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PubMed2002

Managing managed care: the enabling role of IS/IT.

In their conceptualization of the principal/agent relationship, Jensen and Meckling were not referring to a knowledge worker (KM) agent. Agency theory is extended to the context of a KW agent to identify a key role for IS/IT in facilitating the monitoring function. To test this, the dynamics of a critical principal-KW agent relationship in the health-care industry are investigated It is demonstrated that IS/IT goes beyond just alleviating the agency problem to enabling the KW agent to perform "self-monitoring". The results are significant for health care, agency relationships and the use of IS/IT with knowledge workers.

Faculty↗
PubMed2004

After the euphoria: HIV medical technologies from the perspective of their prescribers.

This paper focuses on the relationship of HIV medical technologies to current styles of medical practice and highlights issues posed by the technologies for those working and/or living with HIV. The paper examines HIV anti-retroviral combination therapies and associated tests from the perspective of their prescribers. The prescribers were interviewed during the later part of 2002 at three London HIV clinics. Their comments, considered in light of other recent studies in the field, suggest that current therapies are part of a transitional phase in the epidemic which informs the identification and negotiation of known risks and uncertainty. An undetermined but extended life expectancy, afforded by anti-retroviral therapies, is understood against risk of iatrogenic diseases and/or viral drug resistance. The tension arising in this situation of unwanted and even uncertain phenomena poses ethical dilemmas and affects doctor/patient relations. Indeed, it also contributes to a reconfiguring of the lived experience of managing HIV. While the new technologies have offered considerable advances in the medical management of HIV, they are altering the nature of HIV medicine both materially and socially. The scenario is further complicated by the uneven allocation of resources and different patient health and disease states. The heterogeneity of resources, disease states and technological effects points to the need for ongoing and extended evaluation as the relationship between these and the everyday practice of medicine continues to change.

Antiretroviral Therapy, Highly Active↗
PubMed2004

Rising trends in cesarean section rates in Egypt.

BACKGROUND: Cesarean section rates have been increasing worldwide, but little research exists on trends of cesarean section delivery for any country in the Arab world. The purpose of this study was to document recent levels and trends of cesarean section rates in Egypt, and to estimate trends in cesarean section by type of hospital from three population-based national surveys. METHODS: This descriptive study used merged data files from three nationally representative samples of ever-married women aged 15 to 49 years. RESULTS: A significant rise in cesarean deliveries occurred for all births, from a low of 4.6 percent in 1992 to 10.3 percent in 2000. However, hospital-based cesarean deliveries were much higher in 1987-1988 (13.9%), increasing to 22.0 percent in 1999-2000. Although the cesarean section rate was slightly higher in private hospitals, the rate also increased consistently in public hospitals. CONCLUSIONS: The high and unprecedented increase in cesarean section rates reported in this study may be partly due to cesarean sections that are not medically indicated, and suggest that physician practice patterns, financial incentives or other profitability factors, and patient preferences should be explored.

Adult↗
PubMed1991

Profile of doctors who participate in continuing medical education in Malaysia.

A random survey of 400 doctors was carried out over a period of 3 months to determine the factors that would facilitate or inhibit the participation of doctors in continuing medical education (CME) in Malaysia. Regular participation in CME was defined as participation in any activity (self-directed reading or attending organized activities) at least once a month during the past year. It was found that 78% of doctors regularly participated in CME. Working in a hospital environment and being members of the Malaysian Medical Association and at least one specialty organization appeared to be important facilitatory factors in CME participation. These doctors also read the local medical journals regularly and subscribed to other journals. In addition, they were more likely to possess postgraduate qualifications and would have teaching, research, diagnostic or clinical responsibilities as major components of their work. They were more likely to practise in the big cities and would tend to be active in at least one voluntary or social organization. If they were in the Government sector, they were more likely to work in the Universities or in the Hospital Division of the Ministry of Health. The 22% who were less likely to participate in CME were general practitioners in the private sector. They worked long hours with day, evening and/or night shifts every day. If the doctors were in the Government sector, they were more likely to be in the Health Division, working in administration and public health, or they were in the armed forces and other organizations such as local councils. They worked in the smaller towns or in the districts.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed2004

Control and exacerbation of asthma: a survey of more than 3000 French physicians.

BACKGROUND: Asthma control and prevention of exacerbations are primary objectives for asthma care. However there is a lack of universal definition of these notions which may therefore have a different meaning according to the physician's practice. METHODS: In the present survey, 1805 general practitioners, 551 pulmonologists, 176 allergologists and 470 resuscitation/emergency care physicians were randomly selected in fall 2001 and asked to answer one question on asthma control and three questions on asthma exacerbation. RESULTS: Regarding asthma control, the presence of minimum symptoms was the primary criterion for asthma specialists (pulmonologists and allergologists), while a normal respiratory function was first considered by nonspecialist physicians (general practitioners and emergency care physicians). The first criterion of mild exacerbation for asthma specialists was the occurrence during at least 2 days of an increase in the frequency of dyspnoea and/or the use of short-acting bronchodilators. For nonspecialist physicians, dyspnoea affecting daily activities and/or sleeping was the preferred notion. Hospitalization was unanimously recognized as the first criterion for severe exacerbations. A decrease in peak expiratory flow of more than 30% below the baseline value on two consecutive days and an episode requiring systemic corticosteroids were the next criteria. CONCLUSIONS: This survey emphasizes the complexity of the notions of asthma control and exacerbation and provides novel informations to orient continuing education programmes.

Asthma↗
PubMed2005

Engaging Australian physicians in evidence-based medicine: a representative national survey.

AIM: To assess Australian adult physicians' views about evidence-based medicine (EBM) and quality improvement (QI). BACKGROUND: Cross-sectional postal survey of two hundred and forty-four randomly selected Australian physicians (78.5% response rate). METHOD: Physicians' views about the promotion of EBM and QI and their impact on patient care, strategies to support better clinical practice and self-reported understanding of EBM terms. RESULTS: Sixty-eight per cent (95% confidence interval (CI): 62-74%) of physicians had a positive view of the current promotion of EBM in Australia. Significantly fewer (45%; 95% CI: 38-51%) were so positive about QI (P <0.001). Although 74% (95% CI: 68-79%) indicated that EBM improves patient care, significantly fewer (46%; 95% CI: 40-53%) held this view with respect to QI (P <0.001). Although 70% (95% CI: 64-76%) of physicians agreed they had adequate skills to search for evidence, significantly fewer (21%; 95% CI: 17-27%) agreed they had sufficient time to do so (P <0.001). EBM skills were positively associated with involvement in teaching. Physicians were significantly more positive about approaches exclusive to themselves compared with those involving other disciplines. CONCLUSIONS: Although Australian physicians have positive views of EBM, QI appears less well regarded. Initiatives to improve quality and safety that incorporate principles and language of EBM will likely be received better by physicians than isolated QI. Further enhancement of EBM requires concomitant attention to physician training, workplace infrastructure and supportive professional development.

Adult↗
PubMed2004

Hypnotic and tranquillizer use among general practitioners in south-eastern France and its relation to occupational characteristics and prescribing habits.

Previous research suggests that practising physicians are more likely than the general population to use psychotropic drugs. Hypnotic and tranquillizer use in France is among the highest in Europe; most hypnotic and tranquillizer prescriptions are written by general practitioners (GPs). The objective was to compare the hypnotic and tranquillizer use of GPs in private practice in Provence (south-eastern France) with that of the general population and to study factors associated with physicians' hypnotic and tranquillizer use. A cross-sectional telephone survey was carried out with a panel of 600 GPs in Provence. The data were collected with a 53-item questionnaire about their social and demographic status, family, occupation, training, information-seeking behaviour, job satisfaction, hypnotic and tranquillizer drug use, tranquillizer and antidepressant prescriptions. The data were analysed using univariate and backward multiple logistic regressions. We found that GPs in Provence use hypnotics and tranquillizers at a significantly higher rate than the general population. We found significant associations with hypnotic and tranquillizer use only among the older group of GPs (older than 48 years). In this group, this drug use was related to the volume of services provided (billing sector), job dissatisfaction, lack of training, the 'family burden' and tranquillizer prescriptions. The strains associated with both medical practice and family burden have some influence on hypnotic and tranquillizer use among GPs; individual factors may influence prescribing attitudes and patient care as well.

Adult↗
PubMed2006

Effects of compensation methods and physician group structure on physicians' perceived incentives to alter services to patients.

OBJECTIVE: To examine how health plan payment, group ownership, compensation methods, and other practice management tools affect physician perceptions of whether their overall financial incentives tilt toward increasing or decreasing services to patients. DATA SOURCE: Nationally representative data on physicians are from the 2000-2001 Community Tracking Study Physician Survey (N=12,406). STUDY DESIGN: Ordered and multinomial logistic regression were used to explore how physician, group, and market characteristics are associated with physician reports of whether overall financial incentives are to increase services, decrease services, or neither. PRINCIPAL FINDINGS: Seven percent of physicians report financial incentives are to reduce services to patients, whereas 23 percent report incentives to increase services. Reported incentives to reduce services were associated with reports of lower ability to provide quality care. Group revenue in the form of capitation was associated with incentives to reduce services whereas practice ownership and variable compensation and bonuses for employee physicians were mostly associated with incentives to increase services to patients. Full ownership of groups, productivity incentives, and perceived competitive markets for patients were associated with incentives to both increase and reduce services. CONCLUSIONS: Practice ownership and the ways physicians are compensated affect their perceived incentives to increase or decrease services to patients. In the latter case, this adversely affects perceived quality of care and satisfaction, although incentives to increase services may also have adverse implications for quality, cost, and insurance coverage.

Attitude of Health Personnel↗
PubMed2001

Personal preferences of obstetricians towards childbirth.

Our objective was to determine obstetricians' personal choices in relation to modes of delivery and long-term outcomes. A structured confidential survey was mailed out to all Australian and New Zealand Fellows, Members, and Australian Trainees with The Australian and New Zealand Journal of Obstetrics and Gynaecology November 1999 edition. The response rate overall was 26% (478). Eleven per cent (54) chose to have an elective Caesarean section (ECS) in the absence of any clinical indication. The most common reason for this was fear of faecal and urinary incontinence (82%). Two-thirds (318) were agreeable to patients requesting an ECS in this same setting. Twenty-six per cent said they would choose ECS if the estimated fetal weight (EFW) was > 4000 g which more than doubled to 55% (261) if EFW was > 4500 g. Ventouse delivery was the most popular method of assisted rotational delivery at 45% (214) followed closely by Keilland's forceps at 40% (189). Caesarean section (CS) was chosen by only 14% (65) in this scenario. ECS was the preferred method for breech delivery at 38% (181) followed by trial of breech delivery at 23% (109). Thirty-two per cent (154) of respondents would attempt external cephalic version prior to deciding mode of delivery. Respondents felt the most important factors for postnatal incontinence included: antenatal incontinence (64%), length of second stage > one hour (50%), forceps delivery (46%), and EFW > 4000 g at term (44%).

Attitude of Health Personnel↗
PubMed1987

The care of elderly patients by elderly physicians.

To examine the content of care that elderly patients receive from physicians greater than or equal to 65 years of age, data from the 1981 National Ambulatory Medical Care Survey were analyzed. Compared to physicians aged 35 to 54 years, elderly physicians devoted a larger proportion of their practices to the care of elderly patients. In caring for these patients, elderly physicians spent more time per visit than did younger physicians and were more likely to conduct general examinations and provide counseling. In contrast, elderly physicians were less likely to perform mental status or vision examinations. Elderly physicians were also less likely to provide telephone follow-up for those patients greater than or equal to 75 years of age and more likely to discharge patients greater than or equal to 65 years of age without any specific follow-up planned. These data suggest that the content of care for elderly patients may differ substantially depending upon the physician's age.

Aged↗
PubMed1996

Clinical variables influencing treatment decisions for agitated dementia patients: survey of physician judgments.

OBJECTIVE: To better understand primary treatment recommendations and the variables that might influence treatment decisions of physicians who treat agitated dementia patients. DESIGN: A written cross-sectional survey of three physician groups (geriatric psychiatrists, primary care physicians, and neurologists) who typically treat agitated dementia patients in community settings. We used a written clinical vignette describing a home-bound, agitated dementia patient to ask respondents to provide information regarding their primary treatment recommendation and to estimate the degree to which clinically relevant variables might influence their treatment recommendation. Using principal component analysis, the original set of clinical variables was collapsed into a smaller set of composite factors that better defined the fundamental constructs of the variables that influenced decision making. Analyses compared primary treatment recommendations and factors influencing treatment recommendations by physician groups. PARTICIPANTS: The pool of survey respondents consisted of a random selection of 207 primary care physicians from western North Carolina, 147 geriatric psychiatrists obtained from the roster of the 1991 American Association for Geriatric Psychiatry, and 120 neurologists obtained from the roster of the American Board of Medical Specialties. The response rate was 65% for geriatric psychiatrists, 38% for primary care physicians, and 33% for neurologists. RESULTS: Differences in primary treatment recommendations by physician group were not found. Physicians, regardless of specialty, recommended neuroleptic medications as their primary intervention. When medication classes were collapsed into a single category, medications as a primary intervention exceeded 55% for all physician groups. Twenty-two percent of all respondents recommended psychosocial interventions as primary treatment strategies. The principal component analysis of clinical variables influencing treatment recommendations solved for five components that accounted for 64% of the variance. Comparing the five components by specialty groups failed to find significant differences, except for Factor 5, the "Hassle Factor." Primary care physicians were more likely to indicate that this component influenced their decision making than were the other physician groups. CONCLUSIONS: The findings indicate that physicians, regardless of specialty, are likely to use medication and to weight clinically relevant information in a similar fashion when managing agitated dementia patients.

Aged↗
PubMed1994

Appropriateness of geriatric prescribing decisions made by nurse practitioners and physicians.

Legislators' concerns about the ability of nurse practitioners (NPs) to appropriately prescribe medications underlie the regulatory policies governing prescribing in the United States. As a result, state legislation varies concerning whether prescriptive authority is granted to NPs. The prescribing decisions of NPs and physicians were compared using three standardized geriatric case vignettes. NPs scored higher on an index of appropriateness than physicians a difference that remained whether or not the nurse had regulatory support to prescribe. Recommendations are made for more equitable state prescription policies.

Decision Making↗