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Rationale: The principle of inseparability of teaching, academic research and assistance to patients, to which university physicians are subject in carrying out their work, invites reflection, aimed at identifying a combination of the three activities characterised, at the same time, by efficiency and effectiveness. Aims and Objectives: The present paper illustrates a paradigm based on the balance of intrinsic and extrinsic motivations with the purpose of identifying an efficient solution in the performance of the duties of university doctors. Methods: The analysis refers to Italy in terms of the main scenario, or, conversely, the achievement of more profit‐related goals. Results and Conclusion: Depending on the prevailing goal, it is possible to recognise the superiority of the constitutional principles. [ABSTRACT FROM AUTHOR]

Copyright of Review of Policy Research is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The relationship between attendance at birth and maternal mortality rates: an exploration of United Nations’ data sets including the ratios of physicians and nurses to population, GNP per capita and female literacy Background. This is the third and final paper drawing on data taken from United Nations (UN) data sets. The first paper examined the global distribution of health professionals (as measured by ratios of physicians and nurses to population), and its relationship to gross national product per capita (GNP) (). The second paper explored the relationships between the global distribution of physicians and nurses, GNP, female literacy and the health outcome indicators of infant and under five mortality rates (IMR and u5MR) (). In the present paper, the global distribution of health professionals is explored in relation to maternal mortality rates (MMRs). The proportion of births attended by medical and nonmedical staff defined as ‘attendance at birth by trained personnel’ (physicians, nurses, midwives or primary health care workers trained in midwifery skills), is included as an additional independent variable in the regression analyses, together with the ratio of physicians and nurses to population, female literacy and GNP. Aim. To extend our earlier analyses by considering the relationships between the global distribution of health professionals (ratios of physicians and nurses to population, and the proportion of births attended by trained health personnel), GNP, female literacy and MMR.

Managed care and organized systems of care are restructuring the delivery of care in the United States. As care is reorganized, physician practice styles, autonomy, and compensation are undergoing profound changes. To successfully integrate physicians into the new managed systems of care, their organizational relationship to and their compensation within these systems must be carefully considered. This paper first explores physician motivation as it is related to compensation. The paper then describes a variety of emerging organizational designs aimed at aligning the interests of physicians and hospitals. The author considers fully integrated, physician-hospital organizations with target income compensation arrangements to be most suitable to the collective success of professionals and organized systems of care. The paper concludes with a discussion of the many dilemmas and challenges posed by the intertwining of managed care, organized networks of care, and professional compensation. [ABSTRACT FROM AUTHOR]

Aim To explore the debate on the development of the nurse practitioner profession in the Netherlands. Background In the Netherlands, the positives and negatives of nurse practitioners working in the medical domain have been debated since the role was introduced in 1997. The outcome of the debate is crucial for nurse practitioners' professional development and society's justification of their tasks. Method Review of 14 policy documents, 35 opinion papers from nurses, 363 opinion articles from physicians and 24 Dutch research papers concerning nurse practitioners from 1995 to 2012. Results Two discourses were revealed: one related to efficiency and one to the development of the profession. In both, the nurse practitioner role was presented as a solution for healthcare and workforce problems, while arguments differed. The efficiency discourse seemed most influential. Opinions of nurse practitioners were underrepresented; taking up new responsibilities was driven by the wish to improve patient care. While most physicians were willing to delegate tasks to nurse practitioners, they wished to retain final responsibility for medical care. Limitations All available publications were extensively studied, which could not include unpublished policy documents from the government or influential parties. This may have led to some selectivity. Conclusion The case of the Netherlands shows that nurses in developing their advanced role are facing barriers, similar to those in other countries. The dominance of efficiency arguments combined with protection of medical autonomy undermines the development towards nursing care that really benefits patients. Implications for nursing and health policy Nurse practitioners should strive to obtain positions in which they are allowed to make their own decisions and wise use of healthcare resources for the good of patients and society. Nurse practitioners should aim to become members of influential healthcare Boards in their countries, in which they can raise their voices and be involved in policy making. [ABSTRACT FROM AUTHOR]

The aim of this paper is to explore the consequences of modernisation and regulatory processes for the everyday lives of doctors working the UK National Health Service. We do this by reporting on interview data generated as part of a qualitative investigation into the working lives of 47 doctors. The analysis of the empirical findings is informed by two literatures: that which has sought to theorise the contemporary thrust of regulation and audit and that which has developed a sociology of embodiment. Doctors’ views are presented in relation to four areas of work which have – in the loosest sense of the word – been subject to regulation. Drawing on work from the sociology of embodiment we argue that changes in the institutional and cultural context of medical work could be altering both the ‘field’ and the ‘habitus’– to use Bourdieu's terms – of medicine, with a consequence that medical knowledge is becoming less embodied. [ABSTRACT FROM AUTHOR]

Recent UK health policy initiatives promote a ‘no blame culture’ and learning from adverse events to enhance patient safety in the NHS. Similar initiatives exist in the USA and Australia. Changing the ‘blame culture’ in the NHS has been advocated in policy documents and inquiry reports for over a decade. Some key concepts that are used in the policy discourse –‘blame’; mistakes, errors and misdemeanours; and ‘culture’– are examined and considered in the light of pertinent social science literature to question some of the assumptions concerning these terms in the policy discourse, and to suggest some alternative questions and perspectives. The Three Inquiries, a recent series of statutory inquiries held in the UK, are used as a case study to explore some of the intra- and inter-professional difficulties of reporting errors and misconduct by medical practitioners. The paper offers an interpretive social science perspective as an alternative to more policy oriented and managerial approaches to patient safety issues, focusing on deeper structural aspects of organisational phenomena implicated in the ability or otherwise of medical and other healthcare staff to report mistakes and misconduct as one aspect of patient safety. [ABSTRACT FROM AUTHOR]

The article discusses various reports published within the issue, including one by Avery Kolers on the moral obligations of health care professionals, one by Weinstock on the religious rights of health care professionals and one by Kantymir and McLeod on the conscience of health care professionals.

The article shares the experiences of a physician regarding the impact of his travels on his capacity to carry out various medical procedures. In one of the physician's travels he came across another method of abdominal wall repair. He has also wondered how the ability to avoid pain after a stapled hemorrhoidopexy.

Evidence-based practice (EBP) has been heralded as the most appropriate way of ensuring that patients receive the most effective care possible. It does, however, have several limitations. It is also not enough just to locate and evaluate the evidence without implementing it. This paper discusses EBP and its limitations and potential barriers; it also suggests strategies for changing current practices to more evidence-based ones according to an accurate understanding of the concept of EBP. [ABSTRACT FROM AUTHOR]

Multidisciplinary and interprofessional working is currently a priority in health care policy, in caring for patients and in health professional education. Realising multidisciplinary approaches presents challenges in the context of changes in doctors' and nurses' roles and the increased emphasis placed on communication with patients. In communication in consultations, explanations are employed in the service of numerous activities, including decision making, diagnosis and physical examination, but they have been little studied. This paper presents findings from a comparative study of doctors' and nurses' communication with patients in multidisciplinary health care, focusing on diabetes in primary care. Video- and audio-recorded consultations were subjected to conversation analysis. Output from discussion groups with patient representatives and health professionals underwent qualitative analysis. Distinctive features of explanations in nurses' and doctors' consultations with patients were identified. These can be understood by reference to patterns of communication. Nurses' communication was mediated by patients' contributions; doctors' communication gave an overarching direction to the consultation as a whole. While nurses' explanations began from the viewpoint of a patient's responsibility and behaviour, doctors' explanations began from the viewpoint of biomedical intervention. Their consultations lent different opportunities for patients' involvement. Nurses' and doctors' communications each exhibit their own distinct features. Specification of these features, when considered in the context of a particular consultation activity such as explanations, allows both recognition of the distinct contributions each profession can offer and identification of ways of combining these to maximum effect. This has implications for policy, for practice and for interprofessional education. [ABSTRACT FROM AUTHOR]

Objective: To describe the distribution of pediatricians and family physicians (child physicians) across school districts and examine the association between physician supply and third‐grade test scores. Data Sources and Study Setting: Data come from the January 2020 American Medical Association Physician Masterfile, the 2009–2013 and 2014–2018 waves of American Community Survey 5‐Year Data, and the Stanford Education Data Archive (SEDA), which uses test scores from all U.S. public schools. We use covariate data provided by SEDA to describe student populations. Study Design: This descriptive analysis constructs a physician‐to‐child‐population ratio for every school district in the country and describes the child population served by the current distribution of physicians. We fit a set of multivariable regression models to estimate the associations between district test score outcomes and district physician supply. Our model includes state fixed effects to control for unobservable state‐level factors, as well as a covariate vector of sociodemographic characteristics. Data Collection: Public data from three sources were matched by district ID. Principal Findings: Physicians are highly unequally distributed across districts: nearly 3640 (29.6%) of 12,297 districts have no child physician, which includes 49% of rural districts. Rural children of color in particular have very little access to pediatric care, and this inequality is more extreme when looking exclusively at pediatricians. Districts that have higher child physician supplies tend to have higher academic test scores in early education, independent of community socioeconomic status and racial/ethnic composition. While the national data show this positive relationship (0.012 SD, 95% CI, 0.0103–0.0127), it is most pronounced for districts in the bottom tertile of physician supply (0.163 SD, 95% CI, 0.108–0.219). Conclusions: Our study demonstrates a highly unequal distribution of child physicians in the U.S., and that children with less access to physicians have lower academic performance in early education. [ABSTRACT FROM AUTHOR]

Objective: To analyze how physician clinical note length and composition relate to electronic health record (EHR)‐based measures of burden and efficiency that have been tied to burnout. Data Sources and Study Setting: Secondary EHR use metadata capturing physician‐level measures from 203,728 US‐based ambulatory physicians using the Epic Systems EHR between September 2020 and May 2021. Study Design: In this cross‐sectional study, we analyzed physician clinical note length and note composition (e.g., content from manual or templated text). Our primary outcomes were three time‐based measures of EHR burden (time writing EHR notes, time in the EHR after‐hours, and EHR time on unscheduled days), and one measure of efficiency (percent of visits closed in the same day). We used multivariate regression to estimate the relationship between our outcomes and note length and composition. Data Extraction: Physician‐week measures of EHR usage were extracted from Epic's Signal platform used for measuring provider EHR efficiency. We calculated physician‐level averages for our measures of interest and assigned physicians to overall note length deciles and note composition deciles from six sources, including templated text, manual text, and copy/paste text. Principal Findings: Physicians in the top decile of note length demonstrated greater burden and lower efficiency than the median physician, spending 39% more time in the EHR after hours (p < 0.001) and closing 5.6 percentage points fewer visits on the same day (p < 0.001). Copy/paste demonstrated a similar dose/response relationship, with top‐decile copy/paste users closing 6.8 percentage points fewer visits on the same day (p < 0.001) and spending more time in the EHR after hours and on days off (both p < 0.001). Templated text (e.g., Epic's SmartTools) demonstrated a non‐linear relationship with burden and efficiency, with very low and very high levels of use associated with increased EHR burden and decreased efficiency. Conclusions: "Efficiency tools" like copy/paste and templated text meant to reduce documentation burden and increase provider efficiency may have limited efficacy. [ABSTRACT FROM AUTHOR]

Codes of medical ethics (codes) are part of a longstanding tradition in which physicians publicly state their core values and commitments to patients, peers, and the public. However, codes are not static. Using the historical evolution of the Canadian Medical Association's Code of Ethics as an illustrative case, we argue that codes are living, socio‐historically situated documents that comprise a mix of prescriptive and aspirational content. Reflecting their socio‐historical situation, we can expect the upheaval of the COVID‐19 pandemic to prompt calls to revise codes. Indeed, Alex John London has argued in favour of specific modifications to the World Medical Association's International Code of Medical Ethics (which has since been revised) in light of moral and scientific failures that occurred during the COVID‐19 pandemic. Responding to London, we address the more general question: should codes be modified to reflect lessons drawn from the COVID‐19 pandemic or future such upheavals? We caution that codes face limitations as instruments of policy change because they are inherently interpretive and 'multivocal', that is, they usually underdetermine or provide more than one answer to the question, 'What should I do now?' Nonetheless, as both prescriptive and aspirational documents, codes also serve as tools for reflection and deliberation—collective practices that are necessary to engaging with and addressing the moral and scientific uncertainties inherent to medicine. [ABSTRACT FROM AUTHOR]

Every Doctor, Every Setting: a national framework to guide coordinated action on the mental health of doctors and medical students, 2019 [website]. https://lifeinmind.org.au/every-doctor-every-setting (viewed Feb 2022). For many years, the Australasian Doctors' Health Network (http://www.adhn.org.au/) of doctors' health services has provided confidential helplines for medical practitioners. Keywords: Doctors' health; Health policy; Education, professional EN Doctors' health Health policy Education, professional 338 341 4 09/27/22 20221001 NES 221001 Coordinated systemic change and enhanced access to care are needed to improve doctors' wellbeing Over the past decade, there has been growing recognition of the prevalence of psychological distress across the medical profession and that practitioner wellbeing has significant implications for patient safety. [Extracted from the article]

Background: The supply of primary care physicians is associated with better health outcomes and a lower total cost of health services. However, the effect of the presence or absence of primary care physicians on health‐related quality of life (QOL) is unknown. We comparatively investigated the health‐related QOL of ordinary citizens according to the presence or absence of a primary care physician. Methods: We conducted an observational cross‐sectional study using a propensity score analysis. A questionnaire on health‐related QOL (SF‐36v2, age, gender, presence or absence of a primary care physician, and chronic disease status) was mailed to 2200 individuals identified through stratified random sampling. We used propensity scores to compensate for covariates and analyzed three component SF‐36 summary scores and subscale scores of the "primary care physician" and "no primary care physician" groups. Results: Valid responses were received from 1095 individuals (49.8%). The "primary care physician group" comprised 653 individuals (59.6%). The physical health component scores of the "primary care physician group" were significantly lower than those of the "no primary care physician group," and the "mental health component" scores were significantly higher (p = 0.032, p = 0.009). For the subscales, scores for "vitality" and "mental health" were significantly higher in the "primary care physician group" (p = 0.014, p = 0.018). Conclusions: Patients who had a primary care physician with whom they could comfortably consult at any time had a high mental health component score, and low physical health component score in the health‐related QOL. [ABSTRACT FROM AUTHOR]

Antimicrobial resistance control programmes often aim to "fix" the behaviour of antibiotic users and prescribers. Such behavioural interventions have been widely criticised in social science literature for being inefficient and too narrow in scope. Drawing on these criticisms, this article analyses how political programmes for fixing antibiotic behaviours were adapted into the practices of health‐care professionals and patients in Russia. In 2018, we conducted interviews with medical doctors, pharmacists and patients in a Russian city; focusing on their practices around the policy requirement introduced in 2017 which obligated medical prescriptions of antibiotics. We conceptualised the obligatory medical prescription as a political technique which sought to change practices of self‐treatment and over‐the‐counter sales of medications by establishing doctors as an obligatory passage point to access antibiotics. Our analysis shows that the requirement for medical prescriptions does not fulfil the infrastructural gaps that influence antibiotic practices. By navigating the antibiotic prescriptions, doctors, pharmacists and patients informally compensate for the gaps in the existing infrastructure creating informal networks of antibiotic care parallel to the requirement of obligatory prescriptions. Following these informal practices, we could map the inconsistencies in the current policy approaches to tackle AMR as a behavioural rather than infrastructural problem. [ABSTRACT FROM AUTHOR]

BACKGROUND: The dissemination and implementation (D&I) of evidence‐based initiative (EBIs) is critical to improved public health. The Asthma 411 EBI was piloted in Texas from 2013 to 2015. The pilot's evaluation assessed its effectiveness and identified approaches to support D&I of school‐health EBIs. METHODS: The pilot study was conducted in two schools; service categories included: a consulting physician, enhanced school asthma services, and support for links to community health resources. Data was collected on Emergency Medical Service (EMS) calls, aggregated nursing services, demographic characteristics, availability of medication provided through existing policies, and informal interviews. RESULTS: During the pilot, school‐day asthma‐related Emergency Medical Service (EMS) calls were eliminated. Documented asthma self‐management education, authorization for rescue medication, and efforts to communicate with parents and health providers increased. Between year‐1 and year‐2, the gap between unadjusted, weighted mean absences among students with and without asthma was reduced by 1.1 days. However, this difference was not seen in a fully adjusted negative, binomial regression model. CONCLUSIONS: Evaluation of the Asthma 411 pilot suggests many EBI benefits were retained and identifies factors that may facilitate D&I of school health EBIs. Future research will clarify impacts on absenteeism and determine if observed benefits are sustained. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: Inappropriate antibiotic prescribing is still a major concern that can lead to devastating outcomes including antibiotic resistance. This study aimed to simulate the antibiotic prescribing behaviour by providers for acute respiratory tract infections (ARTIs) and to evaluate the impact of patient expectation, provider's perception of patient's expectation to receive a prescription, and patient's risk for bacterial infection, on the decision to prescribe. Methods: We developed a unique system dynamics (SD) simulation model based on the significant factors that impact the interaction between provider and patient during visits for ARTIs and the decision to prescribe antibiotics. In order to validate the model for different age groups and regions in the United States, we used the sample of 53 000 ARTI patient visits made at outpatient settings between 1993 and 2015, based on the National Ambulatory Medical Care Survey (NAMCS). Results: Simulation results reveal that physician diagnosis for prescribing antibiotics is based on physician's experience from their prior prescribing behaviour, their perception of patient's infection risk, and patient's expectation to receive antibiotics. Also, there are some variations depending on patient's age and residential region. The simulation analysis also depicts the decreasing trend in patient's expectation over the past two decades for most age groups and regions. Conclusions: Given the high number of unnecessary prescriptions for ARTI, we found that policies are needed to influence provider's prescribing behaviour through patient's expectation and provider's perception regarding those expectations. Our simulation framework can further be used by policymakers to design and evaluate interventions that may modify the interaction between health providers and patients to optimize antibiotic prescriptions among ARTI patients for different regions and age groups. [ABSTRACT FROM AUTHOR]

Copyright of European Policy Analysis is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Physician‐assisted death (PAD) has long been a strongly debated moral and public policy issue in the United States, and an increasing number of jurisdictions have legalized this practice under certain circumstances. In light of changing terminology, laws, public and professional attitudes, and the availability of published data about the practice, we review key concepts and terms in the ongoing PAD debate, moral arguments for and against PAD, the current legal status of PAD in the United States and in other nations, and data on the reported experience with PAD in those U.S. jurisdictions where it is a legal practice. We then identify situations in which emergency physicians (EPs) may encounter patients who request PAD or have attempted to end their lives with physician assistance and consider EP responses in those situations. Based on our analysis, we offer recommendations for emergency medical practice and professional association policy. [ABSTRACT FROM AUTHOR]

Background: Outpatients receive observation services to determine the need for inpatient admission. These services are usually provided without the use of condition‐specific protocols and in an unstructured manner, scattered throughout a hospital in areas typically designated for inpatient care. Emergency department observation units (EDOUs) use protocolized care to offer an efficient alternative with shorter lengths of stay, lower costs, and higher patient satisfaction. EDOU growth is limited by existing policy barriers that prevent a "two‐service" model of separate professional billing for both emergency and observation services. The majority of EDOUs use the "one‐service" model, where a single composite professional fee is billed for both emergency and observation services. The financial implications of these models are not well understood. Methods: We created a Monte Carlo simulation by building a model that reflects current clinical practice in the United States and uses inputs gathered from the most recently available peer‐reviewed literature, national survey, and payer data. Using this simulation, we modeled annual staffing costs and payments for professional services under two common models of care in an EDOU. We also modeled cash flows over a continuous range of daily EDOU patient encounters to illustrate the dynamic relationship between costs and revenue over various staffing levels. Results: We estimate the mean (±SD) annual net cash flow to be a net loss of $315,382 (±$89,635) in the one‐service model and a net profit of $37,569 (±$359,583) in the two‐service model. The two‐service model is financially sustainable at daily billable encounters above 20, while in the one‐service model, costs exceed revenue regardless of encounter count. Physician cost per hour and daily patient encounters had the most significant impact on model estimates. Conclusions: In the one‐service model, EDOU staffing costs exceed payments at all levels of patient encounters, making a hospital subsidy necessary to create a financially sustainable practice. Professional groups seeking to staff and bill for both emergency and observation services are seldom able to do so due to EDOU size limitations and the regulatory hurdles that require setting up a separate professional group for each service. Policymakers and health care leaders should encourage universal adoption of EDOUs by removing restrictions and allowing the two‐service model to be the standard billing option. These findings may inform planning and policy regarding observation services. [ABSTRACT FROM AUTHOR]

Aim: The study explored the views and attitudes of nurses and physicians on family presence during resuscitation in emergency departments in Brazil. Background: International emergency associations endorse family presence during resuscitation; however, the extent to which it is practiced remains unclear, particularly in the Brazilian context. Research of emergency staff views and attitudes towards this practice is desirable so that actions can be identified to support families at the bedside. Methods: A qualitative research was conducted. Thirty‐two health professionals (11 physicians and 21 nurses) working in two emergency departments in southern Brazil were purposefully recruited in January 2015. In‐depth interviews were conducted, and data were analysed using content analysis. Findings: Nurses and physicians found family presence during resuscitation controversial and the general attitude towards this practice was negative. They reported that 'changes are needed' to adapt hospital infrastructures for family presence, and to train staff to respond to the information and emotional needs of families. Discussion: Translating a family nursing framework into clinical practice involves the need for reassessing educational and management policies in clinical contexts. Conclusion: This research brings new understanding about the attitudes of some Brazilian nurses and physicians on the implementation of family presence during resuscitation and identifies the need to develop policies and strategies to improve family presence in emergency departments. Implications for nursing and health policy: Hospital‐based policies are required to improve family‐centred care in emergency departments while providing a criterion of legality and safety to professionals to invite families to be present during invasive procedures. Also, family‐focused education in health science degrees, continuing education and in the community is required. [ABSTRACT FROM AUTHOR]

Context Matching the supply of health workers to need is necessary if a health system is to be sustainable, affordable and fit for purpose. On the 30th anniversary of the 1988 Edinburgh Declaration of the World Federation for Medical Education, levels of compliance with the 10th recommendation, 'Ensure admission policies that match the numbers of students trained with national needs for doctors', warrant review. There are two domains to such a review, concerning, respectively, how well these health needs are known, and whether workforce supply is well matched. Methods This is a literature review-based analysis of extant health system planning, which underpins current understanding of national health needs and of the consequent alignment of student selection processes. Results The core finding is that national need for doctors, and any other health workers, is not confidently known for any jurisdiction. Consequently, validation of student selection processes is impossible against this endpoint and data to validate these processes against the alternative endpoint of a positive impact on health outcomes do not exist. Data do exist to suggest some student selection processes result in desirable career and career location uptakes. [ABSTRACT FROM AUTHOR]

Objective Systematically describe the characteristics of rural specialists, their work and job satisfaction by geographical location of work. Design Cross-sectional. Setting and participants Three thousand, four hundred and seventy-nine medical specialists participating in the 2014 Medicine in Australia: Balancing Employment and Life ( MABEL) survey of doctors. Main outcome measure Location of practice, whether metropolitan, large (>50 000 population) or small regional centres (<50 000 population). Result Specialists working in large regional centres had similar characteristics to metropolitan specialists, however, those in small regional centres were more likely men, later career, overseas-trained and less likely to work privately. Rural specialists had more on-call requirements and poorer professional development opportunities. However, satisfaction with work hours, remuneration, variety of work, level of responsibility, opportunities to use abilities and overall satisfaction did not differ. Specialists in general medicine and general surgery were significantly more likely to work rurally compared with anaesthetists, particularly in small regional centres, whereas a range of other relevant specialists had lower than the average rural distribution and paediatricians and endocrinologists were significantly less likely to work in large regional centres. Conclusion Rural specialists are just as satisfied as metropolitan counterparts reporting equivalent variety and responsibility at work. Better support for on-call demands and access to professional development could attract more specialists to rural practice. Increased rural training opportunities and regional workforce planning is needed to develop and recruit relevant specialties. Specifically, targeted support is warranted for training and development of specialists in general medicine and general surgery and overseas-trained specialists, who provide essential services in smaller regional centres. [ABSTRACT FROM AUTHOR]

This study aimed to determine whether the label status of a medicine penetrates into the clinical reasoning of Australian medical practitioners and to explore the possible reasons for our findings using semistructured interviews with 14 Australian physicians. The interviews revealed 3 broad catalysts for off-label prescribing. The first of these was lack of awareness or understanding of the regulatory process in general and labels more specifically. The second was the perception that labels are not meaningful guides for clinical practice. The third was the recognition of alternative mechanisms for ensuring safe, rational, and evidence-based prescribing occurs. This research suggests that Australian physicians do not consider whether a medicine is off-label to be a reliable measure of the appropriateness of their prescribing practices. Rather, the legitimacy of prescribing practices is determined by the abilities, skills, and knowledge base of particular prescribers by a culture that encourages and supports evidence-based practice, and safe prescribing. Although labels are of minimal clinical significance, there are real conceptual, practical, and moral problems associated with conflating 'good' or 'better' practice with 'on-label' practice, and 'bad' or 'worse' practice with off-label prescribing as often occurs. To ascribe greater meaning to the term 'off-label' than is warranted can have the unintended consequence of casting suspicion on and making it more difficult for physicians to provide appropriate clinical care. We conclude that labeling can, in some cases, provide assurances to both clinicians and patients that their medications have been demonstrated to be safe and effective, but that clinicians should be able to continue to prescribe responsibly off-label without having any stigma attached to their practice. [ABSTRACT FROM AUTHOR]

The author discusses the importance of relying on data to resolve problems with clinician retention in loan repayment initiatives. Topics covered include the launch of scholarship programs in Great Britain to boost health care workforce size. Also mentioned is the implication of the programs for the communities and incentives received by clinicians.

The study examined whether high cost-sharing policies for physician care are associated with reduced care utilization and costs differently between individuals with and without chronic conditions. Findings from this study contribute to the benefit structure design of health plans that may improve care delivery efficiencies and maintain health outcomes among chronically ill individuals. The study used the 2010-2011 Medical Expenditure Panel Survey data with a retrospective cohort study design. Difference in difference, negative binomial regression, and generalized linear models were employed to analyze the utilization and cost data. In order to account for national survey sampling design, weight and variance were adjusted. The study sample consisted of 4,368 individuals. Multivariate analysis and sensitivity analysis found consistent patterns between utilization and cost models. High cost-sharing policies for physician care were not associated with different levels of reductions in care utilization and costs between chronically ill people and healthy people (all at p > 0.05). However, the stratification analysis indicated that chronically ill people reduced physician care use and costs to the similarly significant extent as healthy people in response to high cost-sharing policies. Relative to non-chronically ill individuals, chronically ill individuals may decrease their care utilization and expenditures to a similarly significant extent in response to increased physician care cost sharing. This may be due to patients' inability to discern care cost-effectiveness, a short observation window, and chronic condition characteristics. It is possible that, in the long run, these sick people would demonstrate substantial demands for downstream medical care, such as inpatient care, and there could ultimately be a total cost increase for them and their families at the micro level. Health plans need to be cautious of policies for chronically ill private enrollees, such as considering a low cost-sharing policy for physician care or primary care. Individuals with chronic conditions may consider insurance plans with low levels of cost sharing in physician care, especially when more public information about health plan features and designs is available to facilitate their decision-making process. Future studies should examine this research question with a longer observation period and with more measures, such as physician behaviors. [ABSTRACT FROM AUTHOR]

This article reviews the ethics of rhetoric in critical care. Rational appeals in critical care fail to move patients or surrogates to a better course of action. Appeals to their emotions are considered illegitimate because they may preclude autonomous choice. This article discusses whether it is always unethical to change someone's beliefs, whether persuasive communication is inherently harmful and whether it leaves no space for voluntariness. To answer these questions, the article engages with Aristotle's work, Rhetoric. In considering whether there is a place for emotionally charged messages in a patient-provider relationship, the article intends to delineate the nature of this relationship and describe the duties this relationship implies. The article presents examples of persuasive communication used in critical care and discusses whether providers may have a duty to persuade patients. This duty is supported by the fact that doctors often influence patients' and families' choices by framing presented options. Doctors should assume responsibility in recognizing these personal and contextual influences that may influence the medical choices of their patients. They should attempt to modify these contextual factors and biases in a way that would assist patients and families in reaching the desired outcomes. The opening sections surveyed a number of definitions found in relevant literature and outlined some of the concepts included in the proposed definition. This definition helps to distinguish instances of persuasion from cases of manipulation, coercion and deception. Considering the fact that patients and families often make irrational decisions and the fact that doctors inadvertently influence their choices, the article suggested that persuasion can be a positive tool in medical communication. When patients or families clearly do not understand the risks or make decisions that contradict their long-term goals, persuasion can be used as a positive influence. [ABSTRACT FROM AUTHOR]

The concept of medical necessity plays a central role in many healthcare systems, including Canada's, by helping determine which healthcare services will receive funding. Despite its significance in health policy frameworks, medical necessity has proven to be notoriously difficult to define and operationalise. A shift toward a more personalised and genetically-informed approach to the provision of healthcare seems likely to heighten associated policy challenges. One of the stated goals of personalised medicine is to save healthcare systems money by facilitating the use of less and more effective treatments. However, any cost saving potential may ultimately be thwarted by physicians' legal and ethical obligations, given that physicians will inevitably be required to implement and define the bounds of genetically-informed medical necessity for their patients. [ABSTRACT FROM AUTHOR]

Background Approximately 40 percent of individuals using out-of-network physicians experience involuntary out-of-network care, leading to unexpected and sometimes burdensome financial charges. Despite its prevalence, research on patient experiences with involuntary out-of-network care is limited. Greater understanding of patient experiences may inform policy solutions to address this issue. Objective To characterize the experiences of patients who encountered involuntary out-of-network physician charges. Methods Qualitative study using 26 in-depth telephone interviews with a semi-structured interview guide. Participants were a purposeful sample of privately insured adults from across the United States who experienced involuntary out-of-network care. They were diverse with regard to income level, education, and health status. Recurrent themes were generated using the constant comparison method of data analysis by a multidisciplinary team. Results Four themes characterize the perspective of individuals who experienced involuntary out-of-network physician charges: (1) responsibilities and mechanisms for determining network participation are not transparent; (2) physician procedures for billing and disclosure of physician out-of-network status are inconsistent; (3) serious illness requiring emergency care or hospitalization precludes ability to choose a physician or confirm network participation; and (4) resources for mediation of involuntary charges once they occur are not available. Conclusions Our data reveal that patient education may not be sufficient to reduce the prevalence and financial burden of involuntary out-of-network care. Participants described experiencing involuntary out-of-network health care charges due to system-level failures. As policy makers seek solutions, our findings suggest several potential areas of further consideration such as standardization of processes to disclose that a physician is out-of-network, holding patients harmless not only for out-of-network emergency room care but also for non-elective hospitalization, and designation of a mediator for involuntary charges. [ABSTRACT FROM AUTHOR]

Objective To provide a conceptual framework and to assess the availability of empirical data for supply-side microsimulation modeling in the context of health care. Data Sources Multiple secondary data sources, including the American Community Survey, Health Tracking Physician Survey, and SK&A physician database. Study Design We apply our conceptual framework to one entity in the health care market-physicians-and identify, assess, and compare data available for physician-based simulation models. Principal Findings Our conceptual framework describes three broad types of data required for supply-side microsimulation modeling. Our assessment of available data for modeling physician behavior suggests broad comparability across various sources on several dimensions and highlights the need for significant integration of data across multiple sources to provide a platform adequate for modeling. A growing literature provides potential estimates for use as behavioral parameters that could serve as the models' engines. Sources of data for simulation modeling that account for the complex organizational and financial relationships among physicians and other supply-side entities are limited. Conclusions A key challenge for supply-side microsimulation modeling is optimally combining available data to harness their collective power. Several possibilities also exist for novel data collection. These have the potential to serve as catalysts for the next generation of supply-side-focused simulation models to inform health policy. [ABSTRACT FROM AUTHOR]

To cite this article: Int J Dent Hygiene 10, 2012; 91-97 DOI: 10.1111/j.1601-5037.2011.00520.x Clovis JB, Brillant MGS, Matthews DC, Cobban SJ, Romanow PR, Filiaggi MJ, McNally ME. Using interviews to construct and disseminate knowledge of oral health policy. Abstract: Objectives: Policymakers worldwide are challenged by the problem of oral health inequities. The goal of an interprovincial partnership in Canada was to guide policy aimed at improving the oral health of vulnerable populations. Insights regarding barriers and enablers to developing such policy in one province (Newfoundland & Labrador, Canada) were required to enhance collaboration between decision makers and researchers and to contribute to the evidence informing policy development. Methods: Snowball technique identified fourteen key informants. Semistructured audio-recorded interviews were conducted in person or by telephone. Two researchers independently conducted the analyses of the transcribed interviews, one using NVivo software and the second, manual coding. Triangulation of the analyses confirmed the findings. Results: Agreement between the two approaches showed that most key informants believed that oral health is an important policy issue; however, most felt it was not a high priority among the general public and most were unable to articulate the policy process. Barriers to oral health becoming a governmental priority were related to resource allocation and to poor communication among some groups including dentists and dental hygienists. Current government programmes and initiatives were praised but considered weak in health promotion strategies. Recommendations for enhancing oral health priority varied. Conclusions: Attention to the methodological considerations of qualitative research enhanced the credibility of the method and confidence in the findings. Leveraging of existing programmes and improving communication were recommended to contribute to raising the priority of oral health within the government, thereby increasing their commitment to address oral health care, particularly for vulnerable populations. [ABSTRACT FROM AUTHOR]

During the 1980s and 1990s, innovations in the organization, funding, and delivery of primary health care in Canada were at the periphery of the system rather than at its core. In the early 2000s, a new policy environment emerged. This policy analysis examines primary health care reform efforts in Canada during the last decade, drawing on descriptive information from published and gray literature and from a series of semistructured interviews with informed observers of primary health care in Canada. Primary health care in Canada has entered a period of potentially transformative change. Key initiatives include support for interprofessional primary health care teams, group practices and networks, patient enrollment with a primary care provider, financial incentives and blended-payment schemes, development of primary health care governance mechanisms, expansion of the primary health care provider pool, implementation of electronic medical records, and quality improvement training and support. Canada's experience suggests that primary health care transformation can be achieved voluntarily in a pluralistic system of private health care delivery, given strong government and professional leadership working in concert. [ABSTRACT FROM AUTHOR]

Objective. To examine the extent to which health plan quality measures capture physician practice patterns rather than plan characteristics. Data Source. We gathered and merged secondary data from the following four sources: a private firm that collected information on individual physicians and their health plan affiliations, The National Committee for Quality Assurance, InterStudy, and the Dartmouth Atlas. Study Design. We constructed two measures of physician network overlap for all health plans in our sample and linked them to selected measures of plan performance. Two linear regression models were estimated to assess the relationship between the measures of physician network overlap and the plan performance measures. Principal Findings. The results indicate that in the presence of a higher degree of provider network overlap, plan performance measures tend to converge to a lower level of quality. Conclusions. Standard health plan performance measures reflect physician practice patterns rather than plans' effort to improve quality. This implies that more provider-oriented measurement, such as would be possible with accountable care organizations or medical homes, may facilitate patient decision making and provide further incentives to improve performance. [ABSTRACT FROM AUTHOR]

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Background : With the introduction of new and advanced nursing roles, the nursing profession is undergoing dynamic change. Realizing changes will be easier to accomplish if the nursing community and other healthcare professionals welcome the process. Recently the nursing staff mix in Israel has been undergoing a transformation: encouraging registered nurses to enhance their status by acquiring academic degrees and advanced professional training, and initiating the adoption of new nursing roles. Objective : Our goal is to evaluate Israeli nurses' and physicians' attitudes to the introduction of new nursing roles and to expanding the scope of nursing practice. Methods : Two hundred and fifteen nurses and 110 physicians from three large general hospitals and 15 community clinics filled in a questionnaire. Findings : In general the majority of the nurses supported expansion of nursing practice, and such expansion did not cause significant opposition among physicians. However when the task affected patients' health, physicians were less willing to permit nurses to perform skills previously their responsibility alone. In addition, using multiple logistic regressions, support of the expansion of nursing practice was significantly higher among nurses in management or training positions, and among academically accredited nurses. Support for expanded roles was prominent among hospital physicians, graduates from Israeli schools of medicine, and less-tenured physicians. Conclusions : We suggest that confirmation by various groups of physicians and nurses of standardized definitions of the new boundaries in the scope of nursing practice roles could successfully promote development of new roles and facilitate integration of the Israeli healthcare system into the global context of change. Clinical Relevance : Inter- and intra-professional collaboration, agreement, and understanding regarding advanced nursing practice roles and their introduction into the healthcare system might improve the relationship between healthcare professions and ultimately increase quality of care and patient satisfaction. [ABSTRACT FROM AUTHOR]

To examine whether racial and ethnic differences in the distribution of individuals across types of health plans explain differences in satisfaction and trust with their physicians.Data were derived from the 1998–1999 Community Tracking Household and Followback Studies and consisted of a nationwide sample of adults (18 years and older).The data were collected by telephone survey. Surveys were administered in English and Spanish. The response rate for the Household Survey was 63 percent, and the match rate for the Followback Survey was 59 percent.Multivariate analyses used regression methods to detect independent effects of respondent race and ethnicity on satisfaction and trust with physician, while controlling for enrollment in different types of health plans.Racial and ethnic minorities are more likely than whites to have lower levels of trust and satisfaction with their physician. The most prominent differences occurred within the Latino and Native American/Asian American/Pacific Islander/Other (“Other”) populations. Plan type does not mitigate the relationship between race/ethnicity and trust and satisfaction for the overall adult population.Disparate levels of trust and satisfaction exist within ethnic and minority populations, even when controlling for the distribution of individuals across types of health plans. The results demonstrate a need to better understand the health care-related factors that drive disparate trust and satisfaction. [ABSTRACT FROM AUTHOR]

The author proposes goingBeyond attitudes() to a more nuanced assessment of doctors’ discursive variations. Through an application of) interpretative repertoires, she defined three voices– technical, normative and pragmatic– in which Bolivian doctors spoke of abortion. In State and social security hospital contexts, doctors hastened to express compliance with government policy and institutional norms regulating abortion and postabortion care. Technical and pragmatic considerations, however, often entered into conflict with established rules. When contradictions became apparent in their own discourse, doctors regularly drew on the Saving Women device. This accounting strategy enabled them to save face as up-to-date professionals through justifying temporary deviance from norms in terms of benefit to women treated. The author describes her development of the repertoires, their validation with different medical audiences, and doctors’ critical appropriation of the model to explain their own discursive variations. [ABSTRACT FROM AUTHOR]

The article focuses on the public health policy of Denmark "keeping the elderly at home as long as possible." The policy is adopted in other European countries, is now being appraised for restructuring, much to the opposition of the Danish Nurses Organization (DNO). Convinced that the strategy should continue. DNO hosted a conference to get a European perspective from ministers. administrators, social workers and physicians in addition to nurses from other countries. Encouraged by the conference outcome and desirous of informing other health care professionals about how a high quality care programme can be established for elderly citizens, DNO has published a booklet containing the papers from the conference which provide the case for maintaining high quality care for the elderly.

The article focuses on the national health insurance scheme for medical practitioners in Great Britain. The panel system was based on the state health insurance scheme that was introduced by the National Insurance Act of 1911, and came into effect in 1913. The system was gradually increased to cover a greater proportion of the working population. Initially, the act included those aged between 16 and 70 employed in manual labour or in non-manual jobs with an income less than 160 pounds per year. In 1920 this limit was raised to 250 pounds; in 1928 the upper age limit was reduced to 65; and in 1937 the lower limit was also altered since juveniles under 16, but in employment, were added to the panel. This meant that in Great Britain, 13.7 million were insured by 1914 and 19.2 million by 1936; a rise from 47 to 54 percent of the adult population. However, not all the insured population were enrolled on doctors' panels, so that by 1936 only 17.6 million, or 50 percent, of the adult population were panel patients.

The major stimulus for the extensive, state level, reform of medical malpractice during the past two decades was the widespread belief in a malpractice crisis The perception of a crisis arose in the 1960s largely because of what was viewed as sudden and dramatic increases in the malpractice liability of physicians However, historical data demonstrate that the common perception that physician liability increased suddenly and dramatically beginning in the 1960s is incorrect Since malpractice reform has been based upon the false premise that the medical malpractice liability system, previously working smoothly, was in disarray, the soundness of much of the malpractice reform which has occurred in the past two decades is questioned [ABSTRACT FROM AUTHOR]

The article discusses arbitrary restrictive patterns of health care delivery that limit direct access patterns to specialist. A gatekeeper may be a primary care physician or occasionally another specialist or physician extender to whom a defined population is assigned and who is required either to provide all health care or to authorize care from other specialists, if necessary, for the assigned individuals. Legislation enacted in 1981 permitted states to request waivers of freedom of choice for Medicaid beneficiaries so they could be required to participate in arbitrarily restrictive programs limiting direct access to specialist care.

The article discusses that the shortage of human donor corneas has stimulated interest in corneal xenotransplantation, with porcine corneas being considered a feasible source. Partial-thickness acellular porcine corneal grafts are in use but there has been no clinical application of fresh (cellular) porcine corneas, which is considered true “xenotransplantation” by the World Health Organization.