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PubMed2004

Safe administration of contrast media: what do physicians know?

BACKGROUND: Radiographic contrast media (RCM) are among the most commonly used materials in medicine. Nevertheless, there seems to be a little agreement between current practice and accepted guidelines regarding their adverse reactions, the indications for premedication, and use of low-osmolar contrast agents (LOCAs). Misconceptions exist regarding the relationship between hypersensitivity to RCM and foods and medications that contain iodine. OBJECTIVE: To evaluate physicians' knowledge, misconceptions, and attitudes regarding the use of RCM and the prevention of their adverse reactions. METHODS: Physicians from university-affiliated general hospitals were asked to complete an anonymous questionnaire on RCM. RESULTS: A total of 157 physicians (45%), including radiologists, internists, pediatricians, surgeons, and primary family physicians, agreed to participate. All physicians demonstrated limited knowledge regarding adverse effects of RCM and the patients who might be at increased risk of developing them. Most physicians were not familiar with accepted guidelines for using premedication and LOCAs. Misconceptions regarding the association between the use of drugs or foods that contain iodine and adverse effects to RCM were common among all physicians. CONCLUSIONS: The level of knowledge about the adverse reactions of RCM among physicians is unsatisfactory, which may result in unwarranted use of expensive LOCAs or premedication in healthy patients. Alternatively, physicians' failure to use these measures when indicated may endanger patients. Despite the lack of association between adverse effects to RCM and safe consumption of iodine-containing substances, physicians continue to harbor these misconceptions. Educational programs that may improve physicians' knowledge are urgently needed.

Anaphylaxis↗
PubMed2004

Computer physician order entry and the real world: we're only humans.

BACKGROUND: Computer physician order entry (CPOE) may have significant benefit to reducing medical errors in the hospital setting. The belief in the promise of CPOE has led organizations such as the Leap Frog Group to advocate for the implementation of CPOE in hospitals to improve patient safety. Human factors, or ergonomics, is the study of the interaction between humans and the systems and tools they use. It is unclear whether human factors principles have been applied to commercially available CPOE systems. CONCLUSIONS: CPOE's true utility for preventing medical errors and harm is largely undetermined. The evidence that exists for error reduction with CPOE is in the setting of "homegrown" systems and not commercially available products. The cases portrayed in the two scenarios described in this article were drawn from actual events to illustrate how failure to attend to human factors and human-centered design can create or facilitate errors and harm. RECOMMENDATIONS FOR ORGANIZATIONS IN IMPLEMENTING, CPOE: Organizations implementing CPOE or considering doing so could evaluate potential systems on the basis of evidence for human-centered design. An organization interested in addressing human factors issues as they relate to CPOE might, for example, familiarize itself with the basics of human factors, usability, and with existing evaluation methods for CPOE; involve the people who do the daily work in the evaluation and selection process; and ask potential vendors how they have addressed human factors in their CPOE systems.

Drug Prescriptions↗
PubMed1991

Physicians' perceptions of consensus reports.

In a pretest-posttest panel survey of 595 eligible Maryland physicians practicing family or general medicine, internal medicine, cardiology, or nephrology, perceptions of consensus reports designed to alter medical practice are examined. On a 7-point scale, physicians reported positive or neutral views of descriptors, most favorably rating credible (mean = 2.25) and reliable (mean = 2.41), and least favorably rating biased (mean = 3.79). In a regression analysis of factors influencing changes in practice behavior congruent with consensus recommendations before and 1 year after the release of a consensus report on hypertension (8), these perceptions were not significant determinants. The strongest predictor of congruent practice behavior a year after the report was published was congruent practice behavior just prior to the report's release, and the second strongest predictor was perceived influence of the report's sources/sponsors.

Attitude of Health Personnel↗
PubMed2005

Highlights of the 2002 Canadian Neurological Society (CNS) manpower survey.

BACKGROUND: The Canadian Neurological Society commissioned a manpower survey in 2002 to assess demographics, distribution, specialty interests, working conditions, job satisfaction and future plans of neurologists across the country. METHODS: A survey was mailed to all known Canadian neurologists (n = 694) on two separate occasions. Further encouragement by telephone contact was undertaken. The response rate was 54%. RESULTS: The mean age of neurologists who responded was 51 years, with 14% being women. Approximately 55% of neurologists were community-based. Seventy-six percent designated a sub-specialty interest. On average, neurologists worked 57 hours per week and the majority had significant "on-call" commitments. Job satisfaction was higher among academic neurologists when compared with community-based neurologists, and greater among men than women. A greater percentage of older neurologists were satisfied with their work than their younger colleagues. Significant attrition in the neurological work force is a major concern, since up to 20% of neurologists reported that they are likely to retire in the next five years and about 15% are likely to reduce their practice. CONCLUSIONS: This survey suggests that substantial concerns are facing Canadian neurology over the next five years. Major efforts to retain existing expertise and enhance residency training will be required to simply maintain the present quality of neurological care in Canada.

Attitude of Health Personnel↗
PubMed1998

Do specialists do it better? The impact of specialization on the processes and outcomes of care for cancer patients.

OBJECTIVE: To assess the impact of specialization on processes and outcomes of care for cancer patients. DATA SOURCE: Papers published in English between 1980 and 1995 and identified through MEDLINE and Embase (MeSH terms: NEOPLASM (exploded), and PHYSICIAN PRACTICE PATTERNS (or DECISION MAKING, ATTITUDE OF HEALTH PERSONNEL, QUALITY OF HEALTH CARE, DELIVERY OF HEALTH CARE, HEALTH EDUCATION or OUTCOME ASSESSMENT HEALTH CARE), or through the reference lists of review articles. STUDY SELECTION: Studies providing information on the association between quality of care indicators for cancer patients and clinician/centre degree of specialization. A total of 47 papers concerning 46 empirical studies were considered. DATA EXTRACTION: For studies using process of care indicators, the proportion of specific procedures performed by specialists and non-specialists was abstracted. For studies using outcome indicators (e.g., mortality), the effect of specialization was quantified in terms of odds ratio (OR) expressing relative reduction in risk of death. The quality of individual studies using process or outcome indicators was assessed according to study design, avoidance of selection bias in patient identification and data analysis, degree of adjustment of the comparison between clinicians/centres with different levels of specialization. DATA SYNTHESIS: Specialized centres/clinicians fared better both when process and outcome indicators were used. While the former varied widely in different studies and their clinical relevance was often questionable, mortality was consistently lower when care was provided by specialized centres/clinicians, with the effect size being greater in smaller studies. For breast cancer, where all the studies were of sufficiently good quality, a pooled estimate of the effect of specialization was performed which showed that specialized cancer care was associated with an 18% (95% CI: 12%-23%) reduction in mortality. CONCLUSIONS: Despite the fact that care provided by specialized centres/clinicians appeared to be better both when assessed in relation to process indicators and to mortality, this evidence should be considered far from conclusive because of major methodological flaws in these studies. Relative to current efforts to promote evidence-based policy-making, this review underscores the limited capability of scientific information to provide reliable guidelines for structuring better health care systems.

Confidence Intervals↗
PubMed1996

A reasoned action approach to physicians' utilization of drug information sources.

PURPOSE: The effects of attitude and subjective norm were investigated on physicians' intention to use seven drug information sources: the PDR, medical textbooks, medical journals/newsletters, pharmaceutical manufacturers' literature, pharmaceutical manufacturers' representatives, other physicians, and pharmacists. The effects of past behavior and practice characteristics were also examined. METHODS: An eight-page mail questionnaire queried health maintenance organization physicians on their intention to use, attitude (emotional response) and subjective norm (colleagues' approval/disapproval) toward use of each source when searching for drug information on a fictitious, new H2 antagonist agent. RESULTS: Responses were received from 54% (108) of the 200 physicians surveyed. Positive attitudes toward use had the greatest influence upon intention to use each of the sources (b > or = .40) (except for pharmacists, for which subjective norm was the most important predictor (b = .31)). Past behavior directly affected intention to use the PDR (b = .27), and pharmaceutical manufacturers' literature (b = .26). The effects of attitude and/or subjective norm on intention to use non-commercial sources of drug information were moderated by the practice characteristics. CONCLUSIONS: These findings suggest that physicians' use of drug information sources is strongly influenced by their attitudes toward use. In addition, the importance of situational contingencies should not be overlooked when investigating the use of drug information sources.

Drug Information Services↗
PubMed1999

Immunization practices and beliefs of physicians in suburban Cook County, Illinois.

This study was conducted to ascertain the vaccination beliefs and practices of physicians who provide care for low income children. Sixty-two (56.9%) of a sample of 109 physicians in suburban Cook County, Illinois responded to a mail survey. A majority of physicians reported a willingness to immunize during well child care, follow-up, and chronic illness visits; yet, a substantial lack of willingness to immunize given certain acute mild illnesses was reported. Twenty-six percent of providers did not routinely identify children who were behind in immunizations and only 16% had completed a chart audit in the past three years. Seventy-four percent were willing to provide all shots needed at a single visit. Misconceptions regarding true contraindications was found among the group. Missed well child visits were identified as the greatest barrier to complete immunization. Improvements in vaccination rates are expected if physicians utilize all types of medical encounters to monitor the immunization status of patients and provide vaccines using only true medical contraindications.

Adult↗
PubMed1997

Do physicians discuss HIV and AIDS with patients? A survey of physician practices.

HIV and AIDS continue to be major concerns to the health care community and the world around them. Preventive efforts and education have been the focus of the fight against AIDS thus far. By the year 2000, 75% of physicians are expected to conduct risk-reduction counseling for patients regularly. Previous studies show that a smaller percentage "routinely" follow this recommendation. The purpose of our study was to assess with what percentage of patients physicians discuss several HIV/ AIDS-related topics, what percentage of their patients are considered at risk for infection, and how comfortable the physicians are with their knowledge level and discussing the subject matter. We sent surveys to the last five graduating classes from St. Louis University School of Medicine and to 169 physician preceptors in the community. The survey asked about patients considered at risk, physician comfort level with HIV/ AIDS, the percentage of patients they discuss various HIV/AIDS topics with, and his or her preparedness for these discussions. Total responses were 464 (53.7%) representing all areas of medicine. Most of the physicians (72.9%) consider 0-25% of their patients at risk for HIV/AIDS. Eighty-one percent claim they are moderately or very comfortable discussing the material with patients and more than 90% feel they have at least adequate knowledge. Most of the respondents discuss the HIV/ AIDS topics with 0-25% of patients. Recent medical school graduates and primary care physicians are more comfortable with HIV/AIDS and discuss the surveyed topics with a higher percentage of patients.

Communication↗
PubMed1997

Evidence-based medicine and public health.

Much of the everyday work of public health professionals is concerned with the implementation of evidence-based medicine (EBM). Is this likely to improve the quality of the health service that patients' receive? In this paper, I argue that EBM is unlikely, by itself, to improve the dimensions of quality as defined by Maxwell (1994). This is because EBM relies on the individual doctor doing the right thing all of the time. Open systems theory is a way of looking at the influences of the environment on individual clinical behaviour. Using this perspective, it is easy to see why EBM will fail to improve patient care dramatically. The environment in which we work is a much bigger influence on us than we care to admit. I use some published examples to look at the way that the environment affects clinical behaviour to the detriment of the overall service quality. As public health professionals, we should be more concerned with the outcome of the service than with the specifics of a particular consultation. In this context, EBM is likely not to be a very useful tool for public health professionals.

Evidence-Based Medicine↗
PubMed2001

Breast reconstruction after mastectomy: a survey of general surgeons in Singapore.

BACKGROUND: Breast cancer is the leading malignancy among women in Singapore. In the West as many as 30% of eligible patients undergo some form of reconstruction, but in Singapore breast reconstruction is not often performed. METHODS: A postal survey of general surgeons in Singapore (response rate of 46%) was conducted to ascertain the factors influencing their decision to refer for reconstruction and the possible concerns they had about reconstruction. RESULTS: Age, anticipated psychosocial morbidity and the need for adjuvant therapy were the most important factors identified. The survey also found that almost 30% of respondents were unsure of whether reconstruction would mask recurrence. Despite this, almost 80% of respondents felt that reconstruction was worth the effort, but 55% (compared to less than 20% in the West) felt that patients did not want reconstruction despite being advised of its availability. CONCLUSION: Lack of information and the perception that patients would not want reconstruction may be important reasons for the low emphasis placed on the role of breast reconstruction in post-mastectomy patients.

Age Factors↗
PubMed1998

Paediatricians: referral rates and speech pathology waiting lists.

OBJECTIVE: This study aimed to examine paediatricians' training in and understanding of communication development and disabilities and their attitudes to speech pathology waiting lists and management practices. The relationship between these factors and referral rates was also investigated. METHODOLOGY: A total of 229 paediatricians registered with the Australian College of Paediatrics participated in the study in November 1996. They answered 15 multiple-choice questions designed to collect demographic information and data pertaining to their training and understanding of communication development and disabilities. The survey also obtained data on referral rates to public and private speech pathology services and on paediatricians' perceptions of speech pathology waiting lists and possible management strategies. RESULTS: Referral rate to public and private speech pathology services was found to be associated with the quality of paediatricians' training in and knowledge of communication development and disabilities. Paediatricians who had regular contact with speech pathologists were also more likely to make more referrals. Waiting lists had a negative influence on referral rate. Treatment rather than assessment waiting lists were preferred. Paediatricians believed the best solution to speech pathology waiting lists was an increase in staffing levels particularly in community health centres. Respondents reported that 1-4 months was an acceptable time to wait for speech pathology care and indicated the order of importance of factors for prioritising children. CONCLUSIONS: The results have important implications for developing best practice models for improving referral processes and access to speech pathology services for children with communication disabilities.

Australia↗
PubMed2002

An updated systematic review of interventions to improve health professionals' management of obesity.

The objective of this article was twofold (1) to determine the existence and effectiveness of interventions to improve health professionals' management of obesity or the organization of care for overweight and obese people; and (2) to update a previous systematic review on this topic with new or additional studies. The study design was a systematic review of intervention studies, undertaken according to standard methods developed by the Cochrane Effective Practice and Organization of Care (EPOC) Group. Participants were trained health care professionals and overweight and obese patients. The measurements were objective measures of health professionals' practice and behaviours, and patient outcomes including satisfaction, behaviour, psychological factors, disease status, risk factors and measures of body weight, fat, or body mass index (BMI). Twelve studies were included in the original review. A further six were included in this update. Six of the 18 studies were randomized controlled trials of health professional-oriented interventions (such as the use of reminders and training) and one was a controlled before-and-after study to improve collaboration between a hospital clinic and general practitioners (GPs). Ten randomized controlled trials and two controlled clinical trials of interventions comparing either the deliverer of weight-loss interventions or the setting of the delivery of the intervention, were identified. The heterogeneity and generally limited quality of identified studies make it difficult to provide recommendations for improving health professionals' obesity management. To conclude, at present, there are few solid leads about improving obesity management, although reminder systems, brief training interventions, shared care, inpatient care and dietitian-led treatments may all be worth further investigation. Therefore, decisions for the improvement of provision of services must be based on the existing evidence on interventions with patients and good clinical judgement. Further research is needed to identify cost-effective strategies for improving the management of obesity. A full version of this review (including detailed descriptions of the included studies and their methodological quality, and results and excluded studies tables) is available in the Cochrane Library. The Cochrane Library is a database of systematic review and other evidence on the effects of health care, continuously updated as new information emerges. It is available on CD ROM from Update Software. For further information see: http://www.update-software.com/cochrane.

Clinical Competence↗
PubMed2003

Epidemiology of vascular access in the Australian hemodialysis population.

BACKGROUND: A number of demographic and comorbid factors have been demonstrated to be associated with the placement of arteriovenous grafts (AVG) and central venous catheters (CVC) as opposed to native arteriovenous fistulas (AVF). However, no data are available regarding these factors in a hemodialysis population where AVF utilization is high. METHODS: All adult patients on hemodialysis on September 30, 2001 in Australia were included in the study. Vascular access was recorded as AVF, AVG, or CVC. Patients were separated into incident (<150 days since first dialysis) and prevalent cohorts (> or =150 days). Multinomial logistic regression was used to assess factors associated with AVG and CVC use. RESULTS: Of the 4968 patients who were studied, 877(17%) were classed as incident and the remainder prevalent. AVF were present in 61% versus 77%, AVG were present in 11% versus 19%, and CVC were present in 28% versus 4% in the incident and prevalent cohorts, respectively (all P < 0.001). After adjustment for confounding factors, age and female gender were associated with an increased frequency of AVG in both cohorts. In addition, type I diabetes mellitus was associated with increased frequency of AVG use in the incident cohort, whereas body mass index (BMI) > or =30 kg/m2 and peripheral vascular and cerebrovascular disease were significant in the prevalent group. For CVC, female gender, type I and II diabetes mellitus and late referral were associated with increased frequency in the incident cohort, while females, cigarette smoking, and peripheral vascular disease were predictive in the prevalent group. Significant variations in access type were also seen depending on geographic location. CONCLUSION: Certain patient characteristics such as age and female gender, but not type II diabetes mellitus, remain significantly associated with AVG and catheter use despite the high prevalence of AVF use in Australia. However, the significant variation in risk by geographic location suggests more attention needs to be paid to physician practice patterns to increase AVF utilization rates.

Adult↗