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PubMed2001

Implementation of clinical guidelines through an electronic medical record: physician usage, satisfaction and assessment.

CONTEXT: We developed and evaluated the Emergency Department Expert Charting System (EDECS) to provide real-time guidance regarding the care of low back pain in adults, fever in children, and occupational exposure to blood and body fluids in health care workers, by embedding clinical guidelines within an electronic medical record. OBJECTIVE: To describe the behaviors and attitudes of physicians who used EDECS. DESIGN: Pre-post questionnaires were used to assess physician attitudes. Time studies of the intervention phase were observational, using clocks embedded in the software. PARTICIPANTS: One hundred and forty two residents and interns in emergency, pediatric, internal, and family medicine and patients with the above-mentioned complaints. MAIN OUTCOME MEASURES: Physician utilization of EDECS, time spent using EDECS, physician satisfaction and beliefs. RESULTS: Eighty four percent of the 142 eligible physicians used EDECS at least once. Five hundred and ninety one of 789 (75%) eligible cases were completed using EDECS. Median session time decreased from 12 min for session 1, to 5.5 min for sessions 16 and above. Physicians generally agreed that care with EDECS was better than standard care, particularly with respect to documentation. There was, however, considerable heterogeneity in belief among complaints. CONCLUSIONS: These data illuminate both the potentials of computer-assisted decision making and the need for context-specific approaches when attempting to implement guidelines.

Attitude of Health Personnel↗

PubMedDate not supplied

Evaluating humanistic attributes of internal medicine residents.

OBJECTIVE: Methods of assessing humanism in internal medicine residents have not been completely designed or evaluated. This study used patient satisfaction as a measure of humanism, and assessed the validity of using faculty physicians to evaluate residents' humanistic behavior. Residents' ability to assess themselves was also evaluated. SETTING: A university-affiliated internal medicine training program. SUBJECTS: Forty-seven internal medicine residents were evaluated by patients, faculty, and themselves. DESIGN: Faculty physicians were given standard faculty evaluation and patient satisfaction forms, and were asked to evaluate residents. These evaluations were compared with the patients' responses on the same satisfaction forms. Residents performed self-assessment using identical forms; these responses were compared with those of the faculty and patients. RESULTS: There was no correlation between patients' responses and those of the faculty or residents. There was a significant inverse correlation between resident and faculty responses, especially for the female residents (r = 0.71). CONCLUSION: These findings suggest the need for further study of the evaluation process, including what factors influence individuals to respond as they do. It appears that the use of one rating group is not sufficient to achieve an accurate assessment of residents' humanistic skills. The present status of the process of evaluating humanism is discussed.

Adolescent↗

PubMed1996

Information-seeking behavior of health professionals in Hong Kong: a survey of thirty-seven hospitals.

Shortly after the establishment of Hong Kong's Hospital Authority (HA) in 1990, ten library service networks supported by the Library Information Systems (HALIS) were established to pool resources. A survey was undertaken to investigate the information-seeking behavior of health professionals working in thirty-seven public hospitals, examine their information needs, assess user satisfaction with and the impact of library services (including HALIS), and examine why hospital libraries sometimes fail to meet user needs. The findings revealed disparate use patterns among different groups of health professionals and confirmed that medical staff were most satisfied with the library collections and services. The nurses and hospital executives were found to be underserved. They needed information not only for work-related reasons but also to support self-study and development. The new HALIS service was neither well known nor widely used, especially among nurses. The findings provided valuable measures of performance for comparing different hospitals and assessing changes over time. Survey results also highlighted areas in which improvements are needed, such as collection enhancement, promotion and user training, and assessment of the impact of library service on patient care. Subsequent developments in these directions have led to increased awareness and use of library services and confirmed the direction of strategic plans for growth.

CD-ROM↗

PubMed1982

Update on retail store dentistry, 1981. Council on Dental Practice, Council on Dental Care Programs, Bureau of Economic and Behavioral Research.

Retail store dentistry has shown increased activity and growth in recent years. Since 1977, when the first retail store dental facility opened, the number has grown to 63, housed in 18 department store and three drugstore chains in 14 states and the District of Columbia. A limited practice and patient survey was conducted. The participating retail store dental centers reported being open five or six days per week with operating hours extending to 6 pm or 8 pm. Credit cards (store and major bank credit cards) are accepted for payment by all five centers, and each center spent a mean of $1,520 in the past year for advertising. All dentists were younger than 40 years; a fourth were younger than 30. Most patient visits (90%) were by appointment. Patients typically shop regularly at the store and liver near it. The features of the retail store dental office identified as most important by respondents were convenient hours, convenient location, and low cost. Although the survey presents some insight into practice characteristics and patient characteristics of retail store dental practices, only a limited sample from one-particular geographic region was examined. The extent of staff influence or assistance in interpreting or explaining patient questionnaires is also undetermined. Further studies of a larger, more geographically representative group of retail store centers with a larger number of patients, should be undertaken to provide a more comprehensive view of retail store dentistry.

Adult↗

PubMed1985

Patient exposition and physician explanation in initial medical interviews and outcomes of clinic visits.

To replicate an earlier study and explore associations between verbal behaviors in patient-physician interactions and outcomes of care, 102 visits to a medicine walk-in clinic were tape-recorded, transcribed, and coded according to the Verbal Response Mode (VRM) system. Questionnaires given before and after the clinic visit and telephone interviews 1 week and 4 weeks after the visit were used to measure patient satisfaction, compliance, and change in symptoms. Data were collected on patients' sociodemographic characteristics, illness characteristics, and health beliefs. Two verbal exchanges were examined: in the medical history, the Patient Exposition exchange, which was measured as the frequency with which patients make statements about their illnesses in their own words; and in the conclusion, the Physician Explanation exchange, which was measured as the percentage of physician statements that are factual. These verbal indexes showed correlations with patient satisfaction, thus replicating the earlier study, but no significant correlations with compliance. Analysis of variance showed that the association between verbal exchanges and patient satisfaction remained after controlling for physician differences and for patient age, education, and belief in the controllability of the illness.

Adult↗

PubMed2000

[Responses in a questionnaire by medical school students who participated in the new curriculum of the clinical learning in clinical pathology].

The clinical learning taken by medical students are an important part of their medical education. To develop a new, effective curriculum for the clinical learning in Clinical Pathology, the instructors defined clear general instructional objectives and specific behavioral objectives, and discussed the learning strategies and evaluation methods. The medical students at our medical school took this new curriculum in Clinical Pathology in 1999. As an evaluation method of this new curriculum, we asked all students to fill out a questionnaire that asked their opinions about the length of each component in the Clinical Pathology rotation, the content of the rotation, etc. Over 80% of the respondents answered that the rotation in Clinical Pathology was useful. Ninety-six percent of the students felt that the experience and knowledge they gained in this Clinical Pathology rotation will be useful in the clinical learning in other departments. Based on the high percentage of favorable responses from the students, we concluded that the new curriculum, which was developed after intensive planning, was successful. In summary, the feedback from students who took the new curriculum in Clinical Pathology showed that this new course was well-accepted by the students and that it created an excellent relationship between the instructors and students. Some of the responses in the questionnaires will be used to improve the Clinical Pathology rotation in the future.

Consumer Behavior↗

PubMed1986

Medicaid families under managed care. Anticipated behavior.

This study reports the results of a household survey of 495 Medicaid clients eligible under the Aid to Families with Dependent Children program in Monroe County, New York. The purpose of the study has been to examine the views and to anticipate the health care choices/decisions of Medicaid clients prior to their enrollment in a new, county-wide Medicaid-managed care program. The findings indicate significant ethnic differentials among the Medicaid poor, both in the choice of care source and in the reasons offered for that choice. Forty percent of those interviewed would like to change to a new source of care, but less than 13% can actually be expected to change. Private practice arrangements were the preferred source of care, yet distance to such sources appears to represent a major stumbling block to access. This study suggests that the managed-care approach being offered in Monroe County may offer the Medicaid eligibles a new stigma-free way of affiliating with a health care provider. This is being recognized by those surveyed as an important element. The study demonstrates that the choices made by the Medicaid recipients are perfectly rational given the recipients' knowledge of Medicaid and the health care system, and the general conditions in which they find themselves. These findings have important implications for the move of Medicaid programs from the fee-for-service to the managed-care/HMO system.

Adult↗

PubMed2004

Demonstration of an E-mailed worksite nutrition intervention program.

INTRODUCTION: Dietary fat and low fruit and vegetable intake are linked to many chronic diseases, and U.S. population intake does not meet recommendations. Interventions are needed that incorporate effective behavior-change principles and that can be delivered inexpensively to large segments of the population. METHODS: Employees at a corporate worksite were invited to participate in a program, delivered entirely by e-mail, to reduce dietary fat and increase fruit and vegetable intake. Behavior-change principles underlying the intervention included tailoring to the participant's dietary lifestyle, baseline assessment and feedback about dietary intake, family participation, and goal setting. Assessment, tailoring, and delivery was fully automated. The program was delivered weekly to participants' e-mail inboxes for 12 weeks. Each e-mail included information on nutrition or on the relationship between diet and health, dietary tips tailored to the individual, and small goals to try for the next week. In this nonrandomized pilot study, we assessed technical feasibility, acceptability to employees, improvement in Stage of Change, increase in fruit and vegetable consumption, and decrease in fat intake. RESULTS: Approximately one third (n = 84) of employees who were offered the 12-week program signed up for it, and satisfaction was high. There was significant improvement in Stage of Change: 74% of those not already at the top had forward movement (P < .001). In addition, results suggest significant increase in fruit and vegetable consumption (0.73 times/day, P < .001) and significant decrease in intake of fat sources (-0.39 times/day, P < .001). CONCLUSION: This inexpensive program is feasible and appears to be effective. A randomized controlled trial is needed.

Adult↗

PubMed1987

Dimensions of patient control in a free-standing birth center.

This paper explores the phenomenon of patient control in a midwife-run free-standing birth center which emphasized natural, patient controlled childbirth. Specifically, it addresses the ability of patients to translate an incipient desire for control into controlling behavior in the patient care context. It is argued that prior research has tended to conceptualize patient control in rather straightforward and simple terms and, as a consequence of focusing principally upon the formal process of information exchange in the client-provider consultative context, has glossed over the process by which patient control and the differing meanings that it carries are influenced by the cultural and political contexts in which they are embedded. It was found that the meaning that patients attributed to their controlling role was structured by two major factors. The first of these was patient ambivalence about giving birth in an alternative and innovative practice form. This was overlaid with a second factor; political conflict between the birth center and its back-up hospital. The interaction of these two factors prompted women to construe their controlling role around dimensions of individual health maintenance and 'control of self' rather than control over decision making. This occurred despite the fact that the latter type of control was often emphasized by patients when elucidating their reasons for choosing the birth center. Some implications of casting control in terms of health maintenance and 'control of self' for patient experience are discussed.

Attitude to Health↗

PubMed2003

Hedging customers.

You are a marketing director with $5 million to invest in customer acquisition and retention. Which customers do you acquire, and which do you retain? Up to a point, the choice is obvious: Keep the consistent big spenders and lose the erratic small ones. But what about the erratic big spenders and the consistent small ones? It's often unclear whether you should acquire or retain them and at what cost. Businesses have begun dealing with unpredictable customer behavior by following the practices of sophisticated investors who own portfolios comprising dozens of stocks with different, indeed divergent, histories and prospects. Each portfolio is diversified so as to produce the investor's desired returns at the particular level of uncertainty he or she can tolerate. Customers, too, are assets--risky assets. As with stocks, the cost of acquiring them is supposed to reflect the cash-flow values they are likely to generate. The authors explain how to construct a portfolio based on the notion that a customer's risk-adjusted lifetime value depends on its anticipated effect on the riskiness of the group it is joining. They also show how this approach was used to identify the best prospects for Myron Corporation, a global leader in the personalized business-gift industry. The concept of risk-adjusted lifetime value has a transforming power: For companies that rely on it, product managers will be replaced by customer managers, and the current method of accounting for profit and loss--which is by product--will be replaced by one that determines each customer's P&L. Once adjusted for risk, those P&Ls will become the firm's key performance and operational metric.

Consumer Behavior↗

PubMed1976

The effect of prepaid group practice on physicians' utilization behavior.

The study is concerned with the practice of physicians in a prepaid group practice setting. Specifically, it is concerned 1) with investigating the extent of variation in physician behavior concerning use of clinical resources, that is, office visits and telephone calls, and technical resources, that is, x-rays and laboratory procedures, and 2) with determining the factors that account for such variation. The universe of this study consists of all internists practicing in 1970 in the prepaid group setting of Kaiser Permanente at Portland, Oregon, a total of 34. The overall framework for the study is based on the belief that medical training and the setting in which physicians work are significant determinants of their use of clinical and technical resources in different disease situations. Specifically, the framework posits that different sets of organizational variables are important in determining use of resources for acute and undiagnosed conditions. The findings reported in the study suggest that while the teaching environment in which a physician is trained is important in shaping his clinical personality, the setting in which he actually works contains its own source of influence over his professional activity. These results also provide supportive evidence for the widely held notion that prepaid group practice, through changing the nature of the incentives to physicians and introducing professional regulation, leads to a more efficient way of providing medical care by reducing the use of costly resources.

Consumer Behavior↗

PubMed2006

Integrating palliative and critical care: description of an intervention.

A large proportion of deaths in the United States occur in the intensive care unit (ICU) or after a stay in the ICU, and there is evidence of problems in the quality of care these patients and their families receive. In an effort to respond to this problem, we developed a multifaceted, nurse-focused, quality improvement intervention that is based on self-efficacy theory applied to changing clinician behavior. We have called the intervention "Integrating Palliative and Critical Care." This five-component intervention includes: 1) critical care clinician education to increase knowledge and awareness of the principles and practice of palliative care in the ICU, 2) critical care clinician local champions to provide role modeling and promote attitudinal change concerning end-of-life care, 3) academic detailing of nurse and physician ICU directors to identify and address local barriers to improving end-of-life care in each ICU, 4) feedback of local quality improvement data, and 5) system supports including implementation of palliative care order forms, family information pamphlets, and other system supports for providing palliative care in the ICU. The goal of this report is to describe the conceptual model that led to the development of the intervention, and for each of the five components, we describe the theoretical and empirical support for each component, the content of the component, and the lessons we have learned in implementing the component. Future reports will need to examine the ability of the interventions to improve outcomes of palliative care in the ICU.

Attitude of Health Personnel↗

PubMed1993

A controlled study of the effects of an early intervention on acute musculoskeletal pain problems.

Current conceptions of chronic pain clearly suggest that proper care at the acute stage should prevent the development of chronic problems. Patients (198) seeking help for acute musculoskeletal pain (MSP), e.g., back and neck pain participated in two studies of the effects of an Early Active intervention which underscored 'well' behavior and function compared to a Treatment as usual control group. The quantity of the Early Active treatment was a median of 1 doctor's appointment and 3 meetings with a physical therapist. Study I concerned patients with a prior history of sick-listing for MSP, while study II involved patients with no prior history of MSP. Treatment satisfaction, pain experience, activities and sickness absenteeism were assessed before, after and at a 12-month follow-up. In study I (patients with a history of MSP), the results showed significant improvements for both groups, but virtually no differences between the groups. Similarly, in study II (no history of MSP) both groups demonstrated significant improvements, e.g., for pain intensity and activity levels. However, the Early Active treatment resulted in significantly less sick-listing relative to the control group. Moreover, the risk of developing chronic (> 200 sick days) pain was 8 times lower for the Early Activation group. This investigation shows that relatively simple changes in treatment result in reduced sickness absenteeism for 'first-time' sufferers only. Consequently, the content and timing of treatment for pain appear to be crucial. Properly administered early intervention may therefore decrease sick leave and prevent chronic problems, thus saving considerable resources.

Absenteeism↗

PubMed1999

[Health education of women in a rural setting: an interventional study].

OBJECTIVE: To compare the health knowledges and the reasons for the participation between two groups of women with regard to the participation in a health education programme. To describe the satisfaction and the behaviors changes of those who participated. DESIGN: Pos-test intervention study with a control group not aleatory. It was used the test "t" of student for quantitative variables and square "ji" for the qualitative variables. SETTING: Primary health care, auxiliary consulting rooms which belong to Barracas and El Toro, Castellón. PARTICIPANTS: The intervention group was formed by 48 women, and the control group by 43. MAIN RESULTS: All significant different was founded positively associated which the intervention group, and in which questions without significant different, always the percentage of two answers was bigger than the control group. The most important reasons expressed for the women for the participation were: "to learn", "to be interesting", "to feel comfortable". The most important reasons for the non participation were: "to have work", "I didn't know", "I forgot it". CONCLUSIONS: The intervention study outcome shows that women who participated in the workshops had move knowledges in the worked health subjects than those who didn't participate. Every women expresated satisfaction with the experience, and the 66.6% changed something comportment. The knowledge of the causes for which the women participated or not, it is a very useful information to improve the intervention in future experiences.

Adult↗

PubMed1990

A longitudinal study comparing the prenatal care of Puerto Rican and white women.

This study examined the effect of ethnicity on health-seeking attitudes and behavior, including patient compliance, use of the clinic, knowledge of childbirth, and the relationship between the patient and primary health care provider. Anthropologic techniques of observations and interviews were conducted longitudinally with 27 Puerto Rican women and 26 white women who received perinatal care at a tertiary-level hospital throughout the antepartum, intrapartum, and postpartum periods. Approximately 500 standardized and open-ended interviews and 150 observations of clinical interactions with resident physicians and nurse-midwives compared reproductive knowledge, beliefs, and practices. Results of this three-year study indicated that both groups of women were similar in age, years of education, and percentage receiving financial assistance. Puerto Rican women identified strongly as a separate ethnic group; all spoke Spanish and most were bilingual. Office visits and explanations from primary care providers were more important to women in both groups than information obtained from families, friends, or folk beliefs. Knowledge of pregnancy care procedures and childbirth, although limited, was no different between the groups. Long waits, depersonalized service, and a lack of continuity of care adversely affected patient and physician satisfaction and diminished effective doctor-patient interactions. This study suggests that differences in ethnic background do not necessarily adversely affect the delivery of reproductive health care. Indigent white and Puerto Rican women wanted the same thing: quality perinatal care and education.

Adolescent↗

PubMed1991

The relationship of physician medical interview style to patient satisfaction.

The results of previous studies on the relationship between patient satisfaction and specific interviewing behaviors have been difficult to generalize because most studies have examined small samples of patients at one clinical location, and have used initial or acute care visits where the patient and physician did not have an established relationship. The present collaborative study of medical interviewing provided an opportunity to collect interviews from 550 return visits to 127 different physicians at 11 sites across the country. Tape recordings were analyzed using the Roter Interaction Analysis System, and postvisit satisfaction questionnaires were administered to patients. A number of significant relationships were found between communication during the visit and the various dimensions of patient satisfaction. Physician question asking about biomedical topics (both open- and closed-ended questions) was negatively related to patient satisfaction; however, physician question asking about psychosocial topics was positively related. Physician counseling for psychosocial issues was also positively related to patient satisfaction. Similarly, patient talk about biomedical topics was negatively related to satisfaction, while patient talk regarding psychosocial topics was positively related. Furthermore, patients were less satisfied when physicians dominated the interview by talking more or when the emotional tone was characterized by physician dominance. The findings suggest that patients are most satisfied by interviews that encourage them to talk about psychosocial issues in an atmosphere that is characterized by the absence of physician domination.

Adult↗

PubMed2001

Viewpoints of Korean senior high school students on school-based sex education.

The percentage of sexually experienced young persons in South Korea has increased and the age of first intercourse has lowered significantly. However, these marked changes in the sexual behavior of young people have been taking place when schools in the country still generally lack a realistic sex education program. Given this situation, the aim of this study is to gather student opinions on current school-based sex education in Korea. A self-administered questionnaire survey was conducted in Seoul, Incheon, and Kyunggi Province to assess the status and needs of high school sexuality education. Survey data was obtained from 1,160 senior high school students. In this study 68.8% of boys and 94.4% of girls had some school-based sex or sexuality education. The mean hours of sex education instruction of boys and girls were 2.29 and 3.39 hours respectively. There are several reasons for not being satisfied with sex education in schools. Lack of information was the first reason in all categories. About seventy-four percent of respondents felt that the sex education taught in schools did not cover the information that they want. The second reason was that there was no trained sex education teacher. Lack of materials, interactive teaching method, and time were the other reasons given. They advocated starting sex education in elementary school and covering all topics by the age-appropriate level. More than half supported that sex education should be made compulsory in schools.

Adolescent↗

PubMed1987

Physician reimbursement by salary or fee-for-service: effect on physician practice behavior in a randomized prospective study.

We used a resident continuity clinic to compare prospectively the impact of salary v fee-for-service reimbursement on physician practice behavior. This model allowed randomization of physicians into salary and fee-for-service groups and separation of the effects of reimbursement from patient behavior. Physicians reimbursed by fee-for-services scheduled more visits per patient than did salaried physicians (3.69 visits v 2.83 visits, P less than .01) and saw their patients more often (2.70 visits v 2.21 visits, P less than .05) during the 9-month study. Almost all of this difference was because fee-for-service physicians saw more well patients than salaried physicians (1.42 visits and .99 visits per enrolled patient, respectively, P less than .01). Evaluating visits by American Academy of Pediatrics' guidelines indicated that fee-for-service physicians saw more patients for well-childcare than salaried physicians because they missed fewer recommended visits and scheduled visits in excess of those recommendations. Fee-for-service physicians also provided better continuity of care than salaried physicians by attending a larger percentage of all visits made by their patients (86.6% of visits v 78.3% of visits, P less than .05), and by encouraging fewer emergency visits per enrolled patient (0.12 visits v 0.22 visits, P less than .01). Physicians' interest in private practice, as determined by their career plans, correlated significantly with total number of patients enrolled (r = .48, P less than .05) and total clinic patients seen by each resident during the study (r = .40, P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗