceeded the mean cost. DME funding policies are more generous toward teaching hospitals in states with greater primary care physician-to-population ratios and smaller proportions of counties wholly designated PCHPSAS: CONCLUSION: Inherent inequities in DME funding seriously undermine the current Medicare GME payment system's capacity to contribute to U.S. physician workforce reform and to improve access to care. There is actually a financial incentive to train residents in areas in which there is relatively less need for their services.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2001

Shortchanging adolescents: room for improvement in preventive care by physicians.

BACKGROUND AND OBJECTIVES: Behaviors developed in adolescence influence health later in life. Adolescents seldom visit physicians to discuss health-related behaviors. Instead, physicians must incorporate health counseling into the exams for which the adolescents do come. We studied the frequency and duration of adolescents' consultations with family physicians and pediatricians involving counseling about diet and nutrition, exercise, weight reduction, cholesterol reduction, HIV transmission, injury prevention, and tobacco use. METHODS: Data were analyzed from the National Ambulatory Medical Care Survey for the 3-year period from 1995 through 1997. This survey uses a multistage national probability sample of patient visits to nonfederal, office-based physicians. We described patterns of counseling provided to adolescents and compared patterns for family physicians/general practitioners and pediatricians. RESULTS: Of 91,395 physician-reported visits analyzed, 4,242 (4.6%) were by adolescents ages 12-19. Visits to family physicians and pediatricians accounted for 1,846 (43.5%) of these visits. Counseling about any of the seven areas studied was included in 15.8% of family physician visits and 21.6% of pediatrician visits. The length of consultation increased from 13.8 to 17.6 minutes if counseling was included. CONCLUSIONS: Adolescents visits physicians infrequently. When they do, few receive counseling on critical adolescent health issues. Both family physicians and pediatricians have room for improvement.

Adolescent↗
PubMed2000

The effect on medical practice of disciplinary complaints: potentially negative for patient care.

AIM: To explore the personal and professional effect on general practitioners (GPs) of receiving a complaint against them to the (former) Medical Practitioners Disciplinary Committee, when the complaint did not proceed to a formal hearing. METHODS: Ten GPs were interviewed by telephone, following an enrollment procedure that protected identities from the interviewer. Qualitative (thematic) analysis of indepth interviews was used to categorise doctors' perceived effects of complaints on practice and to develop a theory on why such effects should occur. RESULTS: Receipt of a complaint had both short- and long-term effects on the doctor, and on their views of patients, society and the disciplinary process. There were immediate negative emotional responses that were sustained in the long-term in a way that adversely effected doctor-patient relationships beyond the relationship with the original complainant. Doctors reported short-term changes in their practice of medicine, with reduced ability to work confidently and decisively. Doctors also reported altered practice in the long-term in the direction of defensive medicine, by withdrawing from providing some services and avoiding perceived at-risk activities. CONCLUSION: The impact of a complaint on the self of the doctor suggests a shame response. There may be a need for the relevant professional college to establish a rapid response 'crash team' to minimize the negative personal and professional effects of a complaint, even when the complaint does not proceed to a formal hearing.

Attitude of Health Personnel↗
PubMed2000

General practitioners' perception of their role in care for people with intellectual disability.

The present study set out to determine general practitioners' (GPs') view of their role in the care of people with intellectual disability who live in the community, and to explore the special issues which providing this care raises for them. A postal questionnaire was sent to a random sample of 250 out of the 698 GPs in the southern region. Twenty statements were presented and participants indicated the extent of their agreement with each statement on a seven-point Likert-type scale. After each scaled response, an open-ended question obtained a written expansion of the numerical response. These qualitative responses were analysed thematically, and combined with descriptive and cluster analyses of quantitative responses to provide a robust assessment of the characteristics of respondents providing contrasting replies. The role of GPs as part of the group of carers for people with intellectual disability was well recognized. Their normal practice routines may not always be adequate because of the small number of patients an individual GP might care of and their lack of explicit training in the special medical needs of such people.

Adult↗
PubMed2000

Educating doctors to provide counseling and preventive care: turning 20th century professional values head over heels.

Internationally, 20th century medical education concentrated on equipping new graduates with technical skills and pushing the frontiers of technological sciences to extend and enhance life in ways unimaginable in previous decades. In the 21st century, health services are expected to be characterized not by the "fix-up-when-things-go-wrong" type of care that 20th century physicians have become so good at, but by preventive care that can obviate much of the need for these fix-up services. Enabling doctors to deal with the different health care needs of future patients will require a values shift in medical education. The United States leads the world in per capita health care expenditure yet trails in many important measures of health status. It epitomizes many elements of both the good and the bad in current medical education that may be less obvious in other countries that are less wealthy, less technologically oriented, and less committed to individual freedoms. In this paper we use the US as a case study to argue the need for a fundamental shift in values away from the 20th century emphasis on disease, specialization and treatment, and towards health, generalization and prevention. We draw on data from the National Ambulatory Medical Care Survey to compare roles of primary care physicians and other office-based medical specialties in delivering preventive health care. We also estimate the cost of providing preventive care in terms of physician time. Finally, we contemplate how medical education values must change in the US and other countries if 21st century physicians are to be prepared to meet the health care needs of their communities.

Journal Article↗
PubMed1999

Computer support for determining drug dose: systematic review and meta-analysis.

OBJECTIVE: To review the effectiveness of computer support for determining optimum drug dose. DESIGN: Systematic review of comparative studies where computers gave advice to clinicians on the most appropriate drug dose. Search methods used were standard for the Cochrane Collaboration on Effective Professional Practice. SUBJECTS: Comparative studies conducted worldwide and published between 1966 and 1996. MAIN OUTCOME MEASURES: For qualitative review, relative percentage differences were calculated to compare effects of computer support in different settings. For quantitative data, effect sizes were calculated and combined in meta-analyses. RESULTS: Eighteen studies met the inclusion criteria. The drugs studied were theophylline, warfarin, heparin, aminoglycosides, nitroprusside, lignocaine, oxytocin, fentanyl, and midazolam. The computer programs used individualised pharmacokinetic models to calculate the most appropriate dose. Meta-analysis of data from 671 patients showed higher blood concentrations of drug with computer support (effect size 0.69, 95% confidence interval 0.36 to 1.02) and reduced time to achieve therapeutic control (0.44, 0.17 to 0.71). The total dose of drug used was unchanged, and there were fewer unwanted effects of treatment. Five of six studies measuring outcomes of care showed benefit from computer assistance. CONCLUSIONS: This review suggests that using computers to determine the correct dose of certain drugs in acute hospital settings is beneficial. Computers may give doctors the confidence to use higher doses when necessary, adjusting the drug dose more accurately to individual patients. Further research is necessary to evaluate the benefits in general use.

Decision Making, Computer-Assisted↗
PubMed1996

General practitioners' opinions of continence care training.

AIMS: To examine general practitioners' confidence in the diagnosis and management of urinary incontinence, to define their unmet continence training and educational needs, and to evaluate the current provision of continence care in general practice, including the role of practice nurses. METHODS: A pre-tested postal questionnaire was sent to 600 general practitioners throughout New Zealand to obtain information about their demography and training in incontinence management, their confidence in diagnosis and treatment, and their perceptions of met and unmet educational needs in continence care. They were also asked about current provision of continence promotion in their practice and their views on the role of practice nurses in caring for incontinent patients. Confidence data were recorded on five point scales and analysed using chi square tests. Cluster analysis was used to describe groups with different opinions on practice nurses' roles. RESULTS: The response rate from eligible contacts was 81.3%. Although most respondents provide continence care, only 2.6% offered special clinics for continence promotion. Fewer than half felt confident to diagnose the causes of incontinence. Confidence in managing incontinence in children was consistently lower than for other incontinence presentations. There was no difference by sex in confidence in caring for incontinent patients although female respondents were more likely to consider management of continence care part of a practice nurse's role (chi 2 = 47.5, p < 0.01) and to routinely ask well women about incontinence (chi 2 = 243.6, p < 0.01). Most respondents (71.9%) could not remember having had any formal training in the management of incontinence at either undergraduate or postgraduate level. Recall of postgraduate education was associated with greater levels of confidence in management of continence problems. There was general agreement that it was appropriate to include training in continence management in vocational and continuing medical education. CONCLUSION: A substantial proportion of general practitioners perceive a lack of adequate medical training in incontinence care at both undergraduate and postgraduate levels. There is a need for improved education for both general practitioners and practice nurses.

Adult↗
PubMed1996

Trends in antihypertensive prescribing.

AIM: To identify trends in the prescribing of antihypertensive medications and measure the changes in government and patient expenditure resulting from any identified change. METHODS: The computerised records of 16 069 patients from six Otago practices from 1991-3 were examined. Those patients prescribed any antihypertensive medication in all 3 years were selected for investigation. The antihypertensives prescribed were assigned to one of seven classes. The cohort was then divided into two groups; those remaining on the same class of medication for the three years and those changing medication class at any stage. Reasons for any change were identified. The direct costs of the prescribing decisions taken were evaluated. RESULTS: 914 patients were prescribed antihypertensive in all 3 years. Of these 579 (63.3%) remained on the same class of medication, while 335 (36.7%) changed class. A clinical reason was identified for medication change class. A clinical reason was identified for medication change in 98% of cases available for examination. There was no significant shift in expenditure for those remaining on the same medication, while costs for those remaining on the same medication, while costs increased by 20.6% for those changing. CONCLUSION: For this cohort increased expenditure on antihypertensive was driven by those changing medication. Although these changes were prompted by clinical reasons, better health outcomes for patients cannot be assumed due to lack of objective indicators.

Adult↗
PubMed1995

Delivery of hepatitis B immunisations in a selection of computerised general practices.

AIM: To assess the value of computerised general practices in providing information concerning the delivery of hepatitis B immunisation. METHODS: Hepatitis B immunisation data from August 1990 to June 1991 were collected from 27 general practices participating in a sentinel network. RESULTS: The study identified significant limitations in the use of data from computerised general practices for estimating hepatitis B immunisation coverage. While an accurate coverage figure could not be estimated, the results did suggest that hepatitis B coverage for three doses was at least 59.5% and that its use was very similar to the triple vaccine and measles/MMR for the third dose. Hepatitis B immunisation delivery outside the desirable time periods was common at 44%, suggesting a fairly disrupted immunisation schedule for many children. CONCLUSIONS: The relatively infrequent delivery of hepatitis B vaccine at the same time as other vaccinations may reflect provider concern about administering multiple injections at the same visit. Further improvement in the collection of data by computerised practices is necessary before the full value of this data source can be realised. Improvements in reminder/recall systems would improve the efficiency with which hepatitis B immunisation is delivered.

Child, Preschool↗
PubMed1995

Antibiotic use in upper respiratory tract infections in New Zealand.

Upper respiratory tract infections (URTIs) are a common reason for presentation to general practitioners. The current study used computerised consultation records of 100,222 patients from 17 general practices in New Zealand for the 12-month period 1 July 1991-30 June 1992. URTIs were noted in 8.9% of all consultations: 44.1% of cases were children aged less than 10 years. Females presented more frequently than males for all ages above five years. Fifteen different antibiotics were prescribed for URTIs, but in 22.5% of cases no antibiotic was prescribed. There was no statistically significant difference in the likelihood of a successful outcome with or without antibiotic therapy (chi 2 = 0.76, P > 0.05). The treatment failure profile of some antibiotics highlights the need for more prescriber education, especially as the range of medications available for general practitioner prescribing increases.

Adolescent↗
PubMed1992

Treatment of postmenopausal osteoporosis with calcitriol or calcium.

BACKGROUND AND METHODS: Osteoporosis is a common problem whose management is controversial. To evaluate the efficacy and safety of calcitriol (1,25-dihydroxyvitamin D3) in the treatment of postmenopausal osteoporosis, we conducted a three-year prospective, multicenter, single-blind study in 622 women who had one or more vertebral compression fractures. The women were randomly assigned to receive treatment with calcitriol (0.25 micrograms twice a day) or supplemental calcium (1 g of elemental calcium daily) for three years. New vertebral fractures were detected by means of lateral roentgenography of the spine each year, and calcium absorption was measured in 392 of the women. RESULTS: The women who received calcitriol had a significant reduction in the rate of new vertebral fractures during the second and third years of treatment, as compared with the women who received calcium (second year, 9.3 vs. 25.0 fractures per 100 patient-years; third year, 9.9 vs. 31.5 fractures per 100 patient-years; P less than 0.001). This effect was evident only in women who had had five or fewer vertebral fractures at base line (second year, 5.2 vs. 25.3 fractures per 100 patient-years; third year, 4.2 vs. 31.0 fractures per 100 patient-years; P less than 0.0001). The groups also differed significantly in the number of peripheral fractures; 11 such fractures occurred in 11 women in the calcitriol group, whereas 24 occurred in 22 women in the calcium group (P less than 0.05). There was no significant difference between the groups in the incidence of side effects requiring withdrawal of treatment (8.6 percent in the calcitriol group vs. 6.5 percent in the calcium group). CONCLUSIONS: Continuous treatment of postmenopausal osteoporosis with calcitriol for three years is safe and significantly reduces the rate of new vertebral fractures in women with this disorder.

Aged↗