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A substantial amount of health care resources is allocated within the UK using formulae that relate funding to measures of population need. The aim of this paper is to demonstrate the importance of non-need factors in determining utilisation of services at an individual level and explore the implications inclusion of such factors has in the consideration of equity. In the paper we develop a utility model that accords a role to non-health factors in the determination of service use. A series of functions incorporating non-health factors as explanatory variables in GP utilisation functions are estimated using data from the British Household Panel Survey. The functions are decomposed to ascertain the role of service structure and examine the role of income across the four countries of the UK in explaining utilisation. The implications of our findings for the pursuance of equity in the NHS when individual choice has an explicit role are discussed. [ABSTRACT FROM AUTHOR]

Racial-ethnic minorities receive lower quality and intensity of health care compared with whites across a wide range of preventive, diagnostic, and therapeutic services and disease entities. These disparities in health care contribute to continuing racial-ethnic disparities in the burden of illness and death. Several national medical organizations and the Institute of Medicine have issued position papers and recommendations for the elimination of health care disparities. However, physicians in practice are often at a loss for how to translate these principles and recommendations into specific interventions in their own clinical practices. This paper serves as a blueprint for translating principles for the elimination of racial-ethnic disparities in health care into specific actions that are relevant for individual clinical practices. We describe what is known about reducing racial-ethnic disparities in clinical practice and make recommendations for how clinician leaders can apply this evidence to transform their own practices. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this paper was to describe primary care prescribers' perspectives on electronic prescribing drug alerts at the point of prescribing.Design: We used a mixed-method study which included clinician surveys (web-based and paper) and focus groups with prescribers and staff.Participants: Prescribers (n = 157) working in one of 64 practices using 1 of 6 e-prescribing technologies in 6 US states completed the quantitative survey and 276 prescribers and staff participated in focus groups.Measurements: The study measures self-reported frequency of overriding of drug alerts; open-ended responses to: "What do you think of the drug alerts your software generates for you?"Results: More than 40% of prescribers indicated they override drug-drug interactions most of the time or always (range by e-prescribing system, 25% to 50%). Participants indicated that the software and the interaction alerts were beneficial to patient safety and valued seeing drug-drug interactions for medications prescribed by others. However, they noted that alerts are too sensitive and often unnecessary. Participant suggestions included: (1) run drug alerts on an active medication list and (2) allow prescribers to set the threshold for severity of alerts.Conclusions: Primary care prescribers recognize the patient safety value of drug prescribing alerts embedded within electronic prescribing software. Improvements to increase specificity and reduce alert overload are needed. [ABSTRACT FROM AUTHOR]

In this paper we give a practical overview of the changes in the financing of health care in Hungary. We describe the financing system of general practitioners, home care (nursing), out-patient care and the acute and chronic care of hospitals. We show how the financial system has changed after the political changes of 1990. The global budget approach of the 1980s was replaced by performance-related financing methods including the ICPM (International Classification of Procedures in Medicine) code system of the WHO (World Health Organization) in out-patient care and the introduction of HBCS (Homogén Betegségcsoportok, “Homogeneous Disease Groups”) in in-patient care. We underline that the efforts made towards reforming health care financing resulted in an activity-related financing system. [ABSTRACT FROM AUTHOR]

As healthcare systems around the world are facing increasing physician shortages, more physicians are migrating from low to high income countries. Differences in medical education and international interaction may have significant effect on physician flows. The Chinese Medical Graduates (CMGs) in the US present an interesting case to examine this effect. This paper evaluated the current number and historical trends of CMGs in the US from mainland China, Taiwan, and Hong Kong comparing their differences and similarities in terms of demographic and geographic characteristics. Since 2000, the number of CMGs in the US showed a consistent upward trend at a rate of approximately 206 additional graduates per year. In 2010, there were 8,797 CMGs in the US. Compared to CMGs from mainland China, CMGs from Taiwan and Hong Kong were much older. Much larger proportion of Taiwan and Hong Kong CMGs were male. However, they were more likely to practice in solo settings than mainland CMGs. The vast majority of CMGs are concentrated in urban areas and no significant differences were found for their distributions in underserved areas. However, a larger proportion of Taiwan and Hong Kong CMGs were in western coastal states; whereas a larger proportion of mainland CMGs were located in eastern coastal states. Fluctuations in CMG numbers in the US reflect the significant differences within the medical education systems among the three. The seemingly homogenous CMGs in the US do show significant differences. Given the magnitude and historical trends of migration of CMGs to the US, further exploration of its causes and impact is needed. [ABSTRACT FROM AUTHOR]

The authors discuss the multiple testing, selection issues, and the analysis of mortality rates in their article. They say that their results do not show that patients registered to general practitioner-complementary and alternative medicine (GP-CAM) have higher mortality rates. They add that the text and the title of their paper show that they do not claim to have found a formal evidence of cost-effectiveness.

This paper presents parameter estimates for physician service equations using the “European Community Household Panel” for 12 countries covering the period 1994–1996. The focus is on two specific points: (1) the identification of behavioural similarities and differences in the demand for health services across the 12 countries; (2) the variability in demand for health services represented through a joint model for all countries. We found that there are significant differences among countries, although there are also similarities in the effect of variables such as health stock, labour situation or family structure. An important fraction of the variability in the demand for health services across countries could be explained by differences in age, income and the role of general practitioners as gatekeepers in the public health system. We found some evidence of induced demand in the decision to visit a specialist and in the number of such visits. [ABSTRACT FROM AUTHOR]

Background: Patients with advanced heart failure may benefit from palliative care, including advance care planning (ACP). ACP, which can include referral back to the general practitioner (GP), may prevent unbeneficial hospital admissions and interventional/surgical procedures that are not in accordance with the patient's personal goals of care. Aim: To implement ACP in patients with advanced heart failure and explore the effect of ACP on healthcare utilisation as well as the satisfaction of patients and cardiologists. Methods: In this pilot study, we enrolled 30 patients with New York Heart Association class III/IV heart failure who had had at least one unplanned hospital admission in the previous year because of heart failure. A structured ACP conversation was held and documented by the treating physician. Primary outcome was the number of visits to the emergency department and/or admissions within 3 months after the ACP conversation. Secondary endpoints were the satisfaction of patients and cardiologists as established by using a five-point Likert scale. Results: Median age of the patients was 81 years (range 33–94). Twenty-seven ACP documents could be analysed (90%). Twenty-one patients (78%) did not want to be readmitted to the hospital and subsequently none of them were readmitted during follow-up. Twenty-two patients (81%) discontinued all hospital care. All patients who died during follow-up (n = 12, 40%) died at home. Most patients and cardiologists indicated that they would recommend the intervention to others (80% and 92% respectively). Conclusion: ACP, and subsequent out-of-hospital care by the GP, was shown to be applicable in the present study of patients with advanced heart failure and evident palliative care needs. Patients and cardiologists were satisfied with this intervention. [ABSTRACT FROM AUTHOR]

The determinants of general practitioner (GP) visiting patterns in Ireland, in particular the role of eligibility for free GP care, are examined using microdata from a nationally representative survey of the population in 2001. Whereas most studies find that need factors such as age and health status are most important in determining GP visiting rates, the Irish situation is complicated by the distinction between medical card patients, who receive free GP visits, and private patients, who must pay for each visit. Controlling for a variety of need-related and other factors, the results show that health status and medical card eligibility are consistently most important in explaining differences in GP visiting patterns. The medical card result is particularly noteworthy; even when differences in age and other observable characteristics between medical card and private patients are taken into account, medical card patients are both more likely than private patients to visit their GP, and they visit more frequently when they do. In addition, we investigated whether individuals just above the income threshold for a medical card are disadvantaged in terms of accessing GP services in comparison with other private patients on higher incomes. We found that there is little significant difference among private patients in GP visiting rates as we move up the income distribution. [ABSTRACT FROM AUTHOR]

SARS-CoV-2 is a highly contagious virus causing mainly respiratory track disease called COVID-19, which dissemination in the whole world in the 2020 has resulted in World Health Organisation (WHO) announcing the pandemic. As a consequence Polish Government made a decision to go into a lockdown in order to secure the population against SARS-CoV-2 outbreak what had its major influence on the Polish Health Care System. All of the social and medical factors caused by the pandemic might influence children's health care, including urgent cases. The aim of this survey was the analysis of medical charts with focus on the course and results of surgical treatment of children who underwent appendectomy before and during the COVID-19 pandemic. Material and methods: We performed analysis of charts of 365 subjects hospitalized in the Pediatric Surgery Department from 1st January 2019 to 31st December 2020 because of acute appendicitis. Patients were divided into two groups—those treated in 2019—before pandemic outbreak, and those treated in 2020 in the course of pandemic. Results: the most common type of appendicitis was phlegmonous (61% of cases in 2019 and 51% of cases in 2020). Followed by diffuse purulent peritonitis (18% of cases in 2019 vs 31% of cases in 2020), gangrenous (19% of cases in 2019 vs 15% of cases in 2020) and simple superficial appendicitis (1% of cases in 2019 vs 3% of cases in 2020). There was statistically significant difference in the length of hospitalization: in 2019 the mean length of hospi-talization was 4.761 vs 5.634 in 2020. Laparoscopic appendectomy was performed more frequently before the COVID period (63% of cases treated in 2019 vs 61% of cases treated in 2020). In the pandemic year 2020, there was double increase in the number of conversion from the laparoscopic approach to the classic open surgery. In the year 2019 drainage of abdominal cavity was necessary in 22% of patients treated with appendectomy, in 2020 the amount of cases threated with appendectomy and drainage increased to 32%. Conclusions: fear of being infected, the limited availability of appointments at General Practitioners and the new organisation of the medical health care system during pandemic, delay proper diagnosis of appendicitis. Forementioned delay leads to higher number of complicated cases treated with open appendectomy and drainage of abdominal cavity, higher number of conversions from the laparoscopic to classic open technique, and longer hospitalization of children treated with appendectomy in the year of pandemic. [ABSTRACT FROM AUTHOR]

A large majority of patients and close family members are interested in discussing end-of-life issues with their physician. Most expect their physician to initiate such dialogue. End-of-life discussions, however, must go beyond the narrow focus of resuscitation. Instead, such discussions should address the broad array of concerns shared by most dying patients and families: fears about dying, understanding prognosis, achieving important end-of-life goals, and attending to physical needs. Good communication can facilitate the development of a comprehensive treatment plan that is medically sound and concordant with the patient's wishes and values. This paper presents a practical 4-step approach to conducting end-of-life discussions with patients and their families: (1) Initiating Discussion, (2) Clarifying Prognosis, (3) Identifying End-of-Life Goals, and (4) Developing a Treatment Plan. By following these 4 steps, communication can be enhanced, fears allayed, pain and suffering minimized, and most end-of-life issues resolved comfortably, without conflict. [ABSTRACT FROM AUTHOR]

Background: Michigan's approach to Medicaid expansion, the Healthy Michigan Plan (HMP), emphasizes primary care, prevention, and incentives for patients and primary care practitioners (PCPs).Objective: Assess PCPs' perspectives about the impact of HMP on their patients and practices.Design: In 2014-2015, we conducted semi-structured interviews then a statewide survey of PCPs.Setting: Interviewees came from varied types of practices in five Michigan regions selected for racial/ethnic diversity and a mix of rural and urban settings. Surveys were sent via mail.Participants: Interviewees were physician (n = 16) and non-physician practitioners (n = 3). All Michigan PCPs caring for ≥ 12 HMP enrollees were surveyed (response rate 55.5%, N = 2104).Measurements: PCPs' experiences with HMP patients and recent changes in their practices.Results: Interviews include examples of the impact of Medicaid expansion on patients and practices. A majority of surveyed PCPs reported recent increases in new patients (52.3%) and patients who had not seen a PCP in many years (56.2%). For previously uninsured patients, PCPs reported positive impact on control of chronic conditions (74.4%), early detection of serious illness (71.1%), medication adherence (69.1%), health behaviors (56.5%), emotional well-being (57.0%), and the ability to work, attend school, or live independently (41.5%). HMP patients reportedly still had more difficulty than privately insured patients accessing some services. Most PCPs reported that their practices had, in the past year, hired clinicians (53.2%) and/or staff (57.5%); 15.4% had colocated mental health care. Few (15.8%) reported established patients' access to urgent appointments worsened.Limitations: PCP reports of patient experiences may not be accurate. Results reflect the experiences of PCPs with ≥ 12 Medicaid patients. Differences between respondents and non-respondents present the possibility for response bias.Conclusions: PCPs reported improved patient access to care, medication adherence, chronic condition management, and detection of serious illness. Established patients' access did not diminish, perhaps due to reported practice changes. [ABSTRACT FROM AUTHOR]

Background: The shortage of primary care providers and the provisions of the Affordable Care Act (ACA) have spurred discussion about expanding the number, scope of practice (SOP), and independence of primary care nurse practitioners (NPs). Such discussions in the media and among professional organizations may insinuate that changes to the laws governing NP practice will engender acrimony between practicing physicians and NPs. However, we lack empirical, descriptive data on how practicing professionals view NP independence in primary care.Objective: The aim of the present study was to explore and describe the attitudes about NP independence among physicians and NPs working in primary care.Design: A qualitative study based on the principles of grounded theory.Participants: Thirty primary care professionals in Missouri, USA, including 15 primary care physicians and 15 primary care NPs.Approach: Semi-structured, in-depth interviews, with data analysis guided by grounded theory.Key Results: Participants had perspectives that were not well represented by professional organizations or the media. Physicians were supportive of a wide variety of NP roles and comfortable with high levels of NP independence and autonomy. Physicians and NPs described prerequisites to NP independence that were complementary. Physicians generally believed that NPs needed some association with physicians for patient safety, and NPs preferred having a physician readily accessible as needed. The theme "knowing your limits" was important to both NPs and physicians regarding NP independence, and has not been described previously in the literature.Conclusions: NP and physician views about NP practice in primary care are not as divergent as their representative professional organizations and the news media would suggest. The significant agreement among NPs and physicians, and some of the nuances of their perspectives, supports recommendations that may reduce the perceived acrimony surrounding discussions of NP independent practice in primary care. [ABSTRACT FROM AUTHOR]

Background: Little is known about how primary care physicians (PCPs) in routine outpatient practice use paid price information (i.e., the amount that insurers finally pay providers) in daily clinical practice.Objective: To describe the experiences of PCPs who have had paid price information on tests and procedures for at least 1 year.Design: Cross-sectional study using semi-structured interviews and the constant comparative method of qualitative analysis.Participants: Forty-six PCPs within an accountable care organization.Intervention: Via the ordering screen of their electronic health record, PCPs were presented with the median paid price for commonly ordered tests and procedures (e.g., blood tests, x-rays, CTs, MRIs).Approach: We asked PCPs for (a) their "gut reaction" to having paid price information, (b) the situations in which they used price information in clinical decision-making separate from or jointly with patients, (c) their thoughts on who bore the chief responsibility for discussing price information with patients, and (d) suggestions for improving physician-targeted price information interventions.Key Results: Among "gut reactions" that ranged from positive to negative, all PCPs were more interested in having patient-specific price information than paid prices from the practice perspective. PCPs described that when patients' out-of-pocket spending concerns were revealed, price information helped them engage patients in conversations about how to alter treatment plans to make them more affordable. PCPs stated that having price information only slightly altered their test-ordering patterns and that they avoided mentioning prices when advising patients against unnecessary testing. Most PCPs asserted that physicians bear the chief responsibility for discussing prices with patients because of their clinical knowledge and relationships with patients. They wished for help from patients, practices, health plans, and society in order to support price transparency in healthcare.Conclusions: Physician-targeted price transparency efforts may provide PCPs with the information they need to respond to patients' concerns regarding out-of-pocket affordability rather than that needed to change test-ordering habits. [ABSTRACT FROM AUTHOR]

Background:The Cancer Networks Supporting Primary Care programme was a National Health Service (NHS) initiative in England between 2011 and 2013 that aimed to better understand and improve referral practices for suspected cancer.Methods:A mixed methods evaluation using semi-structured interviews with purposefully sampled key stakeholders and an analysis of Cancer Waiting Times and Hospital Episode Statistics data for all 8179 practices in England were undertaken. We compared periods before (2009/10) and at the end (2012/13) of the initiative for practices taking up any one of four specified quality improvement initiatives expected to change referral practice in the short to medium term and those that did not.Results:Overall, 38% of general practices were involved in at least one of four quality improvement activities (clinical audit, significant event analysis, use of risk assessment tools and development of practice plans). Against an overall 29% increase in urgent cancer referrals between 2009/10 and 2012/13, these practices had a significantly higher increase in referral rate, with reduced between-practice variation. There were no significant differences between the two groups in conversion, detection or emergency presentation rates. Key features of successful implementation at practice and network level reported by participants included leadership, organisational culture and physician involvement. Concurrent health service reforms created organisational uncertainty and limited the programme's effectiveness.Conclusions:Specific primary care initiatives promoted by cancer networks had an additional and positive impact on urgent referrals for suspected cancer. Successful engagement with the programmes depended on effective and well-supported leadership by cancer networks and their general practitioner (GP) leads. [ABSTRACT FROM AUTHOR]

BACKGROUND: Prior literature suggests that the fragmented U.S. health care system places a large administrative burden on physicians. Less is known about how this burden varies with physician contracting practices. OBJECTIVE: To assess the extent to which physician practice outcomes vary with the number of managed care contracts held or the availability of such contracts. DESIGN, PARTICIPANTS, AND MAIN MEASURES: We perform secondary data analyses of the first four rounds of the nationally representative Community Tracking Study Physician Survey (1996-2005), which includes 36,340 physicians (21,567 PCPs [primary care physicians] and 14,773 specialists) across the four survey periods. Our measures include reported hours in patient care, share of hours outside patient care, adequacy of time with patients, career satisfaction, and income. RESULTS: Doctors who contract with more plans report spending more time in patient care (per 11 additional contracts, about 30 min per week for PCPs and 20 min per week for specialists), report spending a modestly larger share of their time outside patient care (per 11 additional contracts, about 10 min per week for PCPs and specialists), are slightly more likely to report inadequate time with patients (odds ratio 1.005 per additional contract for PCPs), and earn higher incomes (per 11 additional contracts, about 3 % more per year for specialists). CONCLUSIONS: Contracting opportunities confer significant benefits on physicians, although they do add modest costs in terms of time spent outside patient care and lower adequacy of time with patients. Simplifications that reduce the administrative burden of contracting may improve care by optimizing allocation of physician effort. [ABSTRACT FROM AUTHOR]

We study how market conditions influence referrals of patients by general practitioners (GPs). We set up a model of GP referral for the Norwegian health care system, where a GP receives capitation payment based on the number of patients in his practice, as well as fee-for-service reimbursements. A GP may accept new patients or close the practice to new patients. We model GPs as partially altruistic, and compete for patients. We show that a GP operating in a more competitive market has a higher referral rate. To compete for patients and to retain them, a GP satisfies patients' requests for referrals. Furthermore, a GP who faces a patient shortage will refer more often than a GP who does not. Tests with Norwegian GP radiology referral data support our theory. [ABSTRACT FROM AUTHOR]

Medical malpractice reform is both necessary and desirable, yet certain types of reform are clearly preferable to others. We argue that "traditional" tort reform remedies such as stringent damage caps not only fail to address the root causes of negligence and the adverse effects that fear of suit can have on physicians, but also fail to address the needs of patients. Physicians ought to view themselves as professionals who are dedicated to putting patients' interests ahead of their own. Professionally responsible malpractice reform should therefore be at least as patient-centered as it is physician-centered. Examples of more professionally responsible malpractice reform exist where institutions take a pro-active approach to identification, investigation, and remediation of possible malpractice. Such programs should be implemented more generally, and state laws enacted to facilitate them. [ABSTRACT FROM AUTHOR]

Self-monitoring of blood pressure by patients at home (home blood pressure monitoring (HBPM)) is being increasingly used in many countries and is well accepted by hypertensive patients. Current hypertension guidelines have endorsed the use of HBPM in clinical practice as a useful adjunct to conventional office measurements. Recently, a detailed consensus document on HBPM was published by the European Society of Hypertension Working Group on Blood Pressure Monitoring. However, in daily practice, briefer documents summarizing the essential recommendations are needed. It is also accepted that the successful implementation of clinical guidelines in routine patient care is dependent on their acceptance by involvement of practising physicians. The present document, which provides concise and updated guidelines on the use of HBPM for practising physicians, was therefore prepared by including the comments and feedback of general practitioners. [ABSTRACT FROM AUTHOR]

Background: Religiously affiliated hospitals provide nearly 20% of US beds, and many prohibit certain end-of-life and reproductive health treatments. Little is known about physician experiences in religious institutions.Objective: Assess primary care physicians' experiences and beliefs regarding conflict with religious hospital policies for patient care.Design: Cross-sectional survey.Participants: General internists, family physicians, and general practitioners from the AMA Masterfile.Main Measures: In a questionnaire mailed in 2007, we asked physicians whether they had worked in a religiously affiliated hospital or practice, whether they had experienced conflict with the institution over religiously based patient care policies and how they believed physicians should respond to such conflicts. We used chi-square and multivariate logistic regression to examine associations between physicians' demographic and religious characteristics and their responses.Key Results: Of 879 eligible physicians, 446 (51%) responded. In analyses adjusting for survey design, 43% had worked in a religiously affiliated institution. Among these, 19% had experienced conflict over religiously based policies. Most physicians (86%) believed when clinical judgment conflicts with religious hospital policy, physicians should refer patients to another institution. Compared with physicians ages 26-29 years, older physicians were less likely to have experienced conflict with religiously based policies [odds ratio (95% confidence interval) compared with 30-34 years: 0.02 (0.00-0.11); 35-46 years: 0.07 (0.01-0.72); 47-60 years: 0.02 (0.00-0.10)]. Compared with those who never attend religious services, those who do attend were less likely to have experienced conflict [attend once a month or less: odds ratio 0.06 (0.01-0.29); attend twice a month or more: 0.22 (0.05-0.98)]. Respondents with no religious affiliation were more likely than others to believe doctors should disregard religiously based policies that conflict with clinical judgment (13% vs. 3%; p = 0.005).Conclusions: Hospitals and policy-makers may need to balance the competing claims of physician autonomy and religiously based institutional policies. [ABSTRACT FROM AUTHOR]

Given the important role that physicians play in clinical care, disease advocacy, national health policy making and clinical research, the IMPACT survey sought to assess the attitudes and perceptions of physicians in 3 general categories: diagnosis and treatment of Alzheimer's disease (AD); caregivers and families of patients with AD; and the role of government in dealing with this disease and its consequences. Survey respondents comprised a total of 250 generalists and 250 specialists (neurologists, geriatricians, neuro-psychiatrists, psychiatrists and psychogeriatricians) from France, Germany, Italy, Spain and the United Kingdom. Physicians were aged 25 to 69 years, in practice for between 5 and 30 years and currently spending more than 50% of their time in direct patient care. Results showed that a sizable majority of physicians throughout Europe, specialists and generalists alike, agree that: 1) AD is underdiagnosed and undertreated; 2) patients and families are not prepared to recognise the early symptoms of the disease; 3) early treatment can help to slow the progression of the disease; and 4) more effective treatments are needed. Attitudes were statistically significantly different between some groups of physicians regarding disclosure of the diagnosis of AD, the benefits of lifestyle modification, and the value of AD-specific medication in patients whose symptoms are worsening. Differences in attitudes and perceptions of AD between specialists and generalists were limited; differences between countries were more common and of greater magnitude, particularly with respect to barriers to the use of prescription medications. [ABSTRACT FROM AUTHOR]

Background: General internists and other generalist physicians have traditionally cared for their patients during both ambulatory visits and hospitalizations. It has been suggested that the expansion of hospitalists since the mid-1990s has "crowded out" generalists from inpatient care. However, it is also possible that declining hospital utilization relative to the size of the generalist workforce reduced the incentives for generalists to continue providing hospital care.Objective: To examine trends in hospital utilization and the generalist workforce before and after the emergence of hospitalists in the U.S. and to investigate factors contributing to these trends.Design: Using data from 1980-2005 on inpatient visits from the National Hospital Discharge Survey, and physician manpower data from the American Medical Association, we identified national trends before and after the emergence of hospitalists in the annual number of inpatient encounters relative to the number of generalists.Results: Inpatient encounters relative to the number of generalists declined steadily before the emergence of hospitalists. Declines in inpatient encounters relative to the number of generalists were driven primarily by reduced hospital length of stay and increased numbers of generalists.Conclusions: Hospital utilization relative to generalist workforce declined before the emergence of hospitalists, largely due to declining length of stay and rising generalist workforce. This likely weakened generalist incentives to provide hospital care. Models of care that seek to preserve dual-setting generalist care spanning ambulatory and inpatient settings are most likely to be viable if they focus on patients at high risk of hospitalization. [ABSTRACT FROM AUTHOR]

The ability to copy and paste text within computerized physician documentation facilitates electronic note writing, but may affect the quality of physician notes and patient care. Little is known about physicians’ collective experience with the copy and paste function (CPF). To determine physicians’ CPF use, perceptions of its impact on notes and patient care, and opinions regarding its future use. Cross-sectional survey. Resident and faculty physicians within two affiliated academic medical centers currently using a computerized documentation system. Responses on a self-administered survey. A total of 315 (70%) of 451 eligible physicians responded to the survey. Of the 253 (80%) physicians who wrote inpatient notes electronically, 226 (90%) used CPF, and 177 (70%) used it almost always or most of the time when writing daily progress notes. While noting that inconsistencies (71%) and outdated information (71%) were more common in notes containing copy and pasted text, few physicians felt that CPF had a negative impact on patient documentation (19%) or led to mistakes in patient care (24%). The majority of physicians (80%) wanted to continue to use CPF. Although recognizing deficits in notes written using CPF, the majority of physicians used CPF to write notes and did not perceive an overall negative impact on physician documentation or patient care. Further studies of the effects of electronic note writing on the quality and safety of patient care are required. [ABSTRACT FROM AUTHOR]

Most current strategies to improve quality and efficiency in health-care delivery focus on measuring and improving physician practice. A new "second generation" of physician profiling--episode-based profiling--is moving beyond legacy "first-generation" physician profiles based on population health and preventive services measures. Episode-based profiling measures physician practice at the "episode of care" level with sophisticated analytic methods and tools using data from claim and other administrative data sets, and it has an underlying "theory of change" consistent with the evolution of the US health-care marketplace. While offering potential advantages in informing consumer choice and enabling practice improvement, episode-based profiling also has limitations and challenges, both analytically and in the process of physician engagement and improvement. Nonetheless, episode-based profiling is likely to continue to spread and have growing influence, and it has significant implications for research, policy, and clinical stakeholders. [ABSTRACT FROM AUTHOR]

Background: Little research investigates the role of patient-physician communication in understanding racial disparities in depression treatment.Objective: The objective of this study was to compare patient-physician communication patterns for African-American and white patients who have high levels of depressive symptoms.Design, Setting, and Participants: This is a cross-sectional study of primary care visits of 108 adult patients (46 white, 62 African American) who had depressive symptoms measured by the Medical Outcomes Study-Short Form (SF-12) Mental Component Summary Score and were receiving care from one of 54 physicians in urban community-based practices.Main Outcomes: Communication behaviors, obtained from coding of audiotapes, and physician perceptions of patients' physical and emotional health status and stress levels were measured by post-visit surveys.Results: African-American patients had fewer years of education and reported poorer physical health than whites. There were no racial differences in the level of depressive symptoms. Depression communication occurred in only 34% of visits. The average number of depression-related statements was much lower in the visits of African-American than white patients (10.8 vs. 38.4 statements, p = .02). African-American patients also experienced visits with less rapport building (20.7 vs. 29.7 statements, p = .009). Physicians rated a higher percentage of African-American than white patients as being in poor or fair physical health (69% vs. 40%, p = .006), and even in visits where depression communication occurred, a lower percentage of African-American than white patients were considered by their physicians to have significant emotional distress (67% vs. 93%, p = .07).Conclusions: This study reveals racial disparities in communication among primary care patients with high levels of depressive symptoms. Physician communication skills training programs that emphasize recognition and rapport building may help reduce racial disparities in depression care. [ABSTRACT FROM AUTHOR]

Addressing upstream or fundamental causes (such as poverty, limited education, and compromised healthcare access) is essential to reduce healthcare disparities. But such approaches are not sufficient, and downstream interventions, addressing the consequences of those fundamental causes within the context of any existing health system, are also necessary. We present a definition of healthcare disparities and two key principles (that healthcare is a social good and disparities in outcomes are a quality problem) that together provide a framework for addressing disparities downstream. Adapting the chronic care model, we examine a hierarchy of three domains for interventions (health system, provider-patient interactions, and clinical decision making) to reduce disparities downstream and discuss challenges to implementing the necessary changes. [ABSTRACT FROM AUTHOR]

Objectives: To examine how practice constraints contribute to barriers in the health care of persons with dementia and their families, particularly with respect to behavioral aspects of care.Design: Cross-sectional qualitative interview study of primary care physicians.Setting: Physicians' offices.Participants: Forty primary care physicians in Northern California.Measurements: Open-ended interviews lasted 30-60 minutes and were structured by an interview guide covering clinician background and practice setting, clinical care of a particular patient, and general approach to managing patients with AD or dementia. Interviews were transcribed and themes reflecting constraints of practice were identified through a systematic coding process.Results: Recurring themes (i.e., those present in > or = 25% of physician interviews) included insufficient time, difficulty in accessing and communicating with specialists, low reimbursement, poor connections with community social service agencies, and lack of interdisciplinary teams. Physician narratives suggest that these constraints may lead to delayed detection of behavior problems, "reactive" as opposed to proactive management of dementia, and increased reliance on pharmacological rather than psychosocial approaches.Conclusion: Physicians often feel challenged in caring for dementia patients, particularly those who are more behaviorally complex, because of time and reimbursement constraints as well as other perceived barriers. Our results suggest that more effective educational interventions (for families and physicians) and broader structural changes are needed to better meet the needs of the elderly with dementia and their families now and in the future. Without these changes, dementia care is likely to continue to fall short. [ABSTRACT FROM AUTHOR]

Research studies demonstrate wide variation in how physicians diagnose and treat patients with similar medical conditions and suggest that at least some of the variation reflects inefficiencies and unnecessary medical costs. Health care researchers are actively examining ways to reduce variations in practice through standardization of medicine to reduce the cost of treatment and ensure the quality of outcomes. The most widely accepted form of this standardization is Evidence Based Best Practices (EBBP). Furthermore, financial health care providers such as hospitals and managed care organizations are investigating methods to tie resource usage to medical protocols in their efforts to monitor and control health care costs. Such proposals are contentious because they report on physicians’ medical practice behaviors (such as the number of tests ordered, use of specific therapies, etc.) and such reports could potentially be used to influence their clinical behaviors. The intent of this exploratory study was to examine physicians’ perceptions about linking a standard costing system to EBBP guidelines. The authors interviewed nine practicing physicians asking each physician to respond to the question, ‘As a physician working in a hospital environment, what are your reactions to and concerns with combining standard costing techniques with EBBP?’ The interviews were in-depth and free form in nature. The physicians’ responses were recorded and analyzed using Grounded Theory Methodology. Using this methodology the field data was categorized into two major themes. The most important theme centered on ethics and the second theme was concerned with the implementation and use of a standard cost system in regard to EBBP. If physicians’ worries about ethical dilemmas and implementation issues are not resolved, then it is likely that doctors would be unwilling to participate in any efforts to develop or use a standard cost-reporting system in medicine. While this study was exploratory in nature, it should provide future guidance to accountants, health care researchers and health care providers about physicians’ issues with the use of standard costing methods in medicine. [ABSTRACT FROM AUTHOR]

Objectives: To identify the different practice profiles of general practitioners (GPs) in order to test the hypothesis of heterogeneity in physician behaviour.Data: For the year 2000, 4,660 GPs from two regions in France.Variables: volume and structure of the physicians' medical activity, income level, personal characteristics, socioeconomic and geographical environment, characteristics of their patients.Methods: A cluster analysis to identify different practice profiles and a regression analysis to display the determinants of the physicians' activity.Results: Four different homogeneous groups can be identified, each one associating a physician's level of activity to his socioeconomic status. The level and the intensity of medical activity depend on individual factors, patients' characteristics as well as the socioeconomic context.Conclusions: There is no uniformity in the way GPs practice medicine. An immediate consequence is that any cost-containment measure that is applied uniformly to all GPs inevitably results in different outcomes according to the physicians' category type. [ABSTRACT FROM AUTHOR]

Background: Prostate cancer screening (PCS) is controversial. Ideally, patients should understand the risks and benefits of screening before undergoing PSA testing. This study assessed whether primary care physicians routinely discuss PCS and explored the barriers to and facilitators of these discussions.Methods: Qualitative pilot study involving in-depth, semistructured interviews with 18 purposively sampled, academic and community-based primary care physicians. Barriers and facilitators of PCS discussions were ascertained using both interviews and chart-stimulated recall--a technique utilizing patient charts to probe recall and provide context to physician decision-making during clinic encounters. Analysis was performed using consensus conferences based on grounded theory techniques.Results: All 18 participating physicians reported that they generally discussed PCS with patients, though 6 reported sometimes ordering PSA tests without discussion. A PCS discussion occurred in only 16 (36%) of the 44 patient-physician encounters when patients were due for PCS that also met criteria for chart-stimulated recall. Barriers to PCS discussion were patient comorbidity, limited education/health literacy, prior refusal of care, physician forgetfulness, acute-care visits, and lack of time. Facilitators of PCS discussion included patient-requested screening, highly educated patients, family history of prostate cancer, African-American race, visits for routine physicals, review of previous PSA results, extra time during encounters, and reminder systems.Conclusions: PCS discussions sometimes do not occur. Important barriers to discussion are inadequate time for health maintenance, physician forgetfulness, and patient characteristics. Future research should explore using educational and decision support interventions to involve more patients in PCS decisions. [ABSTRACT FROM AUTHOR]

BACKGROUND: Uncertainty shapes many decisions made by physicians everyday. Uncertainty and physicians' inability to handle it may result in substandard care and Unexplained variations in patterns of care. OBJECTIVE: To describe socio-demographic and professional characteristics of reactions to uncertainty among physicians from all specialties, including physicians in training. DESIGN: Cross-sectional postal survey. PARTICIPANT: AU physicians practicing in Geneva, Switzerland (n= 1,994). MEASUREMENT: Reaction to medical care uncertainty was measured with the Anxiety Due to Uncertainty and Concern About Bad Outcomes scales. The questionnaire also included items about professional characteristics and work-related satisfaction scales. RESULTS: After the first mailing and two reminders, 1,184 physicians responded to the survey. In univariate analysis, women, junior physicians, surgical specialists, generalist physicians, and physicians with lower workloads had higher scores in both scales. In multi- variate models, sex, medical specialty, and workload remained significantly associated with both scales, whereas clinical experience remained associated only with concern about bad outcomes. Higher levels of anxiety due to uncertainty were associated with lower scores of work-related satisfaction, while higher levels of concern about bad outcomes were associated with lower satisfaction scores for patient care, personal rewards, professional relations, and general satisfaction, but not for work-related burden or satisfaction with income-prestige. The negative effect of anxiety due to uncertainty on work-related satisfaction was more important for physicians in training. CONCLUSION: Physicians' reactions to uncertainty in medical care were associated with several dimensions of work-related satisfaction. Physicians in training experienced the greatest impact of anxiety due to uncertainty on their work-related satisfaction. Incorporating strategies to deal with uncertainty into residency training may be useful. [ABSTRACT FROM AUTHOR]

Background: Despite accurate diagnostic tests and effective therapies, the management of osteoporosis has been observed to be suboptimal in many settings. We tested the effectiveness of an intervention to improve care in patients at-risk of osteoporosis.Design: Randomized controlled trial.Participants: Primary care physicians and their patients at-risk of osteoporosis, including women 65 years and over, men and women 45 and over with a prior fracture, and men and women 45 and over who recently used > or =90 days of oral glucocorticoids.Intervention: A multifaceted program of education and reminders delivered to primary care physicians as well as mailings and automated telephone calls to patients.Outcome: Either undergoing a bone mineral density (BMD) testing or filling a prescription for a bone-active medication during the 10 months of follow-up.Results: After the intervention, 144 (14%) patients in the intervention group and 97 (10%) patients in the control group received either a BMD test or filled a prescription for an osteoporosis medication. This represents a 4% absolute increase and a 45% relative increase (95% confidence interval 9-93%, p = 0.01) in osteoporosis management between the intervention and control groups. No differences between groups were observed in the incidence of fracture.Conclusion: An intervention targeting primary care physicians and their at-risk patients increased the frequency of BMD testing and/or filling prescriptions for osteoporosis medications. However, the absolute percentage of at-risk patients receiving osteoporosis management remained low. [ABSTRACT FROM AUTHOR]

Background: Evaluating the quality of care provided by individual primary care physicians (PCPs) may be limited by failing to know which patients the PCP feels personally responsible for.Objective: To develop and validate a model for linking patients to specific PCPs.Design: Retrospective convenience sample.Participants: Eighteen PCPs from 10 practice sites within an academic adult primary care network.Measurements: Each PCP reviewed the records for all outpatients seen over the preceding 3 years (16,435 patients reviewed) and designated each patient as "My Patient" or "Not My Patient." Using this reference standard, we developed an algorithm with logistic regression modeling to predict "My Patient" using development and validation subsets drawn from the same patient set. Quality of care was then assessed by "My Patient" or "Not My Patient" designation by analyzing cancer screening test rates.Results: Overall, PCPs designated 11,226 patients (68.3%, range per provider 15% to 93%) to be "My Patient." The model accurately categorized patients in development and validation subsets (combined sensitivity 80.4%, specificity 93.7%, and positive predictive value 96.5%). To achieve positive predictive values of > 90% for individual PCPs, the model excluded 19.6% of PCP "My Patients" (range 5.5% to 75.3%). Cancer screening rates were higher among model-predicted "My Patients."Conclusions: Nearly one-third of patients seen were considered "Not My Patient" by the PCP, although this proportion varied widely. We developed and validated a simple model to link specific patients and PCPs. Such efforts may help effectively target interventions to improve primary care quality. [ABSTRACT FROM AUTHOR]

Background: Referral from primary care to the mental health specialty sector is important but poorly understood.Objective: Identify physician characteristics influencing mental health referral.Design: Randomized controlled trial using Standardized Patients (SPs).Setting: Offices of primary care physicians in 3 cities.Participants: One hundred fifty-two family physicians and general internists recruited from 4 broad practice settings; 18 middle aged Caucasian female actors.Intervention: Two hundred and ninety-eight unannounced SP visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder.Measurements: Mental health referrals via SP written reports; physician and system characteristics through a self-administered physician questionnaire.Results: Among 298 SP visits, 107 (36%) resulted in mental health referral. Referrals were less likely among physicians with greater self-confidence in their ability to manage antidepressant therapy (adjusted odds ratio [AOR] 0.39, 95% confidence interval [CI] 0.17 to 0.86) and were more likely if physicians typically spent > or =10% of professional time on nonclinical activities (AOR 3.42, 95% CI 1.45 to 8.07), had personal life experience with psychotherapy for depression (AOR 2.74, 95% CI 1.15 to 6.52), or usually had access to mental health consultation within 2 weeks (AOR 2.94, 95% CI 1.26 to 6.92).Limitation: The roles portrayed by SPs may not reflect the experience of a typical panel of primary care patients.Conclusions: Controlling for patient and health system factors, physicians' therapeutic confidence and personal experience were important influences on mental health referral. Research is needed to determine if addressing these factors can facilitate more appropriate care. [ABSTRACT FROM AUTHOR]

It is widely recognized that general practitioners (GPs) play a key role in determining the use of resources for ambulatory care. In addition to the GPs' working hours, these resources consist of the work of specialists and that of hospital physicians treating the GPs' referrals and the cost of medication and other measures induced by the GP. Different systems of remuneration differ in their power to lead to efficient service provision. This contribution provides empirical evidence on the efficiency of service provision by Austrian GPs. The analysis is based on data for some 600 GPs. The data comprise sufficient information to assess the GPs' efficiency with regard to the way they manage their cases. Data Envelopment Analysis, a nonparametric technique, is used to estimate the production frontier. The results suggest that almost one-half of the GPs in the sample have a relative efficiency of 0.8 or less. A Malmquist decomposition of the productivity change reveals a decline in productivity. This is due to a pronounced negative shift of the frontier whereas individual efficiency rises against the weaker benchmark of the new frontier. [ABSTRACT FROM AUTHOR]

The article presents 10 bold steps to prevent physician burnout in practicing general internal medicine. Burnout is a long-term stress reaction which includes exhaustion, depersonalization and lack of sense of personal accomplishment. It mentions the possible issues of physician burnouts for both health care organizations and patients. It also lists the ten quality improvement (QI) models for health organizational self-care.

Background: This study aimed to develop and provide a psychometric and feasibility pilot evaluation of the Heart Failure (HF) Symptom Tracker (HFaST), a new patient-reported tool designed to facilitate communication between patients and health care providers (HCPs) in routine clinical care. The HFaST enables patients to identify worsening HF symptoms, with a long-term goal of preventing hospitalizations or emergency room visits. Methods: The HFaST was developed drawing on evidence from the literature, qualitatively with cognitive interviews (12 patient/caregiver and 8 HCPs), and evaluated quantitatively (psychometric, feasibility assessment). The HFaST was administered for 7 consecutive days to 100 individuals diagnosed with HF during a multisite, non-interventional US pilot study. Health care providers then completed a survey assessing the feasibility and importance of the HFaST in clinical practice. Qualitative development included a literature review and cognitive interviews with patients, caregivers, and HCPs. The psychometric properties of the HFaST were evaluated using classical test theory methods. Descriptive statistics provided insight into HCPs' perceptions of the feasibility of using the HFaST in clinical practice. Results: A preliminary set of 40 items was developed for the symptom tracker and iteratively reduced to 10 items based on the qualitative phase. Test-retest reliability (weighted kappa 0.71–0.97), discriminating validity, and construct validity of the HFaST were acceptable. HCPs rated the HFaST as a good (70%) or excellent (30%) means of tracking HF symptoms. Six HFaST items were ultimately retained, covering concepts of fatigue, shortness of breath (3 items), swelling, and rapid weight gain. Conclusions: The 6-item HFaST is an easy-to-use tool designed to raise patients' awareness of HF symptoms and facilitate communication with HCPs. Future research should evaluate HFaST implementation in clinical practice and effectiveness as an intervention to potentially prevent hospitalizations and emergency room visits. [ABSTRACT FROM AUTHOR]

The article reports on the results of a survey that show pharmaceutical companies-sponsored medical courses inclined training material in favour of commercial interests. According to the author, the industry spends over $1 billion a year to fund more than half of the continuing medical education (CME) courses that qualified physicians are required to take. Despite that drug firms are scrupulous about separating their CME involvement from promotional efforts, some may be influencing doctors and may even be putting the health of their patients at risk.

Objective:To improve the management of obese adults (18–75 y) in primary care.Design:Cohort study.Settings:UK primary care.Subjects:Obese patients (body mass index ≥30 kg/m2) or BMI≥28 kg/m2 with obesity-related comorbidities in 80 general practices.Intervention:The model consists of four phases: (1) audit and project development, (2) practice training and support, (3) nurse-led patient intervention, and (4) evaluation. The intervention programme used evidence-based pathways, which included strategies to empower clinicians and patients. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation.Main outcome measures:Proportion of practices trained and recruiting patients, and weight change at 12 months.Results:By March 2004, 58 of the 62 (93.5%) intervention practices had been trained, 47 (75.8%) practices were active in implementing the model and 1549 patients had been recruited. At 12 months, 33% of patients achieved a clinically meaningful weight loss of 5% or more. A total of 49% of patients were classed as ‘completers’ in that they attended the requisite number of appointments in 3, 6 and 12 months. ‘Completers’ achieved more successful weight loss with 40% achieving a weight loss of 5% or more at 12 months.Conclusion:The Counterweight programme provides a promising model to improve the management of obesity in primary care.Sponsorship:Educational grant-in-aid from Roche Products Ltd.European Journal of Clinical Nutrition (2005) 59, Suppl 1, S93–S101. doi:10.1038/sj.ejcn.1602180 [ABSTRACT FROM AUTHOR]