Search

Introduction and aims: Czech music therapists lacked the skills and knowledge to adapt their practice to virtual music therapy (VMT) at the beginning of the COVID-19 pandemic, when physical contact was restricted. The aims of this project were to implement the best evidence-based recommendations concerning VMT in the practice of Czech music therapists and increase the number of therapists using VMT. Methods: The project used the JBI Evidence Implementation Framework to promote change in the practice of participants. A baseline audit of 26 practitioners was conducted using questionnaires and interviews. The audit criteria consisted of 8 best practice recommendations, followed by the implementation of targeted strategies and a follow-up audit. Results: Of the 26 music therapists, 18 began practicing VMT following the rollout of the implementation strategies. Strategies included educational workshops, instructional materials, technological support, individual counseling, and interactive training sessions. There was an increase in compliance with all audit criteria. The most critical barriers were lack of knowledge about VMT and lack of technical skills; lack of resources; technological challenges; low confidence of music therapists to provide VMT; and reduced need for VMT after the lockdown restrictions were relaxed. Conclusions: The implementation project helped to overcome temporary pandemic restrictions, increase the quality of VMT practice, develop strategies for VMT training, and identify reasons for using VMT during the pandemic and beyond. [ABSTRACT FROM AUTHOR]

Introduction: Very few papers investigated the etiologic breakdown and demographic characteristics of patients with facial nerve (FN) palsy. Our paper aims to present the etiologic breakdown and demographic characteristics of patients with FN palsy, presenting at a private care center between 2014 and 2019, along with the treatment modalities that were offered to them., Methods: Charts of 800 patients with facial palsy (FP) were reviewed. Data included the etiology of their diagnosis, family history, recurrent FP, demographic information, and treatment provided before and after presentation., Results: Seventy-five percent of our study population were females. The average period between diagnosis with FP and presentation at our center was 10.8 years. The most commonly identified etiology was Bell's palsy, followed by acoustic neuroma. Eighty-one percent of the study subjects were prescribed steroids and/or antivirals. Facial neuromuscular retraining, electrical stimulation, chemodenervation, and surgical intervention were also part of some treatment plans for our population., Discussion: Recommendations for the treatment of idiopathic FP include steroids with adjuvant antiviral medications. Data remains uncertain whether the combination therapy of steroids and antivirals has better results compared to steroids alone. Electrical stimulation is still a controversial therapeutic tool for facial paralysis with a potential role in exacerbating synkinesis. The difference in referral patterns between tertiary and private care centers can explain the disparity in the ranking of the etiologies between our study and what has been published., Conclusion: Management of FP is a complex process. The FN community must develop a common database to improve its understanding of the different presentations., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Cash-based physical therapy, a model in which the clinicians do not accept insurance payments and accept only direct payment, is quickly becoming an enticing option for clinicians who own their own practice. The purpose of this study was to describe service utilization for a single cash-based physical therapy clinic. Forty-eight charts of patients who had been discharged between 2013 and 2016 were randomly selected. The data were deidentified prior to the researchers gaining access. Chronic diagnoses were predominately prevalent (n = 28). The lumbo/pelvic region of diagnoses (39.6%) and knee/leg region of diagnoses (29.2%) encompassed the majority of the diagnoses. The mean physical therapy utilization for the cohort per episode of care was 8.0 ±8.1 visits per episode of care, total cost of $780.19 ± 530.30 per episode of care, and $97.52 per visit. This study is the first to present data regarding costs, utilization, and patient demographics for a cash-based physical therapy clinic. [ABSTRACT FROM AUTHOR]

Background: To facilitate the expansion of nurse practitioners working in community and primary health settings, legislative changes were enacted in 2010. These led to privately practicing nurse practitioners (PPNPs) being enabled to provide care subsidized through the Australian Government Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme. Little is known about the impact of this legislation on patient access to care in Australia. Purpose: To explore how, why and in which contexts PPNP services in Australia impact on patient access to care. Methods: Semistructured interviews using realist evaluation were undertaken with 20 participants, selected through stratified sampling using geographic criteria (State/territory in which practicing) and dividing the sample representatively between those who worked solely in private practice and those who worked in both private and public practice. Thematic analysis of qualitative data was undertaken. Conclusion: Findings suggest that PPNPs have increased access to care for patients, predominantly in community and primary health settings. Implications for practice: In increasing access to care, PPNPs have the potential to reduce hospital and general practitioner attendance, thereby potentially reducing the ever-increasing demand for health care. [ABSTRACT FROM AUTHOR]

Background and Purpose: Self-employed nurse practitioners (NPs) have been part of the American health care landscape since the 1970s, owning practices throughout the United States. The purpose of this study was to explore andmeasure the 2 characteristics of job satisfaction and empowerment in self-employed NPs practicingwithin the 50 states and District of Columbia and to explore factors that influence these characteristics. Methods: A convergent parallel design, mixed methods study, using a survey and semistructured interviews, was completed. The survey included the Misener Job Satisfaction Survey and Conditions of Work Effectiveness Ques- tionnaire II. Conclusions: Self-employed NPs are satisfied and empowered. The more empowered, the higher their level of job satisfaction. Over 40% practiced with full practice authority in a rural location, and 50% had over 10 years of experience as both an RN and NP. Their experience in private practice was explored further in the interviews. Implications for practice: This study identifies barriers to job satisfaction and empowerment in self-employed NPs, including physician oversight and lack of businessmanagement education. Continuingwork to remove restricted and reduced state regulatory environments and to provide education on business management may increase the number of NPs in private practice, expanding access to health care in the United States. [ABSTRACT FROM AUTHOR]

Purpose Australian private practice nurse practitioner (PPNP) services have grown since legislative changes in 2010 enabled eligible nurse practitioners (NPs) to access reimbursement for care delivered through the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS). This article provides data from a national survey on the workforce characteristics of PPNPs in Australia. Method PPNPs in Australia were invited to complete an electronic survey. Quantitative data were analyzed using descriptive statistics and qualitative data using thematic analysis. There were 73 completed surveys. Conclusions One of the intentions of expanding access to MBS and PBS for patients treated by NPs was to increase patients' access to health care through greater flexibility in the healthcare workforce. The results of this survey confirm that the workforce characteristics of PPNPs provide a potentially untapped resource to meet current primary healthcare demand. Implications for practice The findings of this study allow us to understand the characteristics of PPNP services, which are significant for workforce planning. The focus of PPNP practice is toward primary health care with PPNPs working predominantly in general practice settings. The largest age group of PPNPs is over 50 years and means a proportion will be retiring in the next 15 years. [ABSTRACT FROM AUTHOR]

Purpose Advanced Practice Registered Nurse (APRN)-owned clinics in Texas are becoming more common and because of the success of these early clinics, more APRNs are considering opening their own practice; but Texas remains one of the most restrictive states for APRN practice and many questions remain. What are the regulations about physician delegation? Will you get reimbursed from insurance companies and at what rates? Can you be a primary care provider (PCP)? Data sources Changes enacted after the adoption of Senate Bill 406 improved the opportunities for APRNs in Texas yet several requirements must be met and early consultation with a lawyer and accountant can facilitate the initial business setup. The Prescriptive Authority Agreement simplified the delegation requirements and allows the APRN increased flexibility in obtaining and consulting with a delegating physician. Becoming credentialed as a PCP with private insurance companies is often complicated; however, utilizing the Council for Affordable Quality Healthcare's Universal Provider Data source for initial credentialing can facilitate this. Conclusions and implication for practice Although this article does not discuss the financial implications of opening a practice, it does cover many aspects including legislative and regulatory requirements for practice, credentialing process and challenges, business structure, and tax implications. [ABSTRACT FROM AUTHOR]

Purpose of Review: Private equity has made significant inroads into the specialty of ophthalmology. The purpose of this review is to evaluate the effect of private equity on clinical operations in an ophthalmic practice., Recent Findings: Private equity had become an important source of capital and management expertise that has resulted in the consolidation of many ophthalmic practices as an alternative to working for a hospital system, insurance carrier, or independent private practice., Summary: The recent growth of private equity presence in ophthalmology has resulted in significant changes in clinical operations. These changes in clinical operations include the increased importance of data management and data analytics, economies of scale, synergies, and introduction of patient-shared billing opportunities. Although physician input into clinical operations is decreased, provisional care decision-making can be maintained., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: This study aimed to determine benefits of the Enhanced Recovery After Surgery (ERAS) pathway implementation in free flap breast reconstruction related to postoperative narcotic use and health care resource utilization., Methods: A retrospective analysis of consecutive patients undergoing deep inferior epigastric perforator flap breast reconstruction from November of 2015 to April of 2018 was performed before and after implementation of the ERAS protocol., Results: Four hundred nine patients met inclusion criteria. The pre-ERAS group comprised 205 patients, and 204 patients were managed through the ERAS pathway. Mean age, laterality, timing of reconstruction, and number of previous abdominal surgical procedures were similar ( p > 0.05) between groups. Mean operative time between both groups (450.1 ± 92.7 minutes versus 440.7 ± 93.5 minutes) and complications were similar ( p > 0.05). Mean intraoperative (58.9 ± 32.5 versus 31.7 ± 23.4) and postoperative (129.5 ± 80.1 versus 90 ± 93.9) morphine milligram equivalents used were significantly ( p < 0.001) higher in the pre-ERAS group. Mean length of stay was significantly ( p < 0.001) longer in the pre-ERAS group (4.5 ± 0.8 days versus 3.2 ± 0.6 days). Bivariate linear regression analysis demonstrated that operative time was positively associated with total narcotic requirements ( p < 0.001) and length of stay ( p < 0.001)., Conclusions: ERAS pathways in microsurgical breast reconstruction promote reduction in intraoperative and postoperative narcotic utilization with concomitant decrease in hospital length of stay. In this study, patients managed through ERAS pathways required 46 percent less intraoperative and 31 percent less postoperative narcotics and had a 29 percent reduction in hospital length of stay., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

The article discusses reimbursement trends related to medical nutrition therapy, private practice and the reimbursement process in the U.S. It is said that private practice grew significantly in the mid-to late 1980s. It has been realized that major health insurance has found that registered dietitians could play an effective role in a patiet's care.

As many registered dietitians prepare to enter private practice, the expected number of clients as well as reimbursement rates for diet counseling will be important factors to consider. This study found that the rate of nutrition referrals was 29 per 1000 insured lives and payment rates totaled 82% of billed charges in a large physician network in New England. This number was lower than recognized current reimbursement rates and gives some indication that dietitians should become more Familiar with coding guidelines for proper insurance reimbursement. Furthermore, these figures are important in monitoring how many private practices the industry can support and in projecting the rate of growth for the future. [ABSTRACT FROM AUTHOR]

This study identifies differences in rates of multiple chronic conditions at primary care and mental health visits to Community Health Centers and private practice providers using 2013 National Ambulatory Medical Care Survey data. Community health center visits had higher rates of 1 or more, 2 or more, and 3 or more chronic conditions for working-age patient visits (ages 18-64). There were no differences in other age groups. After controlling for age and other covariates using logistic regression, community health center visits had 35% higher odds of having any chronic condition and 31% higher odds of having 2 or more chronic conditions.

Background: Little is known regarding the effect of different emergency department (ED) practice models on computed tomography (CT) and ultrasound (US) utilization for suspected appendicitis in the ED and through the potential inpatient hospital stay., Objectives: Examination rates of CT and US for suspected appendicitis at 2 different pediatric EDs (PEDs) through hospital admission: an academic affiliated tertiary PED (site A) compared with a private practice tertiary care PED (site B)., Methods: All visits with the ICD-9 (International Classification of Diseases, Ninth Revision) chief complaint of abdominal pain were retrospectively examined from May 1, 2009, to February 21, 2012. Suspected appendicitis visits were defined as any visit with the chief complaint of abdominal pain where a complete blood cell count was obtained. Abdominal CT and US in the PED and during hospital admission were compared across the 2 sites. Return visits within 72 hours were evaluated for any missed appendicitis., Results: Overall appendicitis rates were similar at both sites: site A, 4.7%; site B, 4.0%. The odds of having a CT scan performed during visits to the PED for abdominal pain were significantly higher at site B (odds ratio [OR], 3.19; 95% confidence interval [95% CI], 2.74-3.71), whereas the odds of having an US at site B were the opposite (OR, 0.34; 95% CI, 0.28-0.40). When evaluating only the admitted visits, the odds of having a CT were also greater at site B (OR, 2.32; 95% CI, 1.86-2.94) and having an US were less (OR, 0.57; 95% CI, 0.44-0.73)., Conclusions: In this study of 2 PEDs with differing practice models, we identified a dramatic difference in imaging utilization among patients with suspected appendicitis.

Background: A limited number of studies have investigated the safety and efficacy of repetitive transcranial magnetic stimulation (rTMS) in the treatment of resistant depression in an outpatient private practice setting. We hypothesized that rTMS would be safe and effective in the treatment of resistant depression in a nonresearch population., Methods: We treated 22 outpatients with unipolar or bipolar depression who were experiencing a moderate to severe treatment-resistant major depressive episode (MDE). Treatment was based on a flexible dose schedule of either 5 Hz or 10 Hz rTMS applied over the left dorsolateral prefrontal cortex with modified parameters. Assessments were performed at baseline, then on a weekly basis. The patients had received at least 2 trials of antidepressant medication of an adequate dose and duration without satisfactory improvement in the index MDE., Results: There was a significant change in Montgomery-Asberg Depression Rating Scale scores from baseline (29.14±5.85) to the end of week 4 (16.27±11.20); 50.00% (11/22) were responders and 40.9% (9/22) achieved remission. No major side effects were observed aside from mild headache in some patients., Conclusions: rTMS applied to the left dorsolateral prefrontal cortex was safe and effective in an important subset of outpatients with a moderate to severe MDE in a naturalistic setting. Outcomes demonstrated response rates similar to research populations. Further larger studies are needed to confirm the safety and effectiveness of rTMS in naturalistic conditions.

Depersonalization disorder (DPD) is a debilitating dissociative condition with no proven treatments. Although the pathophysiology of DPD is poorly understood, there are reports of increased excitability of the prefrontal cortex in patients with this condition. The temporo-parietal junction may also play a major role in the conscious experience of the spatial unity of the normal self and body. Repetitive transcranial magnetic stimulation has been shown in some case studies to effectively treat this condition. This report describes an additional such case, a 26-year-old man with a 6-month history of DPD who responded safely and significantly to repetitive transcranial magnetic stimulation to the right temporo-parietal junction.

Background: Medical liability exposure varies based on scope of practice, patient demographics, and location of practice. There is a generally held belief that treatment of pediatric patients increases one's medicolegal risk. We examined a large national database of orthopaedic malpractice claims to determine if pediatric malpractice claims were associated with a less favorable medicolegal outcome compared with adults., Methods: Physician Insurers Association of America is an association of medical liability insurance carriers providing liability coverage for 60% of private practice physicians in the United States. The Physician Insurers Association of America data registry of closed medical liability claims was examined, including all orthopaedic claims between 1985 and 2012 in this review. Claims were categorized based on the age of the claimant (pediatric: less than 21 y, adult: 21 y or older). These groups were compared based on percentage of claims resulting in payment, indemnity paid, and years between occurrence of incident and filing of claim. In addition, the top 10 most prevalent claims were identified and compared between groups., Results: A total of 25,702 closed orthopaedic claims were included. Pediatric claims accounted for 13% of the data. The average time from incident to claim filing was 1.92 years for pediatrics and 1.59 years for adults. Pediatric claims resulted in a higher percent of payment (33% vs. 30%) and average indemnity paid ($189,732 vs. $180,171) compared with adults. Five of the top 10 conditions resulting in a claim in each group were the same. Comparing these 5 conditions, in general there were minimal differences in the average time to claim filing between the groups, but larger average indemnity paid in the pediatric group., Conclusions: There appear to be moderate differences in outcomes of orthopaedic malpractice claims between adult and pediatric patients. The longer statute of limitations associated with pediatric claims does not appear to portend a less favorable medicolegal outcome or excessively longer time to claims filing for pediatric patients.

Objectives: Electroconvulsive therapy (ECT) is a stigmatized treatment even among doctors. This restrains the accessibility of ECT for patients in need of this treatment. In Germany, the utilization of ECT is low as compared with other Western industrialized countries. However, increasing application rates of ECT in Germany indicate some degree of support from psychiatrists. Therefore, the present study examined the current attitudes among 3 subgroups of psychiatrists toward ECT., Methods: A questionnaire was sent through e-mail to 423 psychiatric hospitals in the Federal Republic of Germany and through facsimile to 2550 specialists working in private practice. One hundred eighty-three (43%) of the institutions applied ECT (ECT facilities) and 240 (57%) institutions did not apply (non-ECT facilities)., Results: Nine hundred eighty-three answers could be evaluated. One hundred fifteen (63%) of the 183 ECT facilities, 118 (49%) of the 240 non-ECT facilities, and 751 (30%) of the 2500 specialists working in private practice responded. The general attitude toward ECT was favorable: most of the participants agreed that ECT is used less often than it should be to best serve patients' interests (61%-89%) and that it should be applied more often (54%-79%). Most of the participants thought that the image of ECT has improved among psychiatrists (61%-74%) but has not changed among fellow physicians, patients, and the general population., Conclusions: A surprisingly positive attitude toward ECT was found in our study among all 3 groups of German psychiatrists, which might further help improve patients' access to this treatment.

Background: There has been no prospective evaluation of combined spinal-epidural (CSE) analgesia in a private practice setting and few studies have focused on pain relief during the second stage of labor and at delivery. In this randomized controlled trial, we compared verbal pain scores during the first and second stages of labor and at delivery in women receiving CSE or traditional epidural analgesia at a busy private maternity hospital., Methods: Healthy, term parturients received epidural or CSE analgesia for labor pain upon request. Epidural analgesia was initiated with 0.125% bupivacaine plus 2 μg/mL fentanyl, 15 mL; CSE analgesia was initiated with intrathecal plain bupivacaine 3.125 mg plus 5 μg fentanyl. Thereafter, patient-controlled epidural analgesia with 0.125% bupivacaine plus 2 μg/mL fentanyl was used for maintenance analgesia in both groups. The primary outcome was an assessment of "typical" pain, using a verbal rating pain score from 0 to 10, made at the end of the first stage of labor and shortly after delivery., Results: Data from 398 epidural and 402 CSE subjects were analyzed. The typical verbal rating pain score during the first stage was lower in the CSE group (mean: 1.4 vs 1.9; P < 0.001; 99.5% confidence interval [CI] for difference: -0.92, -0.14). Pain scores during the second stage of labor (1.7 vs 1.9; P = 0.17; 99.5% CI for difference: -0.82, 0.28) and at delivery (2.0 vs 2.0; P = 0.77; 99.5% CI for difference: -0.73, 0.59) were the same between groups. Fewer patients received an epidural top-up dose in the CSE group (16.4% vs 25.6%; P = 0.002; 99.5% CI for difference: -17.0%, -1.0%). Epidural catheters were replaced in 1.2% CSE vs 2% in the epidural group (P = 0.39; 99.5% CI for difference: -3.3%, 1.8%)., Conclusions: Compared with traditional epidural labor analgesia, CSE analgesia provided better first-stage analgesia despite fewer epidural top-up injections by an anesthesiologist.

Background: Numerous studies have examined the outcome of reduction mammaplasty. This study evaluates the cosmetic outcome after reduction mammaplasty from the perspective of the patient, a ward surgeon, and a private practitioner in plastic surgery, and analyzes which factors influence it., Methods: The material stems from a Danish quality assurance program in the public health care system. Nonparametric statistics and logistic regression were used to compare cosmetic outcomes and possible confounding., Results: Over 80 percent of the patients evaluated the short- and long-term cosmetic outcome as good or very good. The surgeons and especially the private practitioner were more critical. The evaluation of breast features also differs between patients and surgeons. The main issue for patients is symmetry. With time, patients and the private practitioner become more critical about the scars. Surgeons are most concerned about nipple bottoming out. Predictive factors for surgeons were the patient's age, body mass index, and postoperative complications. Evaluation by patients was, in addition to complications, influenced by the preoperative information given, confidence in the treatment, and the overall course on the ward., Conclusions: Patients evaluate cosmetic outcome significantly more favorably than surgeons and especially the private practitioner. They are also concerned about different breast features. Decreased nipple sensation does not influence the patient's evaluation. Evaluation by the surgeons depends on more objective measures than does evaluation by the patients. One must not underestimate the importance of factors such as preoperative information about the surgery and complications, together with proper and qualified care., Clinical Question/level of Evidence: Therapeutic, II.

The author uses his own recent experience as a basis for discussing the actualities of retiring and closing a private, solo, psychiatric practice of psychotherapy and psychoanalysis. The extended process includes a personal decision about whether, when, and how to retire; preparation of patients and arrangements for their ongoing care; dealing with legal requirements and professional obligations; and the mechanics of closing an office one has occupied for decades. Not the least of concerns is one's own personal transitions in lifestyle, professional persona, attachments to patients, and engagement in psychotherapeutic or psychoanalytic treatment relationships.

Objective: To evaluate maternal and neonatal outcomes of collaborative maternity care for a socioeconomically diverse patient population in a California community hospital., Methods: Collaborative practice structure and clinical guidelines were analyzed, as were de-identified electronic medical records for all primiparous women who delivered term singletons between 2000 and 2010 (N=4,426). Demographics, care processes, and perinatal outcomes were compared among women seen prenatally in a private collaborative practice compared with a Federally Qualified Health Center prenatal clinic run by nurse-midwives., Results: Evidence-based practices were used to achieve excellent perinatal outcomes. Three quarters of women received intrapartum nurse-midwifery care (74.4%). Few differences were seen in management or outcomes among women from different prenatal clinics despite significant variation in demographic and clinical characteristics. Private practice patients were older, less likely to be obese, and more likely to speak English compared with counterparts from public health clinics. They were also more likely to use hydrotherapy or epidural analgesia, or experience severe perineal laceration and repair. Overall, pharmacologic pain relief methods were limited: less than a quarter of primiparous women used narcotics (21.2%), epidural analgesia (23.7%), or warm water immersion (23.2%). Labor induction and augmentation, and cesarean delivery rates (12.5%), were similar among groups and low overall., Conclusion: A collaborative practice of low-tech, high-touch care results in high-quality maternity services. The care model holds promise for replication to address health disparities by limiting obstetric interventions and warrants further investigation with regard to associated costs and resultant outcomes., Level of Evidence: III.

Purpose: The purpose of this study was to retrospectively analyze patients with T1-T2N0 squamous cell carcinomas of the glottic larynx treated at a private institution, to review the pertinent literature, and to compare our outcomes to those of academic institutions., Methods and Materials: A total of 118 patients were treated with radiation therapy between May 1987 and August 2006 at a private institution and followed up for ≥2 years. Three patients were lost to follow-up between 18 and 19 months., Results: The 5-year local control rates were: T1a, 91%; T1b, 95%; T2a, 96%; and T2b, 100%. The 5-year ultimate local control rates after irradiation and including patients who were successfully salvaged with surgery after a local recurrence were: T1a, 94%; T1b, 100%; T2a, 96%; and T2b, 100%. Eight (7%) of the 118 patients developed a local recurrence. There were no isolated regional or distant recurrences. The 5-year overall survival rates were: T1a, 73%; T1b, 78%; T2a, 62%; and T2b, 69%. The 5-year cause-specific survival rates were: T1a, 96%; T1b, 100%; T2a, 100%; and T2b, 100%. Two patients experienced severe complications., Conclusion: Patients with limited T1aN0 cancers may be treated with either transoral laser excision or RT. Those with more advanced T1-T2N0 cancers are treated with definitive RT. We do not advocate elective nodal irradiation, even for those with bulky T2B malignancies. The addition of concomitant weekly cisplatin 30 mg/M² is considered for patients with T2B cancers. Open parotid laryngectomy is reserved for salvage of suitable patients with a local recurrence.

Background: Some patients with severe symptomatic aortic stenosis (AS) do not undergo aortic valve replacement (AVR) despite demonstrated symptomatic and survival advantages and despite unequivocal guideline recommendations for surgical evaluation., Methods and Results: In 3 large tertiary care institutions (university, Veterans Affairs, and private practice) in Washtenaw County, Mich, patients were identified with unrefuted echocardiography/Doppler evidence of severe AS during calendar year 2005. Medical records were retrospectively reviewed for symptoms, referral for AVR, calculated operative risk for AVR, and rationale as to why patients did not undergo valve replacement. Of 369 patients with severe AS, 191 (52%) did not undergo AVR. Of these, 126 (66%, 34% of total) had symptoms consistent with AS. The most common reasons cited for absent intervention were comorbidities with high operative risk (61 patients [48%]), patent refusal (24 patients [19%]), and symptoms unrelated to AS (24 patients [19%]). Operated patients had a lower Society of Thoracic Surgery-calculated perioperative mortality risk than unoperated patients (1.8% [interquartile range, 1.0 to 3.0%] versus 2.7% [interquartile range, 1.6 to 5.5%], P<0.001). However, 28 (24%) of 126 unoperated symptomatic patients had a calculated perioperative risk less than the median risk for patients who underwent AVR. Only 57 (30%) of 191 unoperated patients were evaluated by a cardiac surgeon. There were similar rates of intervention across practice settings, and similar rates of unoperated patients despite symptoms and low operative risk., Conclusions: One third of patients with severe AS are symptomatic but do not undergo AVR, with similar findings in multiple practice environments. For most unoperated patients, objectively calculated operative risks did not appear prohibitive. Despite this, a minority of unoperated patients were referred for surgical consultation. Some patients with severe symptomatic AS may be inappropriately denied access to potentially life-saving therapy.

Melanoma is a serious cancer whose incidence is growing. At this time, its prognosis is dependent on the Breslow index and therefore on early screening. The objective of the study was to evaluate the impact of a campaign to train general practitioners based, in particular, on learning the ABCDE rule. The training, performed by Réseau Mélanome Ouest, involved 210 general practitioners from the Pays de la Loire (Loire region) in France. Eight identical 2-h sessions were held between 2004 and 2006, conducted by a hospital dermatologist, a dermatologist in private practice, and a general practitioner as a moderator. The training was evaluated in two stages, with a self-administered questionnaire followed by a telephone survey. Thirty-six percent of the doctors stated that they had detected melanomas since the training over a median period of 27 months (2-39 months); 15% sent in the corresponding pathological anatomy reports on 37 confirmed melanomas from 30 doctors. The Breslow index scores of the melanomas detected ranged from 0.16 to 4 mm. Therefore, our training promoted the screening of a large number of melanomas, most of them with a low Breslow index. As a result, after a short prior training, the ABCDE rule clearly seems to be a valuable tool. Dermatologists retain an important role both in the diagnostic confirmation of melanomas and in the training of general practitioners.

Objectives: Transition of patients with inflammatory bowel disease (IBD) from pediatric to adult providers requires preparation. Gastroenterologists for adult patients ("adult gastroenterologists") may have expectations of patients that are different from those of pediatric patients. We sought to explore the perspectives of adult gastroenterologists caring for adolescents and young adults with IBD, to improve preparation for transition., Materials and Methods: A survey sent to 1132 adult gastroenterologists caring for patients with IBD asked physicians to rank the importance of patient competencies thought necessary in successful transition to an adult practice. Providers reported which problems occurred in patients with IBD transitioning to their own practice. Adult gastroenterologists were asked about medical and developmental issues that are unique to adolescence., Results: A response rate of 34% was achieved. Adult gastroenterologists reported that young adults with IBD often demonstrated deficits in knowledge of their medical history (55%) and medication regimens (69%). In addition, 51% of adult gastroenterologists reported receiving inadequate medical history from pediatric providers. Adult providers were less concerned about the ability of patients to identify previous and current health care providers (19%), or attend office visits by themselves (15%). Knowledge of adolescent medical and developmental issues was perceived as important by adult gastroenterologists; however, only 46% felt competent addressing the developmental aspects of adolescents., Conclusions: For successful transition, adolescents and young adults with IBD need improved education about their medical history and medications. Pediatric providers need to improve communication with the receiving physicians. In addition, adult providers may benefit from further training in adolescent issues. Formal transition checklists and programs may improve the transition of patients with IBD from pediatric to adult care.

Although the disease management industry has expanded rapidly, there is little nationally representative data regarding medical and behavioral health disease management programs at the health plan level. National estimates from a survey of private health plans indicate that 90% of health plan products offered disease management for general medical conditions such as diabetes but only 37% had depression programs. The frequency of specific depression disease management activities varied widely. Program adoption was significantly related to product type and behavioral health contracting. In health plans, disease management has penetrated more slowly into behavioral health and depression program characteristics are highly variable.

Background: A severe shortage of practicing rheumatologists in the workforce is predicted over the next 2 decades. Identification of factors impacting job satisfaction will be needed to design interventional strategies for physician retention., Objective: To examine predictors of job satisfaction among rheumatologists., Methods: A cross-sectional survey was conducted among rheumatologists from the American College of Rheumatology directory with a portion of this designed to examine their job satisfaction. Questions regarding demographics, practice setting and job satisfaction, emotional exhaustion, and personal accomplishment based from the Maslach Burnout Inventory were included. Also included was a rank item to prioritize perceived changes that would improve job satisfaction. The response rate was 30% (N = 285) and 236 were analyzed. Data were primarily analyzed by the independent samples chi2 test., Results: Physician demographics: mean age: 51 years, 76% were male, 27% were full time academicians, and 24% in solo practice. Significant differences (P < 0.04) between the "high" satisfaction versus "very good" and "low" satisfaction groups includes increased age and solo practice, which were associated with "high" satisfaction. Lower job satisfaction rating correlated with items rating emotional exhaustion (r(s) = -0.43) and better satisfaction with personal accomplishment (r(s) = 0.41, P < 0.001 for both). Priority ranking revealed that "better reimbursement for patient care" and "less administrative/business effort" were the most frequently reported items cited to improve job satisfaction., Conclusions: Measures to improve job satisfaction may promote physician retention as a means of addressing the predicted workforce shortage.

Study Design: Prospective cohort study of lumbar spinal fusion., Objective: To examine the functional changes subsequent to lumbar spinal fusion in a total procedure audit in a community spinal surgery practice., Summary of Background Data: Several randomized controlled trials have demonstrated efficacy of spinal fusion procedures across diagnoses, but demonstrating effectiveness in community practice has been more difficult. Hospital database studies demonstrate incidence, reoperation rates, and complications of spinal fusions, yet cannot demonstrate outcomes consistently. The challenge is to demonstrate functional benefits from spinal fusion in a community setting., Methods: Over a 5-year period all patients in a community practice who underwent lumbar spinal fusion procedures with additional pedicle screw stabilization for degenerative, spondylolytic and spondylolisthetic conditions, were evaluated with application of the Modified Rowland 23 point Questionnaire of Disability preoperatively, and at 1-year postoperative assessment. Statistical analysis was performed., Results: A median 10-point improvement in the Modified Roland Questionnaire score was achieved across 160 patients, and the improvement was highly statistically significant for the major diagnoses--degenerative spondylolisthesis, discogenic low back pain, and spondylolysis and isthmic spondylolisthesis. Greater reduction of disability was seen in primary procedures when compared with revision surgery, and in noncompensation patients when compared with compensation patients, although in neither case was the difference statistically significant., Conclusions: This study has demonstrated that consistent functional improvements can be achieved across a total population of lumbar spinal fusions in a nonacademic setting. It also demonstrated that use of prospective cohort analysis techniques, with adequate follow up, and minimal increased costs to patients and practice, is a sustainable prospective audit technique.

Background: Physician turnover threatens continuity of care for patients and is a huge expense for health care organizations. Health care organizations have been advised to help physicians build positive relations with colleagues, staff, and patients as a strategy to socially integrate physicians in the workplace and to increase physician retention. Although these recommendations are touted as "evidence-based" practices, the importance of workplace relationships for physician retention has not been established empirically., Purpose: The purpose of this study is to examine two questions: Are physicians who report better relationships with colleagues, staff, and patients less likely to intend to withdraw from practice? Do the effects of these relational factors differ for large-group and solo/small-group practice physicians?, Methodology: Using data from the Physician Worklife Survey, we analyzed the associations between physicians' reported relationships with colleagues, staff, and patients and intention to withdraw from practice within 2 years using logistic regression., Findings: : Relationships with colleagues had a significant and negative association with intended withdrawal from practice for large-group practice physicians. The joint effect of relationships with colleagues, staff, and patients was significant for large-group practice physicians, but it only approached significance for solo/small-group practice physicians., Practice Implications: This study suggests that workplace relationships may influence physicians' intention to withdraw from practice, but the mechanisms by which they do so are unclear. Possible interventions to improve physician retention include promotion of informal mentoring and efforts to support community involvement of physicians and their families. Further research examining the role of these and other programs in promoting physician retention can help employers to foster positive workplace relationships and improve retention.

Purpose of Review: The new graduate entering the private practice arena faces many challenges. Expectations regarding both the professional environment and personal lifestyle have changed from previous generations, and these are reviewed and discussed. The challenges for both professional and personal development and the responsibilities of the new graduate to continue to learn and stay on top of the specialty are enormous., Recent Findings: The best graduates add to the reputation and performance of a department. Marginal graduates have a much tougher experience; their career in a tertiary care, level 1 trauma center environment is unlikely to be sustainable. The motivation and expectations of the new graduates, as they relate to lifestyle, schedules, and reimbursement, have changed. The expectations of the practice, the institution, the payers, and the public have also changed and are increasingly focused on performance, efficiency, and safety., Summary: Anesthesiology continues to attract some of our best physicians, and this is vital for the survival of anesthesiology as a medical specialty. The new generation challenges us to make the necessary changes in practice pattern and lifestyle to sustain this goal. The new generation is also challenged by an environment of performance-based expectations.

Background: The muscle-sparing free transverse rectus abdominis muscle (TRAM) flap is a reliable technique that provides great versatility, with potentially decreased donor-site morbidity. However, because of the inherent nature of microvascular techniques, it is still regarded as a time-consuming and technically difficult procedure. The goal of this retrospective study was to document the validity of this technique in the private practice setting., Methods: Data were reviewed retrospectively and included patient demographics, total operative time, choice of recipient vessels, outcome, and perioperative morbidities., Results: One hundred one consecutive patients underwent 111 muscle-sparing free TRAM flap procedures for breast reconstruction (immediate, 89 patients; delayed, 12 patients). The internal mammary artery was used in 75 cases and the thoracodorsal artery was used in 36 cases. Average operative time was 185 minutes (3 hours 5 minutes). Average blood loss was 195 cc. There was no total flap loss. Revision of the microvascular anastomosis was performed in four patients, with flap salvage in all of them. Thirteen patients (13 percent) required primary mesh for abdominal wall closure. Fourteen (14 percent) had fat necrosis. Two patients had hematoma that required surgical evacuation. Abdominal wall weakness was detected in two patients (2 percent) and required mesh repair., Conclusions: The technical difficulties associated with the free TRAM flap have been ameliorated using a well-designed surgical plan and consistent technique performed by a team familiar with the procedure to achieve an acceptable average 3-hour operating time, with minimal complications. The authors advocate the muscle-sparing free TRAM flap as the operation of choice for unilateral breast reconstruction using autogenous tissue. The technique is expeditious and relatively safe.

Objective: To evaluate whether the performance of stapes surgery by residents during residency has decreased during the last 40 years, and if so, whether such a decrease has impacted the number of general otolaryngologists performing stapedectomy in the private practice setting., Study Design: Survey questionnaire of members of the American Academy of Otolaryngology-Head and Neck Surgery., Methods: A short questionnaire was mailed to 1,700 members of the American Academy of Otolaryngology-Head and Neck Surgery. Data collected included age, year of residency graduation, fellowship (if any), practice setting, geographic location, number of stapedectomies performed in residency, and number of stapedectomies performed currently., Results: Seven hundred fifty-six (44%) of 1,700 surveys were returned; 558 (74%) of 756 respondents did not complete a fellowship and were included in the general otolaryngologist group. Overall, 41% of general otolaryngologists are performing stapes surgery. There was a significant decline in the number of resident stapedectomies performed between 1960 and 1986; since 1986, this number has plateaued to an average of 8 to 9 (self-reported) cases per resident. More recent graduation from residency trended toward decreased inclination to do stapedectomy, although the result was not statistically significant. Increasing number of stapedectomy cases performed in residency correlated with an increased likelihood of performing the operation in practice., Conclusion: Despite a decreasing case volume of stapes surgery in residency, stapedectomy remains an operation performed by general otolaryngologists.

Apligraf is supplied as a ready-to-use living fibroblast and keratinocyte bilayer in culture. This therapy has been shown to facilitate healing of venous ulcers and diabetic foot ulcers. Several case reports suggest that Apligraf may also be effective in healing acute excisional wounds and complicated surgical defects. Apligraf can, in appropriate settings, be used as an alternative to autografts, avoiding the morbidity of donor site wounds. The present case review summarizes outcomes in 16 patients with 18 complicated surgical and nonsurgical wounds treated with Apligraf, which was meshed or fenestrated as needed to obtain better wound coverage and to allow drainage. Of 16 patients, 15 (94%) experienced complete healing (16 of 18 wounds; 89%). Both surgical and nonsurgical wounds responded well, with healing times ranging from 21 to 550 days. Patients generally stated that they were satisfied with their degree of healing and with the opportunity to avoid the surgical procedures associated with autograft donor sites.

The prevalence of autistic spectrum disorder (ASD) in the United States is approximately 1 in 150 children. Many health care providers are unaware of parental beliefs and treatments, both medical and complementary, that parents use for their child with ASD. Understanding these beliefs and practices concerning diagnosis, cause, and utilization of medical and complementary care may help physicians provide better comprehensive care. Parents of children with ASD from 2 private practices-one in New York and one in New Jersey-were mailed a 6-page, self-administered survey. In addition to demographics and ASD type, the survey asked parents who diagnosed their child and if there was a perceived delay in that diagnosis; whether they believed there was any causal reason for their child's autism; what chronic symptoms, if any, their child experiences; and, if they had used any complementary and/or alternative therapies and at whose recommendation. Respondents included 77 of the 150 parents (51%) contacted. Most children were diagnosed by a neurologist and/or developmental pediatrician (54% and 47%, respectively). Average perceived delay in diagnosis was 18 months. Parents most frequently cited immunizations (54%), genetic predisposition (53%), and environmental exposure (38%) as a cause of their child's autism. Approximately half of children were reported as having at least one gastrointestinal, neurological, and/or allergic symptom; more than a third had immunological symptoms. Almost all parents (95%) indicated some use of complementary and alternative medicine (CAM) therapies, with most of the self-reported referrals generated from a physician or nurse (44%). Systemic complaints, parental beliefs, and use of CAM practices warrant open discussion by all health care professionals who provide care to this population.

Data from naturalistic samples provide an important complement to findings from randomized trials of psychotherapy. A random national sample of US clinicians provided data on 145 completed treatments of patients with bulimic symptoms. Treatment in the community was substantially longer than treatment prescribed in manuals, with a mean length of cognitive-behavioral therapy of 69 sessions and significantly longer for eclectic and psychodynamic therapies. Most patients treated in the community had substantial comorbidity, and this comorbidity was associated with longer treatments and poorer outcome. Using four common exclusion criteria from randomized controlled trials for bulimia nervosa, approximately 40% of the naturalistic sample would have been excluded from randomized controlled trials. These patients showed higher pretreatment severity and required longer treatments to achieve positive outcomes relative to patients who did not meet these exclusion criteria.

Data from naturalistic samples provide an important complement to findings from randomized trials of psychotherapy. A random national sample of US clinicians provided data on 145 completed treatments of patients with bulimic symptoms. We attempted to characterize the nature of treatments in the community and to examine the relation between treatment variables and outcome. Clinicians of all theoretical orientations report using interventions with polysymptomatic cases designed to address clinically significant personality characteristics and interpersonal patterns. Whereas cognitive-behavioral therapy is associated with more rapid remission of eating symptoms, psychodynamic interventions and increased treatment length predict better global outcome across treatment modalities, suggesting the importance of integrative treatments for the broad range of pathology seen in patients with bulimic symptoms.

Objective: Physicians are encouraged to actively involve patients in clinical decision-making, but this expectation has not been adequately examined from the physicians' perspective. Our objective was to identify and characterize physicians' attitudes toward patient participation in decision-making and to gain insight into how they consequently think about and structure the decision-making process., Design: This was a qualitative cross-sectional study of physicians' reported attitudes and practices., Setting: The study took place in private practice and academic physicians' practices., Participants: A total of 53 academic and private practice physicians from primary care and surgical specialties, ranging from first year residents to recently retired, participated in the study., Measurements: We performed a qualitative analysis of semistructured individual interviews., Results: The physicians in this study expressed consistently positive attitudes toward patient participation in medical decision-making. They identified patient autonomy as an essential justification for patient participation but often went beyond an autonomy-based rationale. Several were motivated by the fundamental principle of beneficence as well as their own self-interest in avoiding legal liability. Many physicians saw their role as an expert who educates the patient but retains control over the decision-making process; others took a more collaborative approach, encouraging patients to assume decisional priority. The decision-making process often was modified by patient, physician, and environmental factors., Conclusions: The physicians in this study demonstrated a positive, flexible approach toward including patients in decision-making. A one-dimensional model of shared decision-making based solely on the principle of autonomy fails to account for variability in how physicians allocate decisional priority and is therefore ethically inadequate.

Background: Nonmelanoma skin cancer is the most common malignancy. Multiple therapies prevent recurrence but vary widely in cost. The most common therapies are local destruction, excision, and Mohs surgery (histologically guided tumor removal). Clinical variables that may affect treatment choices can be identified, but little is known about how clinicians choose among therapies., Objective: The objective of this study was to learn if variations exist in the treatment of nonmelanoma skin cancer in different practice settings., Research Design: Prospective cohort study., Subjects: Subjects consisted of consecutive patients with nonmelanoma skin cancer at a university-affiliated private dermatology practice and the dermatology clinic at the nearby affiliated Veterans Affairs (VA) medical center., Data: We studied data from medical records and patient surveys., Results: Overall, 1777 nonrecurrent nonmelanoma skin cancers were diagnosed in 1375 patients. Compared with the VA site, patients at the private site were younger, more likely to be female, and less likely to be poor, and their tumors were smaller and less likely to be on visible areas of the body. Treatments varied between the 2 sites (P <0.001). The proportions of tumors treated at the private and VA sites, respectively, were 23% and 19% for destruction, 25% and 48% for excision, and 37% and 25% for Mohs surgery. In multiple clinical subgroups, Mohs surgery was more likely to be performed at the private site than at the VA. Moreover, in multivariable models controlling for clinical features that may have affected treatment choice, tumors at the private site were more likely than tumors at the VA to be treated with Mohs surgery (odds ratio, 2.39; 95% confidence interval, 1.54-3.70)., Conclusions: Care for nonmelanoma skin cancer varied at 2 academic practice sites that are near each other and that share some clinician staff. These findings raise questions not only about overuse or underuse of procedures at the 2 sites, but also about systematic differences in patient preferences and/or physician incentives in prepaid and fee-for-service settings.

Background: Several trials support the usefulness of disease management (DM) for improving clinical outcomes in heart failure (HF). Most of these studies are limited by small sample size; absence of concurrent, randomized controls; limited follow-up; restriction to urban academic centers; and low baseline use of effective medications., Methods and Results: We performed a prospective, randomized assessment of the effectiveness of HF DM delivered for 90 days across a diverse provider network in a heterogeneous population of 200 patients with high baseline use of approved HF pharmacotherapy. During a 90-day follow-up, patients randomized to DM experienced fewer hospitalizations for HF [primary end point, 0.55+/-0.15 per patient-year alive versus 1.14+/-0.22 per patient-year alive in control subjects; relative risk (RR), 0.48, P=0.027]. Intervention patients experienced reductions in hospital days related to a primary diagnosis of HF (4.3+/-0.4 versus 7.8+/-0.6 days hospitalized per patient-year; RR, 0.54; P<0.001), cardiovascular hospitalizations (0.81+/-0.19 versus 1.43+/-0.24 per patient-year alive; RR, 0.57; P=0.043), and days in hospital per patient-year alive for cardiovascular cause (RR, 0.64; P<0.001). Intervention patients showed a trend toward reduced all-cause hospitalizations and total hospital days. On long-term (mean, 283 days) follow-up, there was substantial attrition of the 3-month gain in outcomes, with sustained significant reduction only in days in hospital for cardiac cause., Conclusions: In a population with high background use of standard HF therapy, a DM intervention, uniformly delivered across varied clinical sites, produced significant short-term improvement in HF-related clinical outcomes. Longer-term benefit likely requires more active chronic intervention, even among patients who appear clinically stable.

The rapid development of new drugs, therapies, and devices has created a dramatic increase in the number of trials needed to properly evaluate them. The majority of patients treated today, many of whom could be eligible for participation in these studies, are seen in community hospitals and medical practices that are not affiliated with an academic medical center. Thus, there is a demonstrable need for physicians in private practice to enlist as investigators in these trials. This article is intended to encourage those physicians by describing the need and providing the rationale for their participation. It covers basic requirements for participating in clinical trials and outlines ethical, regulatory, financial, and other logistical issues of importance for the potential investigator and provides an algorithm for selecting a study for participation. Finally, the appendices review basic elements of study design and statistical principles, which may be of interest to a potential investigator.

Introduction: There has been a concern about indiscriminate use of electroconvulsive therapy (ECT) in Asian countries. This study examined the rates of ECT use and the characteristics and outcomes of patients treated with ECT in Hong Kong., Method: A central database of ECT treatments was used to calculate annual rates of ECT use from 1997 to 2002. We surveyed prospectively patients received ECT over 12 months by a standardized questionnaire., Results: The ECT utilization rates varied from 0.27 to 0.34 patients treated per 10,000 population and 1.34 to 1.88 patients treated per 100 inpatients discharged. There were differences in the pattern of ECT use among Hong Kong, the United States, and the United Kingdom. Only 15% of ECT recipients were 65 years old or older and 23% had schizophrenia as primary diagnosis for ECT. Ninety-five percent of patients who received ECT improved with the treatment as assessed by clinicians. No severe complications and deaths occurred, and 6% stopped ECT due to undesirable results., Conclusion: The rate of ECT use in Hong Kong continues to be below that in the United States and the United Kingdom. Access to ECT is most limited to the elderly and private patients.

To plan targeted, relevant continuing medical educational activities, a study was undertaken to assess demographic data, practice patterns, and current continuing medical educational needs of former graduates of the physical medicine and rehabilitation program. A survey was sent to the 168 physicians who had completed a physical medicine and rehabilitation residency program from 1961 to 1995 and to the 34 then current residents in the program. Questions were asked regarding gender, year of completion of residency, certification, fellowships, current employment situation, size of practice community, work time distribution, and busiest areas of clinical practice. In addition, from a list of 47 topics plus "other," the respondents indicated in which topics they had a current strong interest in continuing their education. They also responded to questions about their most important considerations when deliberating about attending an educational activity, the amount of notice required regarding an upcoming course, and the preferred duration of educational activities. The response rate of former residents was 56% and of then current residents was 100%. Topics of interest to greater than half of the respondents, in descending order, were musculoskeletal/soft tissue disorders, therapeutic injections/nerve blocks, industrial medicine, back and neck pain rehabilitation, and sports-related disorders. There were significant differences on some topics based on gender, year of residency completion, academic affiliation, private practice, and ratings of residency training in that topic. The most important consideration when deciding whether to attend an educational activity was, by far, interest in topic, followed by provision of continuing medical educational credits. There are among physiatrists several differences in educational interests that challenge continuing medical education planners to determine efficient, effective ways to deliver continuing medical education to meet these needs within the financial and time constraints imposed by today's clinical practice.