Physician attitudes toward the use of type IC antiarrhythmics after the Cardiac Arrhythmia Suppression Trial (CAST).
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Anilides↗
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Results for “Practice Patterns, Physicians'”
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A community-wide perspective of gender differences and temporal trends in the use of diagnostic and revascularization procedures for acute myocardial infarction.
This study compares the overall use, as well as temporal trends, of various diagnostic and revascularization procedures for acute myocardial infarction (AMI) in men and women. The study sample comprised a total of 2,924 men and 1,838 women with validated AMI admitted to any of the 16 teaching and community hospitals in the Worcester, Massachusetts, metropolitan area during 1975, 1978, 1981, 1984, 1986 and 1988. During the period under study there was a significant increase in use of each of the examined procedures during hospitalization for AMI in both men and women. Increasing use of multiple procedures was also seen for each of the sexes. After controlling for a variety of demographic and clinical factors that might affect utilization rates, men were marginally more likely to undergo radionuclide ventriculography, and significantly more likely to undergo Holter monitoring, exercise treadmill testing, cardiac catheterization, and percutaneous transluminal coronary angioplasty than women. However, there were no gender differences in the use of coronary artery bypass grafting. On the other hand, men were significantly less likely to undergo echocardiography. The results of this multihospital, population-based study suggest sex differences in the use of several diagnostic and revascularization procedures during hospitalization for AMI. These differences may be attributed to physicians' practice patterns, although gender bias in the delivery of medical care cannot be excluded. Temporal trends in increased overall use of these procedures raise questions about cost-effectiveness that need to be further addressed.
Age Factors↗
Diagnosis and treatment of outpatient insomnia by psychiatric and nonpsychiatric physicians.
Insomnia is commonly encountered in general medical practice, but little is known about how primary care physicians manage this problem. We reviewed medical records describing 536 patient encounters in which either triazolam (Halcion) or flurazepam (Dalmane) was prescribed for outpatient use. Only 12% of the progress notes written by internists or surgeons contained even a remote reference to sleep, whereas 74% of psychiatrist's notes contained at least some sleep symptom documentation. In a multivariate analysis including the number of medical and psychiatric diagnoses, patient age, and physician gender, only the prescriber department was independently associated with the presence of symptom documentation. We also found that 30% of the prescriptions written by internists or surgeons were for inappropriately large quantities of these drugs (180 or more doses) compared with 6% of the prescriptions written by psychiatrists. We conclude that the evaluation of insomnia by nonpsychiatrists is often incomplete and that hypnotic drugs may be inappropriately prescribed by these physicians. Further efforts are needed to improve the management of insomnia by primary care physicians in the outpatient setting.
Disease↗
Obstetric hospital stays by diagnosis related groups: a community-based analysis.
The study analyzed obstetric inpatient hospital stays by diagnosis related group in Sacramento, California, and Syracuse, New York, two areas with similar admission rates, between 1981 and 1984. The sample included 123,308 hospital discharges. The data indicated that aggregate obstetric stays in Syracuse were 32.9% longer than those in Sacramento, which was typical of differences between these stays in the western and northeastern United States. Obstetric stays in both areas declined between 1981 and 1984; however, the rate of decline in Sacramento (6.1%) was substantially higher than that of Syracuse (3.5%). Variability of obstetric stays was substantially lower in Syracuse for most diagnosis related groups, including those with the largest caseloads. These results suggest that community and regional differences in obstetric hospital stays may be produced by system-wide consumer preferences and physician practice patterns, more than by hospital bed availability, health maintenance organization activity, or other factors.
California↗
Reducing cesarean births at a primarily private university hospital.
OBJECTIVE: The rise in cesarean birth at Northwestern Memorial Hospital in 1986 to 27.3% prompted implementation of three initiatives to reverse the escalating cesarean section rate. STUDY DESIGN: First, vaginal birth after cesarean section was more strongly encouraged. Second, after the 1988 calendar year the cesarean section rate of every obstetrician was circulated annually to each attending physician. Third, on completion of a prospective, randomized trial of the active management of labor in early 1991, this protocol was recommended as the preferred method of labor management for term nulliparous patients. RESULTS: The total, primary, and repeat cesarean section rates declined from 27.3%, 18.2%, and 9.1% in 1986 to 16.9%, 10.6%, and 6.4%, respectively, in 1991. At the same time the perinatal mortality dropped from 19.5 to 10.3. Significant reductions in abdominal deliveries occurred for both private patients (30.3% to 19.1%, p < 0.0001) and clinic patients (20.8% to 11.5%, p < 0.0001). A decline in operative deliveries for dystocia and an increase in vaginal birth after prior cesarean section were the principal factors contributing to the lower cesarean section rates. However, in 1991 individual private physicians still had wide variations in primary cesarean section rates (4.6% to 21.1%) and use of vaginal birth after prior cesarean section (5.3% to 90%). CONCLUSION: The cesarean section rate has been significantly reduced for both private and clinic patients. Differences in population demographics and individual physician practice patterns contributed to a higher incidence of cesarean birth on the private service.
Birth Weight↗
The bright future of cardiothoracic surgery in the era of changing healthcare delivery.
We are currently at a crossroads in our specialty and in the American healthcare delivery system. The manner in which we approach the next 5 to 10 years will deeply affect the future of our specialty. Thoracic surgery has had many accomplishments during my 35-year career that have improved the healthcare for the American public and others. As cardiothoracic surgeons, we have a legacy to be proud of, and the future promises to be every bit as exciting. In spite of these tremendous advances and the potential for future scientific achievements, there has been considerable uncertainty and pessimism because of the changing structure of healthcare in the United States. This has largely been stimulated by increasing health-care expenditures leading to the development of health maintenance organizations in the hopes of curtailing expenses by competition and capitation. In addition to cost containment, managed care is likely to have an impact on the future workforce of cardiothoracic surgeons. Much of our future will be determined by how well we adapt to the changing environment and take charge of our destiny. The demand for performance information for managed care plans will be much greater than it has been in the past. It is, therefore, imperative that we collect data to reflect the quality and value of our work to ensure that significant quality is not being sacrificed for cost containment. We cardiothoracic surgeons must develop our own information management strategies so that we can be in control of our future. If we do this, I am confident that the future of cardiothoracic surgery will be a bright one indeed.
Academic Medical Centers↗
Physicians' attitudes, recommendations and practice of male and female sterilization in São Paulo.
While prevalence of vasectomy is low in Brazil, female sterilization is very high. The potential for growth of vasectomy services may be related to attitudes and practices of physicians. In 1984, 660 physicians at seven major hospitals in São Paulo were randomly selected from a total population of 2207 physicians in these hospitals. They were interviewed about their attitudes towards family planning in general, and specifically towards voluntary sterilization. A high degree of vasectomy among this medical community is indicated by its relatively high prevalence among married physicians and their spouses; about one in ten reported that either they or their spouse had had a vasectomy. Half of the physicians who perform sterilizations perform vasectomies: 22% of obstetricians and gynecologists, 85% of surgeons, and all urologists. In general, physicians would recommend vasectomy and tubal ligation equally often to their clients. Depending on the circumstances, up to 85% of all physicians recommend some sterilization procedure. Recommendation was modified by the type of procedure a physician performed, and by the patient's characteristics. Physician's recommendations of sterilization increased with age and parity of patient and was related to the health conditions and socioeconomic circumstances of the couple.
Adult↗
Professional uncertainty and physician medical decision-making in a multiple treatment framework.
This paper develops a new microanalytic approach to physician medical decision-making treatment setting. Physician medical decision-making is modelled as a two-stage sequential process. In Stage 1, the patient's illness is diagnosed and the health outcomes for all illness-related restoration options are identified. In Stage 2, an "optimal" restoration option is selected. This model provides new insights into physician medical decision-making and the complexity of proving physician-induced demand in a medical care market where professional uncertainty and consumer heterogeneity exist.
Clinical Competence↗
Prescription intentions in relation to therapeutic information: a study of 117 French general practitioners.
In 1987 we conducted a mailed questionnaire survey involving 250 GPs, randomly drawn from the 3061 GPs in the 'Rhône-Alpes' region in France, in order to study how general practitioners (GPs) react to information about drugs in terms of their prescribing practices. The aim of the questionnaire was to investigate the GPs reactions (prescription intentions) to 25 statements containing information concerning drugs. These included results from randomized clinical trials with adequate clinical criteria (pertinent information), but there were also some statements containing non-relevant information such as intermediate criteria, physiopathological or pharmacological information, and some containing general information such as advice from colleagues, the established position of the drug etc. The GPs were also asked through which channels they commonly received therapeutic information (i.e. medical journals, conferences). A total of 117 GPs returned completed questionnaires. We found the prescription intentions, for pertinent information to be between 76.9% and 95.7%, whilst the intentions, as a result of personal knowledge and/or success with a drug were around 93%. More theoretical information resulted in prescription intentions which were more widely scattered (between 23.1% and 80.3%), and for external advice the intentions were not as high but they were also widely scattered (between 3.4% and 65%). The search for latent dimensions corresponding to GPs reactions to therapeutic information, with both principal component analysis and Rasch Modelling, showed that two orthogonal latent dimensions, i.e. 'sensitivity to clinical and theoretical information', and 'sensitivity to external standards', best explained the responses to the questionnaire. These two dimensions appeared to be independent of age, sex, medical school and type of practice (urban, rural). The use of the journal 'Prescrire' by GPs was found to be significantly associated (P less than 0.005) with low scores, or good quality of perception of pertinent information in the first dimension. The use of specialists' prescriptions was associated with similar scores for the first dimension, but also with poor quality of perception of pertinent information scores (i.e. high scores) for the second dimension. These results could be used to draw up proposals for the improvement of post-graduate medical education, which should take into consideration these two dimensions of therapeutic information assessment by doctors, in order to obtain better quality of perception profiles for information assessment and prescription by doctors.
Adult↗
The influence of patient and physician gender on prescription of psychotropic drugs.
There is a wealth of evidence that more psychotropic drugs are prescribed to female than to male patients. We studied the psychotropic drug prescription of 15 male and 9 female physicians to 2493 patients in the Ambulatory Care Clinic of a University hospital. The relative odds (RO) of benzodiazepine prescription to a female compared to a male patient was the same when the physician was a male or a female (adjusted RO: 1.8; 95% CL: 1.5-2.1). But female patients were significantly more likely to be prescribed psychotropic drugs of all types from a female than from a male physician (adjusted RO: 1.3; 95% CL: 1.0-1.7). Information on patient diagnosis or on severity of symptoms would be needed to determine whether the present results reflect gender differences in medical care needs, overprescription of psychotropic drugs to females or underprescription of psychotropic drugs to males.
Attitude of Health Personnel↗
Scanning systems and protocols used during imaging for acute pulmonary embolism: how much do our clinical colleagues know?
RATIONALE AND OBJECTIVES: The imaging systems and protocols used during ventilation-perfusion lung (V-P) scintigraphy and computed tomographic (CT) pulmonary angiography (CTPA) can affect diagnostic performance. We investigated the level of awareness of these factors among US clinicians who refer patients for imaging for suspected acute pulmonary embolism. MATERIALS AND METHODS: Between September 2004 and February 2005, we conducted a mail survey of 855 physicians selected at random from three professional organizations. We asked participants how important the availability of state-of-the-art equipment was in their imaging decisions, whether V-P scintigraphy was performed with planar or single-photon emission CT (SPECT) equipment in their communities, to identify the most advanced type of CT scanner used for CTPA, and whether CT venography (CTV) was performed routinely after CTPA. RESULTS: We received completed surveys from 240 (29.8%) physicians practicing in 44 states. One hundred sixty-six respondents (70.9%) indicated that state-of-the-art equipment was an extremely or very important factor when they made imaging decisions. However, 191 clinicians (80.3%) did not know whether SPECT equipment was used for V-P scintigraphy, and 119 (50.6%) did not know the type of CT scanner used for CTPA in their communities. Of respondents, 39.2% reported access to multidetector row CT technology for CTPA, whereas 10.2% referred patients to facilities using single-detector CT. Only 9.3% of respondents indicated that CTV was performed routinely after CTPA. CONCLUSION: Although state-of-the-art equipment is important to them, clinicians practicing in the United States have limited knowledge of the equipment being used during CTPA and V-P scintigraphy scanning in their communities. Radiologists should intensify efforts to familiarize their clinical colleagues with the equipment they use.
Attitude of Health Personnel↗
Smoking-related attitudes and clinical practices of medical personnel in Minnesota.
CONTEXT: Effective clinic-based, smoking-cessation activities are not widely implemented. OBJECTIVE: To compare and contrast the smoking-cessation attitudes and clinical practices of five types of primary healthcare team members. DESIGN AND SETTING: From July to October 2002, a cross-sectional survey was mailed to randomly selected primary care physicians (MDs), advanced practice nurses (APRNs), registered nurses (RNs), licensed practical nurses (LPNs), and medical assistants (MAs). MAIN OUTCOME MEASURES: Factors associated with limited smoking-cessation service delivery. RESULTS: The overall response rate was 68% (n =3021). Most respondents reported that patients' smoking status was consistently documented at their clinic (79%); other system prompts were less common (30%). Many respondents reported documenting smoking status or recommending quitting; few reported consistently assessing, assisting, or arranging follow-up. The mean rank of smoking cessation as an important preventive service among nine preventive services declined from MDs (1.9) to APRNs (2.5), RNs (3.4), LPNs (4.2), and MAs (4.6). Smoking prevalence increased from 1% in MDs to 3% APRNs, 9% RNs, 17% LPNs, and 22% MAs. Those who reported no consistent smoking-cessation service delivery were more likely to be RNs, LPNs, or MAs, currently smoke, and work more hours. They were less likely to consider patients receptive to cessation messages, to consider themselves qualified to counsel on smoking, or to work in clinics that had smoking-cessation guidelines or system prompts such as chart reminders. CONCLUSIONS: Smoking-cessation service delivery may be enhanced if educational offerings, system changes, and training include all clinical staff members.
Adult↗
Improving completion of advance directives in the primary care setting: a randomized controlled trial.
BACKGROUND: Since 1991, hospitals have asked patients whether they have advance directives, but few patients complete these documents. We assessed two simple interventions to improve completion of advance directives among elderly or chronically ill outpatients. METHODS: We conducted a cluster randomized controlled trial involving 1079 patients from five general medicine clinics that were affiliated with an academic medical center. Patients were either > or =70 years of age or > or =50 years old with a chronic illness. The study comprised three arms: physician reminders recommending documentation of advance directives, physician reminders plus mailing advance directives to patients together with educational literature, or neither intervention (control). The main outcome measure was completion of an advance directive. RESULTS: After 28 weeks, 1.5% (5/332) of patients in the physician reminder group, 14% (38/277) in the physician reminder plus patient mailing group, and 1.8% (5/286) in the control group had completed advance directives. In multivariate analyses, patients in the physician reminder plus patient mailing group were much more likely than controls to have completed advance directives (odds ratio [OR] = 5.9; 95% confidence interval [CI]: 1.5 to 22), whereas patients in the physician reminder-only group were no more likely than controls to have completed advance directives (OR = 0.88; 95% CI: 0.21 to 3.7). CONCLUSION: Mailing health care proxy and living will forms and literature to patients before an appointment at which their physicians received a reminder about advance directives yielded a small but significant improvement in completion of these documents. A physician reminder alone did not have an effect.
Adult↗
Differences in antibiotic prescribing among physicians, residents, and nonphysician clinicians.
PURPOSE: State legislatures have increased the prescribing capabilities of nurse practitioners and physician assistants and broadened the scope of their practice roles. To determine the impact of these changes, we compared outpatient antibiotic prescribing by practicing physicians, nonphysician clinicians, and resident physicians. METHODS: Using the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), we conducted a cross-sectional study of patients >/=18 years of age receiving care in 3 outpatient settings: office practices, hospital practices, and emergency departments, 1995-2000. We measured the proportion of all visits and visits for respiratory diagnoses where antibiotics are rarely indicated in which an antibiotic was prescribed by practitioner type. RESULTS: For all patient visits, nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians for visits in office practices (26.3% vs 16.2%), emergency departments (23.8% vs 18.2%), and hospital clinics (25.2% vs 14.6%). Similarly, for the subset of visits for respiratory conditions where antibiotics are rarely indicated, nonphysician clinicians prescribed antibiotics more often than practicing physicians in office practices (odds ratio [OR] 1.86, 95% confidence intervals [CI]: 1.05 to 3.29), and in hospital practices (OR 1.55, 95% CI: 1.12 to 2.15). In hospital practices, resident physicians had lower prescribing rates than practicing physicians for all visits as well as visits for respiratory conditions where antibiotics are rarely indicated (OR 0.56, 95% CI: 0.36 to 0.86). CONCLUSION: Nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians in outpatient settings, and resident physicians were less likely to prescribe antibiotics. These differences suggest that general educational campaigns to reduce antibiotic prescribing have not reached all providers.
Adult↗
Doctors and the drug industry: reader feedback.
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Conflict of Interest↗
Doctors and the drug industry: reader feedback.
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Conflict of Interest↗
Warfarin prescribing in atrial fibrillation: the impact of physician, patient, and hospital characteristics.
PURPOSE: The study investigated the determinants of warfarin use in patients with atrial fibrillation (AF). METHODS: We assembled a retrospective cohort of community-dwelling elderly patients (aged > or = 66 years) with AF using linked administrative databases. We identified the physicians responsible for the ambulatory care of these patients using physician service claims and compared patients who did and did not have an identifiable provider. For those patients with an identifiable provider, we assessed the association between patient, physician, and hospital factors and warfarin use. RESULTS: Our cohort consisted of 140,185 patients, of whom 116,200 (83%) had an identifiable cardiac provider. Patients without a provider were significantly more likely to have comorbid conditions that increase their risk of warfarin-associated bleeding. After adjustment for clinical factors, patients without a provider were significantly less likely to receive warfarin (odds ratio 0.37, 95% confidence interval: 0.36-0.38). Of patients with providers, 50,551 patients (43.5%) received warfarin within 180 days after hospital discharge. Warfarin use was positively associated with AF-associated stroke risk factors (eg, prior stroke, congestive heart failure) and negatively associated with warfarin-associated bleeding risk factors (eg, history of intracerebral hemorrhage). After controlling for patient and hospital factors, patients cared for by noncardiologist physicians with cardiology consultation were more likely to receive warfarin then patients treated in noncollaborative environments. CONCLUSIONS: Warfarin continues to be substantially underprescribed to patients who are at high risk for AF-associated cardioembolic stroke. Our findings highlight the need for targeted quality improvement interventions and suggest preferred models of AF care involving routine collaboration between cardiologists and other physicians.
Aged↗
Therapeutic ultrasound and fracture healing: a survey of beliefs and practices.
OBJECTIVE: To explore current beliefs among senior physiotherapy (PT) students and orthopedic surgeons on the clinical utility of therapeutic ultrasound for assisting fracture healing. DESIGN: Cross-sectional survey. SETTING: University. PARTICIPANTS: Orthopedic surgeons, senior orthopedic surgery residents, and PT students in their final 6 months of study. INTERVENTIONS: Not applicable. Main outcome measures Percentage of respondents reporting specific perceptions on (1) the role of therapeutic ultrasound in fracture healing, (2) clinical use of therapeutic ultrasound for fracture healing, (3) rationale for not using therapeutic ultrasound for healing fractures, and (4) what constitutes a clinically significant difference in fracture healing time. Between-group comparisons were conducted for survey responses. RESULTS: The response rate was 20 of 22 (90.9%) orthopedic surgeons, 5 of 5 (100%) senior orthopedic residents, and 34 of 50 (68.0%) senior PT students. The majority of senior PT students (58.8%) and orthopedic residents and surgeons (60.0%) surveyed reported the belief that therapeutic ultrasound may help in assisting fracture healing in some cases. However, the majority of respondents do not use this modality (60.0% of surgeons, 88.2% of Senior PT students), with most surgeons (32.0%) citing lack of evidence and most senior PT students (58.8%) indicating lack of availability as the predominant barrier. Thirty-two percent of surgeons felt that ultrasound was contraindicated and harmful to healing fractures, or that it was of no use, and 20.5% of PT students reported the belief that ultrasound was contraindicated and was, or may be, harmful to healing bone. Most orthopedic residents and surgeons (52.0%) reported that a reduction in fracture healing time of 4 weeks would be clinically significant versus senior PT students, the majority of whom (64.7%) indicated that a reduction of 2 weeks would be clinically significant. CONCLUSIONS: Some surgeons and PT students believed that therapeutic ultrasound is contraindicated and harmful to healing bone; however, most believed that therapeutic ultrasound may help in assisting fracture healing, in at least some cases. Current usage of this modality is rare, primarily due to the perceived lack of evidence and lack of availability. Large randomized trials are needed to define further the role of ultrasound in fracture healing.
Attitude of Health Personnel↗