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PubMedDate not supplied

The decision systems group: creating a framework for decision making.

The Decision Systems Group is pursuing a vision in which every available medical resource can be brought together at the point of need. The DSG focuses on the components and tools in specific areas as well as on the models, approaches, and infrastructure that make this type of integration possible. Its academic mission is to train individuals with dual expertise: those who understand and appreciate the issues involved in developing and validating a method or technique, plus the issues of deployment, operation, and interaction in practical environments. Ultimately, the application of this vision can only serve to enhance the current level of healthcare.

Boston↗
PubMed1993

Professional satisfaction and dissatisfaction of family physicians.

BACKGROUND: Physicians' satisfaction with their professional life influences the quality of patient care they provide and helps to determine the number and type of students attracted to the various fields of medicine. In this study, we sought to delineate areas of satisfaction and dissatisfaction among family physicians. METHODS: A self-administered questionnaire was sent to all physicians in the state of Pennsylvania who were included in the 1990 directory of the American Board of Family Practice (N = 1944). RESULTS: Completed questionnaires were received from 1066 family physicians in full-time practice. Sixty-five percent were satisfied with their professional lives. Patient relationships, a sense of clinical competence, and their relationships with their partners were among the most satisfying aspects of practice for all family physicians. Problems identified included regulations by third-party payers and government agencies and the large amount of paperwork encountered in practice. There were significant (P < .001) differences in satisfaction between physicians in different practice arrangements. Significant differences between practice types were also found in the degree of dissatisfaction with third-party payers and government agencies, paperwork, isolation from other physicians, and the threat of a malpractice suit. CONCLUSIONS: Almost two thirds of family physicians are satisfied with their general professional lives. Conversely, one third are not. Clear areas of satisfaction and dissatisfaction have been defined for family physicians in general as well as for family physicians in various practice environments. This information may be useful in the development of policy to structure a medical system that meets the needs of both patients and physicians.

Adult↗
PubMedDate not supplied

Characteristics of patient visits to nurse practitioners in hospital outpatient departments.

Nurse practitioners (NPs) are the largest and the fastest growing groups among nonphysician practitioners in the United States. However, there has been lack of studies on the supply, demand, and use of nurse practitioners in hospital outpatient departments (OPDs) across the nation. Using the National Hospital Ambulatory Medical Care Survey (1997-2000), this study describes patient visits to NPs in general medicine, pediatrics, and obstetrics/gynecology clinics in hospitals across the nation. The percentage of patient visits involving NPs increased from 5.9 percent in 1997 to 7.3 percent in 2000. NPs have greater roles in hospital OPDs in nonmetropolitan areas than in metropolitan areas. Regional difference in patient visits to NPs supports the relationship between the practice environment and the use of NPs. As expected, NPs continue to serve the health care needs of women and children in hospital OPDs. Of all OPD visits with a NP service, NPs saw patients with no presence of a physician in 82 percent of these visits. As the role of the NP evolves in the U.S. health care delivery system, further studies on the clinical practice of NPs in hospital OPDs can help evaluate the impact of NPs in providing quality of patient care at minimum cost.

Diagnosis-Related Groups↗
PubMedDate not supplied

Guidelines for client selection in the home birth midwifery practice.

Numerous studies have documented the safety of planned home birth; yet, few have identified specific criteria for selection of the home birth candidate. Home birth midwifery practice achieves successful outcomes by appropriate evaluation of medical and obstetric risk factors, as well as an ongoing evaluation and development of the client's psychosocial resources and the midwife-client relationship. Relevant medical and obstetric factors include significant medical illnesses, antenatal course, smoking history, commitment to breastfeeding, and the woman's nutritional profile. Social and environmental factors include the need for a stable birthing environment, practical means for hospital transfer, and the presence of loving support for the client during and after delivery. The client's psychological preparedness is a critical variable that may affect the ability to deliver in the home setting without analgesia or labor augmentation. Active participation in prenatal care, preparation of the home and family members, and a realistic attitude regarding the risks, benefits, and potential complications of planned home delivery are all components of this preparedness. Because midwifery practice promotes midwife-client rapport by careful attention to both medical and psychosocial issues during prenatal care, this relationship is itself an important predictor of the client's suitability for home birth. The quality of midwife-client interactions may influence not only the decision to plan a home birth but the indications for hospital transfer should problems arise. In this article, existing literature is reviewed and criteria are proposed for selecting home birth candidates within the American midwifery practice setting.

Female↗
PubMed2001

Physician gender and psychosocial care for children: attitudes, practice characteristics, identification, and treatment.

OBJECTIVE: To examine differences by physician gender in the identification and treatment of childhood psychosocial problems. DESIGN: Survey of patients (n = 19,963) and physicians (n = 366) in primary care offices in 2 large, practice-based research networks. Multivariate regressions were used to control for patient, physician, and visit characteristics, with a correction for the clustered sample. SUBJECTS: Children ages 4 to 15 years seen consecutively for nonemergent care. MEASURES: Physician report of attitudes, training, practice factors, and identification and treatment of psychosocial problems. Parental report of demographics and behavioral symptoms. RESULTS: Compared with male physicians, female physicians were less likely to view care for psychosocial problems as burdensome. They were more likely to see children who were female, younger, black or Hispanic, in single-parent households, enrolled in public or managed health plans, and with physical health limitations. Children seen by male physicians had higher symptom counts. Male physicians were more likely to report having primary care responsibility for their patient and that parents agree with their care plan. Female physicians spent more time with patients. After controlling for these differences, female physicians did not differ from male physicians in identification or treatment of childhood psychosocial problems. CONCLUSIONS: Male and female physicians see different kinds of children for different visit purposes and have different kinds of relationships with their patients. After controlling for these factors, management of childhood psychosocial problems does not differ by physician gender. Improving management of psychosocial conditions depends on identifying modifiable factors that affect diagnosis and treatment; our work suggests that characteristics of the practice environment, physician-patient relationship, and patient self-selection deserve more research.

Adolescent↗
PubMed2006

Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: a randomized controlled trial.

CONTEXT: Most older adults with dementia will be cared for by primary care physicians, but the primary care practice environment presents important challenges to providing quality care. OBJECTIVE: To test the effectiveness of a collaborative care model to improve the quality of care for patients with Alzheimer disease. DESIGN, SETTING, AND PATIENTS: Controlled clinical trial of 153 older adults with Alzheimer disease and their caregivers who were randomized by physician to receive collaborative care management (n = 84) or augmented usual care (n = 69) at primary care practices within 2 US university-affiliated health care systems from January 2002 through August 2004. Eligible patients (identified via screening or medical record) met diagnostic criteria for Alzheimer disease and had a self-identified caregiver. INTERVENTION: Intervention patients received 1 year of care management by an interdisciplinary team led by an advanced practice nurse working with the patient's family caregiver and integrated within primary care. The team used standard protocols to initiate treatment and identify, monitor, and treat behavioral and psychological symptoms of dementia, stressing nonpharmacological management. MAIN OUTCOME MEASURES: Neuropsychiatric Inventory (NPI) administered at baseline and at 6, 12, and 18 months. Secondary outcomes included the Cornell Scale for Depression in Dementia (CSDD), cognition, activities of daily living, resource use, and caregiver's depression severity. RESULTS: Initiated by caregivers' reports, 89% of intervention patients triggered at least 1 protocol for behavioral and psychological symptoms of dementia with a mean of 4 per patient from a total of 8 possible protocols. Intervention patients were more likely to receive cholinesterase inhibitors (79.8% vs 55.1%; P = .002) and antidepressants (45.2% vs 27.5%; P = .03). Intervention patients had significantly fewer behavioral and psychological symptoms of dementia as measured by the total NPI score at 12 months (mean difference, -5.6; P = .01) and at 18 months (mean difference, -5.4; P = .01). Intervention caregivers also reported significant improvements in distress as measured by the caregiver NPI at 12 months; at 18 months, caregivers showed improvement in depression as measured by the Patient Health Questionnaire-9. No group differences were found on the CSDD, cognition, activities of daily living, or on rates of hospitalization, nursing home placement, or death. CONCLUSIONS: Collaborative care for the treatment of Alzheimer disease resulted in significant improvement in the quality of care and in behavioral and psychological symptoms of dementia among primary care patients and their caregivers. These improvements were achieved without significantly increasing the use of antipsychotics or sedative-hypnotics. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00246896.

Activities of Daily Living↗
PubMed1989

Attitudes of some young female bank employees to dentistry.

Structured interviews were undertaken with one hundred 18-30-year-old females, seeking their views on dental care. Almost all regarded their own past experience as affecting their general level of dental anxiety. Over half were anxious about visiting the dentist and almost all of these were anxious before entering the surgery. The Anxious emphasized the negative features in dental care and the practice environment whereas the Non-anxious concentrated on positive features, particularly their relationship with the dentist. Many spontaneously commented that their attitudes had been improved by changing dentists, although some still remained anxious. 'Worst visits' had frequently occurred early in their lives. Appearance was of prime importance; function was ignored. Interviewees believed that visiting the dentist would be eased by lower costs, more convenient hours, better surroundings in the practice and improved techniques to make dentistry more comfortable.

Adolescent↗
PubMed1993

Organizing for communication and integration.

Using the departmental philosophy as its foundation, an integrated organizational model was designed for a nursing department. This patient-centered model was implemented to streamline operations, focus resources, and provide a professional practice environment for nursing staff. The "molecule" is used as a teaching tool and organizational framework, with applications ranging from orientation of new staff to management of daily operations.

Communication↗
PubMed2001

Process evaluation of a tailored multifaceted approach to changing family physician practice patterns improving preventive care.

BACKGROUND: We conducted a process evaluation of a multifaceted outreach facilitation intervention to document the extent to which the intervention was implemented with fidelity. We also hoped to gain insight into how facilitation worked to improve preventive performance. METHODS: We used 5 data collection tools to evaluate the implementation of the intervention, and a combination of descriptive, quantitative, and qualitative analyses. Triangulation was used to attain a complete understanding of the quality of implementation. Twenty-two intervention practices with a total of 54 physicians participated in a randomized controlled trial that took place in Southwestern Ontario, Canada. The key measures of process were the frequency and time involved to deliver intervention components, the scope of the delivery and the utility of the components, and physician satisfaction with the intervention. RESULTS: Of the 7 components in the intervention model, prevention facilitators (PFs) visited the practice most often to deliver the audit and feedback, consensus building, and reminder system components. All the study practices received preventive performance audit and feedback, achieved consensus on a plan for improvement, and implemented a reminder system. Ninety percent of the practices implemented a customized flow sheet, and 10% used a computerized reminder system. Ninety-five percent of the intervention practices wanted critically appraised evidence for prevention, 82% participated in a workshop with opinion leaders in preventive care, and 100% received patient education materials in a binder. Content analysis of the physician interviews and bivariate analysis of physician self-reported changes between intervention and control group physicians revealed that the audit and feedback, consensus building, and development of reminder systems were the key intervention components. Ninety-five percent of the physicians were either satisfied or very satisfied with the intervention, and 90% would have been willing to have the PF continue working with their practice. CONCLUSIONS: Primary care practices in Ontario can implement significant changes in their practice environments that will improve preventive care activity with the assistance of a facilitator. The main components for creating change are audit and feedback of preventive performance, achieving consensus on a plan for improvement, and implementing a reminder system.

Family Practice↗
PubMedDate not supplied

Moving mountains together: strategic community leadership and systems change.

Traditional leadership practice frameworks to guide systems change often fall short in today's practice environment. Reclaiming Futures is a national initiative to create an integrated, comprehensive, seamless system of care for teens with substance abuse problems involved in juvenile justice. It uses leadership and systems reform strategies to improve public health institutions. The premise is that interruption of the destructive cycle of drugs and delinquency can only be attained through the cultivation of shared strategic leadership. This article presents the limitations of traditional practice frameworks of leadership, describes the theory of this new approach to leadership development, and clarifies collaborative leadership and system change. The article includes an example of the framework in action, a discussion of lessons learned, and recommendations for community leadership development initiatives.

Adolescent↗
PubMed1998

A comparison of temperature measurements using three ear thermometers.

Following anecdotal and research-based reports of inaccuracies encountered with the use of ear thermometers in patient care settings, this two-phase study was designed to compare the accuracy of three ear thermometers when used in a multioperator environment. The within-subject variation (limits of agreement) in ear temperature measurements obtained with the three ear thermometers in a multioperator condition by using an oral temperature reference standard ranged from +/- 1.25 degrees F to 1.85 degrees F. In multioperator, multisubject patient care environments using a pulmonary artery catheter core temperature as the reference standard, the limits of agreement for ear temperature measurements obtained with the three different ear thermometers ranged from +/- 2.19 degrees F to 2.85 degrees F. These results suggest that there is substantial variation in ear measurements and raise questions about the use of ear thermometers when there are multiple personnel taking temperatures, as occurs in hospital-based clinical practice environments. Handedness of the operator, position of the patient, and the ear used for measurement did not produce clinically significant variability in ear temperature measurements.

Adult↗
PubMed1990

Physician satisfaction under the Ontario Health Insurance Plan.

To determine the level of professional satisfaction experienced by physicians practicing in Ontario, Canada, a probability sample of 1,028 physicians was surveyed; 69% responded. The majority of Ontario doctors were at least moderately satisfied with each of 16 aspects of their work, and the percentage who were dissatisfied exceeded 15% for only four aspects. Factor analysis suggested the presence of four underlying satisfaction facets: satisfaction with quality of care, with the rewards of practice, with patients, and with the practice environment. Multivariate regression analysis supported the validity of the four-facet model and demonstrated a consistent association between lower satisfaction and younger age, lower income, and the perception that it is difficult to obtain fair reimbursement for medical services (P less than 0.05). Least satisfied physicians were most likely to have participated in the June, 1986 Ontario doctors' strike (P less than 0.001). Despite some misgivings, the majority of physicians practicing under the Ontario Health Insurance Plan in 1987 were satisfied with their professional lives. They were least satisfied with their ability to make administrative decisions and to manipulate the system for the benefit of their patients. Policymakers should be cognizant of the effects various strategies may have upon physician satisfaction as they consider new approaches to health care organization.

Adult↗
PubMed1999

Comprehensive education plan for a discrete stroke population: needs, considerations, and gaps.

The patient population which has the most to gain from comprehensive stroke education is the one which has experienced a stroke with minimal deficit and carries an increased risk for experiencing a second more severe stroke. This is the patient population the author selected, yet little published information is available. Given that in Canada stroke carries the third highest rate of mortality and the highest risk of morbidity there is a role for an advanced practice nurse to develop and deliver a comprehensive stroke education program for this population. This is of special significance given the understanding that stroke is considered to be one of the most preventable diseases. The practice environment for this patient population is shifting out of the hospital and into the community. The learning needs and issues as well as the identification of appropriate patient focussed outcomes needs to be examined. A comprehensive plan for the delivery of patient focussed education which includes content, setting, and timing for this target population needs to be developed, piloted and reported on. Nurses have been identified as appropriate for delivering patient education. An advanced practice nurse is poised to address this need and develop a model for others to incorporate in their practice.

Humans↗
PubMed1999

Quality beyond compliance.

The service sector within the biopharmaceutical industry has experienced phenomenal growth over the past decade. In the highly regulated Good Laboratory Practices environment, the need for timely, high-quality service, accurate results, and on-time deliverables becomes paramount for the success and profitability of biopharmaceutical companies. The quality assurance process is a vital component of this drug product-development cycle and ensures compliance to the highest domestic and international regulatory standards. Quality-assurance professionals historically have held the role of independent auditors of the processes, who certify that results meet current standards of practice. Covance, a contract research organization that includes Good Laboratory Practices laboratories, reorganized and expanded the functional responsibilities of its quality assurance team in 1997. Auditors and quality assurance professionals have assumed roles beyond traditional compliance auditing and are forging new leadership and mentoring roles as process-improvement specialists. The results have been tangible, measurable benefits for clients and the Covance organization. This article provides an overview of this cultural change and the processes put in place to improve efficiency, productivity, and customer and employee satisfaction.

Consumer Behavior↗
PubMed2003

Five-year results of a merger between vascular surgeons and interventional radiologists in a university medical center.

OBJECTIVES: We examined economic and practice trends after 5 years of a merger between vascular surgeons and interventional radiologists. METHODS: In 1998 a merger between the Division of Vascular Surgery and the Section of Interventional Radiology at the University of Rochester established the Center for Vascular Disease (CVD). Business activity was administered from the offices of the vascular surgeons. RESULTS: In 1998 the CVD included five vascular surgeons and three interventional radiologists, who generated a total income of $5,789,311 US dollars (34% from vascular surgeons, 24% from interventional radiologists, 42% from vascular laboratories). Vascular surgeon participation in endoluminal therapy was limited to repair of abdominal aortic aneurysms (AAAs). Income was derived from 1011 major vascular procedures, 10,510 catheter-based procedures in 3286 patients, and 1 inpatient and 3 outpatient vascular laboratory tests. In 2002 there were six vascular surgeons (five, full-time equivalent) and four interventional radiologists, and total income was $6,550,463 US dollars despite significant reductions in unit value reimbursement over the 5 years, a 4% reduction in the number of major vascular procedures, and a 13% reduction in income from vascular laboratories. In 2002 the number of endoluminal procedures increased to 16,026 in 7131 patients, and contributions to CVD income increased from 24% in 1998 to 31% in 2002. Three of the six vascular surgeons performed endoluminal procedures in 634 patients in 2002, compared with none in 1998. CONCLUSIONS: Gross revenues increased in a declining reimbursement and conventional practice environment, because of the increased number of endoluminal procedures, in part provided by vascular surgeons. The implications of these data should be considered by those responsible for training vascular surgeons.

Academic Medical Centers↗
PubMed2005

Physician recommendations for follow-up of positive fecal occult blood tests.

Following a positive fecal occult blood test (FOBT), physician recommendation of complete diagnostic evaluation (CDE) is an important first step to ensure identification and treatment of preinvasive or invasive colorectal cancer. Physicians may not recommend CDE, however, potentially compromising the effectiveness of colorectal cancer screening programs and the quality of care for individual patients. The authors used a theoretical model of health behavior and two national physician samples to explore factors associated with recommendations for CDE. Overall, 63 percent of the sample of physicians providing primary care and 76 percent of the gastroenterologist and general surgeon sample reported recommending CDE. Variables representing the theoretical model constructs of physician background, experience, and practice patterns; practice environment; physician psychosocial representations; and patient characteristics were significantly associated with recommendations of CDE. Development of interventions to improve recommendations of CDE is an important area for future research.

Colorectal Neoplasms↗
PubMed2005

Promoting effective social work policy in end-of-life and palliative care.

Policy developments in the health care arena in general, and in end-of-life and palliative care in particular, strongly influence the practice environment for the delivery of hospice and palliative care services and the diverse roles of social work practitioners. This article analyzes policy developments in two crucial areas-ethics and law and disenfranchisement and health disparities. It focuses on the recent social work literature and other key sources and provides recommendations to promote the roles of social workers in ethics consultation, public policy, and advocacy and to integrate better the perspectives and concerns of diverse communities into palliative care practice, education, and policy.

Cultural Diversity↗