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PubMed2002

Prescription habits of dispensing and non-dispensing doctors in Zimbabwe.

The number of dispensing doctors has increased in the last decade, but the implication of this trend on the quality of health care and drug use is unknown. We present a comparative drug utilization study of 29 dispensing doctors and 28 non-dispensing doctors in Zimbabwe based on standard indicators developed by the World Health Organization. Dispensing doctors prescribed significantly more drugs per patient than non-dispensing doctors (2.3 versus 1.7), injected more patients (28.4% versus 9.5%), and prescribed more antibiotics (0.72 versus 0.54) and mixtures (0.43 versus 0.25) per encounter. Dispensing doctors also spent significantly less time on each encounter (8.7 min versus 13.0 min) than their non-dispensing colleagues. The use of generic name, brand name and essential drugs did not differ significantly between the two groups of practitioners. Multivariate analyses controlling for gender, race, place of education, location of practice and patients seen per day showed that dispensing by doctors was associated with less clinically and economically appropriate prescribing. These findings suggest that the quality of health care--as related to drug use, patient safety and treatment cost--is lower with dispensing doctors than with non-dispensing doctors.

Cohort Studies↗
PubMed1999

Physician attitudes, self-estimated performance and actual compliance with locally peer-defined quality evaluation criteria.

BACKGROUND: Physicians' agreement with quality evaluation criteria, and estimates of their own and their colleagues' compliance with these criteria were compared with actual compliance. METHODS: Physicians practicing in 10 health centers in Spain defined 13 quality evaluation criteria for two patient conditions (upper respiratory infections and high serum cholesterol). Compliance with criteria was measured by an external team, using random samples of medical records stratified by condition in each health center (n= 1,000). Concurrently, physicians were surveyed regarding agreement with the criteria, and were asked to estimate their own and their health center's rate of compliance with these criteria. RESULTS: Agreement ratings varied from 5.9 to 9.1 on a 10-point scale. Actual compliance rates ranged from 1.8 to 91.7% of records. Agreement correlated significantly with self-reported compliance but not with actual compliance. Estimates of one's own and one's health center compliance were positive and significantly correlated for all criteria, but were significantly higher for oneself than for one's health center for six of 13 criteria. CONCLUSIONS: Wide variation in physicians' agreement on quality criteria and in actual performance reveal a lack of clear guidelines. Agreement on criteria did not always translate into compliance with criteria. Physicians tended to rate their own performance as better than the average of their peers, suggesting that aggregate data may not influence physicians to change. Self-estimate of one's own or one's colleagues performance is not a good proxy for actual performance so that peer ratings are of dubious value for performance appraisal.

Attitude of Health Personnel↗
PubMed1990

The quality of health care: the practical clinical view.

Quality assurance techniques involving review of charts and performance have been pursued for many years. The establishment of conformance standards, as well as other aspects of QA considered static and non-dynamic, have been subjected to critical analysis by quality workers pursuing a program of total and continuous quality improvement. These new concepts have evolved from a study of industrial methods which have produced perfect products by a process of progressive incremental improvement. The concept of the "bad apple" (which spoils the barrel) has been disparaged by the new quality improvement workers. The contention that deletion of the "bad apple" is a useless procedure is discussed and refuted. The difference between the "rotten apple" (venal or incompetent physician) and the "bad apple" (careless or aggressive physician) is cited. The importance of the physician in the quality process and failure of the quality literature to get physicians involved are discussed. Improvement of physician performance will require changes in basic educational training rather than attempting to improve current performance by rules and standards. In some countries the problem of poor access to the health system by millions of people is at this time a considerably greater problem than lack of quality within the health system. This may be an area toward which quality workers should direct their attentions.

Clinical Competence↗
PubMed1995

Role of prophylactic antibiotics in the prevention of late infection of prosthetic joints. Results of a questionnaire and review of the literature.

A postal survey has revealed wide variation in attitudes towards the need for prophylactic antibiotics in patients with implants who develop intercurrent infections, or who undergo surgical procedures. The available evidence is insufficient to reach any firm conclusions, however any patient who has an implant should receive swift treatment for intercurrent infections.

Anti-Bacterial Agents↗
PubMed2003

Evaluation and treatment of acute bronchitis at an academic teaching clinic.

BACKGROUND: Randomized controlled trials have demonstrated that antibiotics provide no benefit for acute bronchitis, yet 55 to 90% of patients who receive this diagnosis are treated with antibiotics. Given substantial data against antibiotics for acute bronchitis, it could be expected that physicians at academic teaching institutions would be less likely to prescribe antibiotics. However, limited data of antibiotic use for acute bronchitis in this setting has been published. METHODS: Charts of patients seen between January 1 and October 25, 2000, who received an ICD-9 diagnosis of acute bronchitis or upper respiratory infection (URI) at the University of Virginia internal medicine clinic were reviewed. Patients were excluded if they had no cough, chronic obstructive pulmonary disease, symptoms for > or = 3 weeks, or antibiotics for another reason. RESULTS: Of the 160 patients included in this study, 105 (66%) received an antibiotic. Multivariate analysis revealed that patients with increasing age (P = 0.002), purulent cough (P = 0.003), abnormal exam (P = 0.003), and comorbidities (P = 0.03) were most likely to receive an antibiotic. Smoking, duration of symptoms, gender, and race did not predict antibiotic use (P > 0.05). Macrolides accounted for 68% of antibiotics. Twenty-two (14%) of all patients received a chest radiograph and 72 (45%) received an inhaler. Of those who had chest radiographs negative for signs of infection, 76% received an antibiotic. CONCLUSION: In our teaching clinic, antibiotics were overused, whereas chest radiographs and inhalers were underused for the evaluation and treatment of acute bronchitis. Recently published guidelines will help curb use of antibiotics, but a more intensive intervention, including physician and patient education is probably necessary.

Acute Disease↗
PubMed1995

Professional competencies in the changing health care system: physicians' views on the importance and adequacy of formal training in medical school.

PURPOSE: To examine physicians' attitudes toward 16 competencies deemed essential to the effective practice of medicine in the changing health care system. METHOD: In early 1991 a telephone survey was conducted of 300 physicians from random samples selected as representative of the physician population in the continental United States. The physicians were categorized as general practitioners, surgery specialists, and other specialists, and as belonging to the graduation cohorts of 1960-1969, 1970-1979, and 1980-1989. The physicians were asked to rate (1) the importance of formal undergraduate training in each of 16 competencies and (2) the adequacy of their own undergraduate training in the competencies (these ratings are reported only for the 87 physicians in the 1980-1989 cohort). The competencies were derived from the skills, attitudes, and behaviors defined by the Pew Health Professions Commission as necessary for the nation's health care practitioners to meet society's evolving health care needs. RESULTS: Fifty percent or more of the physicians thought that 12 of the 16 competencies were "very important" to include in undergraduate training. Over 75% thought that it was "very important" to include the five competencies involving skills traditionally valued in medical practice: diagnosis and treatment, effective communication with patients, problem solving, lifelong learning, and counseling on medical ethics. More than 50% thought that undergraduate training was "very important" in some competencies that reflect the changing dynamics of medicine and care delivery over the past ten years: health promotion and preventive medicine, involvement of patient and family in care, management of large volumes of information, appropriate use of technology, working on a team with other professionals, and consideration of cost in clinical decision making. In rating their own training, over 50% felt well prepared (ratings of "excellent" or "good") in the five traditional competencies and, in addition, in their abilities to promote health, to manage large volumes of information, to work in teams, to understand and respond to diverse cultures, and to expand access to care. However, a majority felt that their training was only "fair" or "poor" regarding the involvement of patients and their families, evaluation of the appropriateness of costly technology, consideration of cost implications in their decision making, and understanding and supporting the community's role in health care. Forty percent or more felt poorly prepared to work in managed care settings or to accommodate increasing external scrutiny. CONCLUSION: The physicians validated the traditional strengths of medical schools, but revealed curricular weaknesses in the teaching of competencies proposed as important for the emerging health care system, especially in the managed care environment.

Attitude of Health Personnel↗
PubMed2002

How physicians feel about assisting female victims of intimate-partner violence.

PURPOSE: To assess the feelings of physicians about assisting female victims of intimate-partner violence (IPV), and to examine factors related to positive and negative feelings about assisting victims of IPV. METHOD: In 1998, a total site sample of 150 physicians practicing in a large general hospital in the area of Virginia Beach, Virginia, was surveyed by questionnaire via the mail. Four specialties were represented: emergency medicine, family practice, obstetrics-gynecology, and psychiatry. The questionnaire asked about medical training and training in assisting victims of IPV. The physicians' feelings about working with victims of IPV were measured on a nine-item, five-point semantic differential scale. RESULTS: A total of 76 physicians responded to the questionnaire (response rate = 51%). Only a minority (11%) had overall positive feeling scores about assisting victims of IPV. While most physicians reported that it was "significant work," the great majority also felt that it was difficult, low-paying, and stressful. Training in assisting victims of IPV, in medical school or afterwards, did not appear to influence feelings about assisting victims of IPV. However, physicians who were white and who were married (the majority of the respondents) were significantly more likely than the other respondents to feel negatively about providing services to victims of IPV. CONCLUSION: Graduate medical education and training programs need to address the association of negative feelings with helping women harmed by IPV, because these feelings may interfere with the appropriate screening, referral, and treatment of these victims.

Adult↗
PubMed2003

Identification of physician and patient attributes that influence the likelihood of screening for intimate partner violence.

PURPOSE: Effective assessment of intimate partner violence (IPV) demands that everyone at risk be screened. To identify potential barriers, paper-and-pencil case scenarios identified possible practitioner and patient attributes that influence IPV screening. METHOD: First-year residents responded to one of four short written scenarios describing a divorced female patient with nonlocalized abdominal pain; variables were patient's age and abdominal bruising. Residents rated their likelihood of screening for IPV and seven other screening tasks and self-assessed their competence in performing each task. Regression analyses assessed the influence of resident and patient characteristics on screening likelihood. RESULTS: Patient bruising, younger patient age, and resident self-assessed competence best predicted IPV screening. Men were less likely than women to screen for IPV. CONCLUSIONS: Although most physicians receive training on IPV in medical school, barriers to IPV screening still exist. Identifying obstacles to IPV risk-assessment is an essential prerequisite for improving educational programs that promote routine IPV screening.

Age Factors↗
PubMed1999

Forgoing life support in western European intensive care units: the results of an ethical questionnaire.

OBJECTIVE: To determine current views of European intensive care physicians regarding end-of-life decisions. DESIGN: A questionnaire was sent to all physician members of the European Society of Intensive Care Medicine. All questionnaires were anonymous. RESULTS: A total of 504 completed questionnaires from 16 western European countries were analyzed. Eighty-seven percent of the respondents were male. Forty-six percent of respondents said that intensive care unit admissions were generally or commonly affected by bed shortages, particularly in the south. Nevertheless, 73% of units frequently admit patients with no hope of survival, although only 33% of respondents felt that such patients should be admitted. Eighty percent of respondents felt that written do-not-resuscitate orders should be applied, but only 58% did so, with a wide variation according to country (from 8% in Italy to 91% in The Netherlands). Ninety-three percent of physicians sometimes withhold treatment from patients with no hope of a meaningful life, but withdrawal of treatment is less common. Forty percent of respondents said that they would deliberately administer large doses of drugs to such patients until death ensued. Forty-nine percent of respondents involved staff, patients, and family in end-of-life decisions. Forty-five percent of respondents felt that an ethics consultation was useful in such situations. Physicians in the countries of southern Europe were less likely than those in the north to apply do-not-resuscitate orders, withhold treatment, and discuss such issues with the patients. However, they were more likely to value the opinion of an ethics consultant. CONCLUSIONS: Intensive care unit admissions are frequently limited by the availability of beds across Europe, particularly in the south and in the United Kingdom, yet 73% of intensivists still admit patients with no hope of survival. When treating patients with no hope of survival, 40% of intensivists will deliberately administer large doses of drugs until death ensues. There are interesting differences between what a physician actually does and what he or she believes should be done with regard to various ethical questions. Important differences in attitudes also exist between European countries.

Adult↗
PubMedDate not supplied

Debiasing effects of education about appropriate antibiotic use on consumers' preferences for physicians.

A major goal of this research was to identify an antibiotic education intervention that would increase young adult consumers' preference for physicians who do not unnecessarily prescribe antibiotics for simple acute upper respiratory infections (URIs). Results clearly showed that consumers who read the CDC brochure entitled, "A New Threat to Your Health: Antibiotic Resistance" significantly preferred the physician who would not prescribe antibiotics for a URI on Day 3. They also inferred that this physician had significantly greater ability than the physician who would prescribe antibiotics. In contrast, consumers who did not read the CDC brochure significantly preferred the physician who would prescribe antibiotics for a URI on Day 3. They also inferred that this physician had significantly greater ability and greater concern for patients than the physician who would not prescribe antibiotics. Thus, consumers with low knowledge exhibited a treatment bias and preferred physicians who provided more treatment, and consumer education successfully reversed the treatment bias.

Consumer Behavior↗
PubMed1996

Managing space for managed care: the challenge for a multispecialty group practice.

A project that began as an architectural study to determine space requirements and remedy space deficiencies for an academic medical center's faculty multispecialty group practice led to development of an analytical methodology for assessing real space needs and viable options for solutions in the context of the group's operational policies, physician practice patterns, and business goals. Major facility investments for new or renovated construction demand significant capital expenditure, which can severely affect a group's ability to complete as a financially viable player in a marketplace environment of increasingly competitive managed care delivery systems. The methodology created during this project helped the group practice to understand how they could optimize the use of existing space, minimize capital costs, and provide flexibility for future developments.

Academic Medical Centers↗
PubMed1999

The future of physician profiling.

Although enthusiasm for physician profiling dates back to the origins of scientific medicine, the track record of profiling as an intervention is not strong. Profiling appears to be most valuable for simple interventions and processes, but its acceptance, usefulness, and impact will be influenced by future trends. Health care organizations will continue to be complex, and multiple overlapping profiles will be the norm. Technology will advance, but concerns over privacy and confidentiality will influence the social, political, and regulatory approaches to profiling. Public sector purchasers and consumers will increasingly demand profiling, but data will continue to lack the ability to interpret complex profiling data. Medical practice will increasingly accept profiling as part of ongoing quality improvement efforts, but profiling may become focused on key processes, not outcomes. Statistical, cognitive, and epistemological challenges to profiling will remain, and profiling may simultaneously become more complex and more simplified with the rise of information brokers. Greater attention to the human side of profiling will enhance its effectiveness.

Data Collection↗