Search

Background: Overcrowding in hospitals is associated with a panoply of adverse events. Inappropriate decisions in the emergency department (ED) contribute to overcrowding. The performance of individual physicians as part of the admitting team is a critical factor in determining the overall rate of admissions. While previous attempts to model admission numbers have been based on a range of variables, none have included measures of individual staff performance. We construct reliable objective measures of staff performance and use these, among other factors, to predict the number of daily admissions. Such modelling will enable enhanced workforce planning and timely intervention to reduce inappropriate admissions and overcrowding., Methods: A database was created of 232 245 ED attendances at Meir Medical Center in central Israel, spanning the years 2016-2021. We use several measures of physician performance together with historic caseload data and other variables to derive statistical models for the prediction of ED arrival and admission numbers., Results: Our models predict arrival numbers with a mean absolute percentage error (MAPE) of 6.85%, and admission numbers with a MAPE of 10.6%, and provide a same-day alert for heavy admissions burden with 75% sensitivity for a false-positive rate of 20%. The inclusion of physician performance measures provides an essential boost to model performance., Conclusions: Arrival number and admission numbers can be predicted with sufficient fidelity to enable interventions to reduce excess admissions and smooth patient flow. Individual staff performance has a strong effect on admission rates and is a critical variable for the effective modelling of admission numbers., Competing Interests: Competing interests: None declared., (Copyright © 2019 BMJ Publishing Group Ltd & BCS, the Chartered Institute for IT. All rights reserved.)

Introduction: Deep brain stimulation of the internal globus pallidus is an effective treatment for dystonia. However, there is a large variability in clinical outcome with up to 25% non-responders even in highly selected primary dystonia patients. In a large cohort of patients we recently demonstrated that the variable clinical outcomes of pallidal DBS for dystonia may result to a large degree by the exact location and stimulation volume within the pallidal region. Here we test a novel approach of programing based on these insights: we first defined probabilistic maps of anti-dystonic effects by aggregating individual electrode locations and volumes of tissue activated of > 80 patients collected in a multicentre effort. We subsequently modified the algorithms to be able to test all possible stimulation settings of de novo patients in silico based on the expected clinical outcome and thus potentially predict the best possible stimulation parameters for the individual patients. Methods: Within the framework of a BMBF-funded study, this concept of a computer-based prediction of optimal stimulation parameters for patients with dystonia will be tested in a randomized, controlled crossover study. The main parameter for clinical efficacy and primary endpoint is based on the blinded physician rating of dystonia severity reflected by Clinical Dystonia Rating Scales for both interventions (best clinical settings and model predicted settings) after 4 weeks of continuous stimulation. The primary endpoint is defined as "successful treatment with model predicted settings" (yes or no). The value is "yes" if the motor symptoms with model predicted settings are equal or better (tolerance 5% of absolute difference in percentages) to clinical settings. Secondary endpoints will include measures of quality of life, calculated energy consumption of the neurostimulation system and physician time for programming. Perspective: We envision, that computer-guided deep brain stimulation programming in silico might provide optimal stimulation settings for patients with dystonia without the burden of months of programming sessions. The study protocol is designed to evaluate which programming method is more effective in controlling motor symptom severity and improving quality of life in dystonia (best clinical settings and model predicted settings). Trial registration Registered with ClinicalTrials.gov on Oct 27, 2021 (NCT05097001). [ABSTRACT FROM AUTHOR]

Objective: To develop an accurate and reproducible measure of vertical integration between physicians and hospitals (defined as hospital or health system employment of physicians), which can be used to assess the impact of integration on healthcare quality and spending., Data Sources and Study Setting: We use multiple data sources including from the Internal Revenue Service, the Centers for Medicare and Medicaid Services, and others to determine the Tax Identification Numbers (TINs) that hospitals and physicians use to bill Medicare for services, and link physician billing TINs to hospital-related TINs., Study Design: We developed a new measure of vertical integration, based on the TINs that hospitals and physicians use to bill Medicare, using a broad set of sources for hospital-related TINs. We considered physicians as hospital-employed if they bill Medicare primarily or exclusively using hospital-related TINs. We assessed integration status for all physicians who billed Medicare from 1999 to 2019. We compared this measure with others used in the existing literature. We conducted a simulation study which highlights the importance of accurately identifying integrated physicians when study the effects of integration., Data Collection/extraction Methods: We extracted physician and hospital-related TINs from multiple sources, emphasizing specificity (a small proportion of nonintegrated physicians identified as integrated)., Principal Findings: We identified 12,269 hospital-related TINs, used for billing by 546,775 physicians. We estimate that the percentage of integrated physicians rose from 19% in 1999 to 43% in 2019. Our approach identifies many additional physician practices as integrated; a simpler TIN measure, comparable with prior work, identifies only 30% (3877) of the TINs we identify. A service location measure, used in prior work, has both many false positives and false negatives., Conclusion: We developed a new measure of hospital-physician integration. This measure is reproducible and identifies many additional physician practices as integrated., (© 2024 Health Research and Educational Trust.)

Introduction: Emergency physician (EP) turnover is a significant issue that can have strong economic impact on hospital systems, as well as implications on research efforts to test and improve clinical practice. This work is particularly important to researchers planning randomized trials directed toward EPs because a large degree of turnover within a physician group would attenuate the effectiveness of the desired intervention. We sought to determine the incidence and factors associated with EP workforce changes.Methods: In an attempt to determine EP turnover and workforce change, data from the INSTINCT (INcreasing Stroke Treatment through INterventional behavior Change Tactics) trial were used. The INSTINCT trial is a prospective, cluster-randomized, controlled trial evaluating a targeted behavioral intervention to increase appropriate use of tissue plasminogen activator in acute ischemic stroke. Individual EPs staffing each of the study hospitals were identified at baseline and 18 months. Surveys were sent to EPs at both intervals. Models were constructed to investigate relationships between physician/hospital characteristics and workforce change.Results: A total of 278 EPs were identified at baseline. Surveys were sent to all EPs at baseline and 18 months with a response rate of 72% and 74%, respectively. At 18 months, 37 (15.8%) had left their baseline hospital and 66 (26.3%) new EPs were working. Seven EPs switched hospitals within the sample. The total number of EPs at 18 months was 307, a 10.8% overall increase. Among the 24 hospitals, 6 had no EP departures and 5 had no new arrivals. The median proportion of EP workforce departing by hospital was 16% (interquartile range [IQR] ¼ 4%–25%; range ¼ 0%–73%), and the median proportion added was 21% (IQR ¼ 7%–41%; range ¼ 0%–120%). None of the evaluatedcovariates investigating relationships between physician/hospital characteristics and workforce change were significant.Conclusion: EP workforce changes over an 18-month period were common. This has implications for emergency department directors, researchers, and individual EPs. Those planning research involvinginterventions upon EPs should account for turnover as it may have an impact when designing clinical trials to improve performance on healthcare delivery metrics for time-sensitive medical conditions suchas stroke, acute myocardial infarction, or trauma. [West J Emerg Med. 2013;14(1):16–22.]

Copyright of Der Urologe A is the property of Springer Nature 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 article highlights the results of the 2021 Bunbury Regional Hospital Clinical Engagement and Morale Survey, conducted by the Australian Medical Association of Western Australia. Topics discussed include the physicians' classification level, communication between physicians and senior executives, and organizational culture.

The article reports on the strained relationship between doctors and Western Australia Country Health Service (WACHS) senior executives, as revealed by the Bunbury Regional Hospital Clinical Engagement and Morale Survey. Other issues identified in the survey include disengaged clinical workforce, levels of intimidation and disregard by the WACHS senior executives, and quality of healthcare provided by the regional hospital.

The study by Ubels and van Raaij highlights the importance of alignment in hospital-physician relationships and the challenges in understanding, measuring, and managing it. Despite extensive research on alignment, drawing precise conclusions about its nature, drivers, and outcomes is difficult due to construct clarity and construct validity issues. This commentary focuses on clarifying these issues and the problems they create for hospitals attempting to manage alignment, as well as for scientific inquiry in this area. These issues involve the need to specify more clearly the essential nature of alignment and how it is distinct from other constructs such as engagement. It also involves demarcating alignment from the structures, arrangements, or processes intended to foster it, as well as from its outcomes. Improved precision in these areas will enable the development of more reliable and valid measures, thereby supporting hypothesis testing, theory building, and the identification of best practices., (© 2024 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Ubels and van Raaij provide a valuable account of the operation of novel hospital/medical specialist enterprise (MSE) contracts in a Dutch healthcare system shaped by market reform. However, their analytical distinction between the separate domains of contractual and relational governance frames the contractual domain more narrowly than does the relational contract theory widely deployed in socio-legal studies. The authors' conclusion that contract plays little or no part in governing relations between hospitals and MSEs leads them to underplay a wider realm of contractual practices that develop in the shadow of the written contract. Apparent non-use of contracts in favour of shared planning, compromise and extra-legal solutions only takes the form it does because of the potential application of the available legal framework. Larger qualitative field studies involving a more extensive combination of interviews and observations may be needed to gain fuller insights into the relational dimensions of the contracting process., (© 2024 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Training residents to become competent in common bedside procedures can be challenging. Some hospitals have attending physician–led procedure teams with oversight of all procedures to improve procedural training, but these teams require significant resources to establish and maintain. We sought to improve resident procedural training by implementing a resident-run procedure team without routine attending involvement. We created the role of a resident procedure coordinator (RPC). Interested residents on less time-intensive rotations voluntarily served as RPC. Medical providers in the hospital contacted the RPC through a designated pager when a bedside procedure was needed. A structured credentialing process, using direct observation and a procedure-specific checklist, was developed to determine residents' competence for completing procedures independently. Checklists were developed by the residency program and approved by institutional subspecialists. The service was implemented in June 2016 at an 850-bed academic medical center with 70 internal medicine and 32 medicine-pediatrics residents. The procedure service functioned without routine attending involvement. The impact was evaluated through resident procedure logs and surveys of residents and attending physicians. Compared with preimplementation procedure logs, there were substantial increases postimplementation in resident-performed procedures and the number of residents credentialed in paracenteses, thoracenteses, and lumbar punctures. Fifty-nine of 102 (58%) residents responded to the survey, with 42 (71%) reporting the initiative increased their ability to obtain procedural experience. Thirty-one of 36 (86%) attending respondents reported preferentially using the service. The RPC model increased resident procedural training opportunities using a structured sign-off process and an operationalized service. [ABSTRACT FROM AUTHOR]

Family Health Strategy, the primary health care program in Brazil, has been scaled up throughout the country, but its expansion has been heterogeneous across municipalities. We investigate if there are unique municipal characteristics that can explain the timing of uptake and the pattern of expansion of the Family Health Strategy from years 1998 to 2012. We categorized municipalities in six groups based on the relative speed of the Family Health Strategy uptake and the pattern of Family Health Strategy coverage expansion. We assembled data for 11 indicators for years 2000 and 2010, for 5,507 municipalities, and assessed differences in indicators across the six groups, which we mapped to examine spatial heterogeneities. Important factors differentiating early and late adopters of the Family Health Strategy were supply of doctors and population density. Sustained coverage expansion was related mainly to population size, marginal benefits of the program and doctors’ supply. The uptake was widespread nationwide with no distinct patterns among regions, but highly heterogeneous at the state and municipal level. The Brazilian experience of expanding primary health care offers three lessons in relation to factors influencing diffusion of primary health care. First, the funding mechanism is critical for program implementation, and must be accompanied by ways to support the supply of primary care physicians in low density areas. Second, in more developed and bigger areas the main challenge is lack of incentives to pursue universal coverage, especially due to the availability of private insurance. Third, population size is a crucial element to guarantee coverage sustainability over time. [ABSTRACT FROM AUTHOR]

Hospital-physician vertical integration is on the rise. While increased efficiencies may be possible, emerging research raises concerns about anticompetitive behavior, spending increases, and uncertain effects on quality. In this review, we bring together several of the key theories of vertical integration that exist in the neoclassical and institutional economics literatures and apply these theories to the hospital-physician relationship. We also conduct a literature review of the effects of vertical integration on prices, spending, and quality in the growing body of evidence ( n = 15) to evaluate which of these frameworks have the strongest empirical support. We find some support for vertical foreclosure as a framework for explaining the observed results. We suggest a conceptual model and identify directions for future research. Based on our analysis, we conclude that vertical integration poses a threat to the affordability of health services and merits special attention from policymakers and antitrust authorities. [ABSTRACT FROM AUTHOR]

The relationship between physicians and hospitals has dramatically changed over the last decade, with the employer-employee model supplanting the traditional model of private physicians with hospital admitting privileges. We examine the motivation for this form of vertical integration by considering physician-hospital alignment as a tool to increase bargaining power with private insurers. We find a positive and significant relationship between private insurance concentration on physician-hospital alignment, which is driven predominantly by for-profit hospitals. [ABSTRACT FROM AUTHOR]

Introduction: The intoxicated person may cause harm to others, often requiring expert evaluation for the determination of guilt. The primary aim of this study was to determine the mechanisms of mistakes that led 17 doctors accused of working under the influence of alcohol to face malpractice. We also wanted to clarify what were the legal, professional, and financial consequences - depending on specific patient outcomes.Method: We based analysis on the review and meta-analysis of the past forensic evaluation reports of institution-run forensics programs. Furthermore, we apply thematic analysis using combination of grounded theory and Pierre Bourdieu's theoretical framework.Results: During the 2010-2016 timeframe, the regional forensic service opinionated on 17 physicians (3F, 14M) subjected to disciplinary action due to providing treatment under the influence of alcohol. In total, there were 157 patients potentially affected by malpractice - out of those, four were harmed; only one qualified for compensation. In the remaining 153 patients - only 11 persons reported having had awareness about the doctors' intoxication and apparent inability to perform the job, yet they agreed to receive care. Overall, in over 90% of patients, the physician did not harm anyone to a degree threatening patient's life. The supporting staff did not report experiencing distress either. The results of a blood test for the presence of alcohol were available for only four cases. Therefore, it was impossible to analyze the correlation between intoxication level and performance in providing care. All in all, in our analysis - less than 10% of 157 patients' care were compromised by provider's intoxication, either due to a mistake in diagnosis, medical procedure, or lacking communication skills.Conclusion: For physicians, working under the influence of alcohol is an uncommon phenomenon, but when it occurs - patients are at risk for receiving poor treatment. Presented analysis indicates that patients - just as much as supporting staff - frequently agree to receive supervision and care from a drunk doctor, despite possible harm. Therefore, it is evident that patients as much as supporting staff fear retaliation, leading to underreporting of these cases. [ABSTRACT FROM AUTHOR]

Background: There have been few studies of the outcome in elderly patients who have suffered in-hospital cardiac arrest (IHCA) and the association between cardiac arrest characteristics and survival.Aim: The aim of this large observational study was to investigate the survival and neurological outcome in the elderly after IHCA, and to identify which factors were associated with survival.Methods: We investigated elderly IHCA patients (≥70years of age) who were registered in the Swedish Cardiopulmonary Resuscitation Registry 2007-2015. For descriptive purposes, the patients were grouped according to age (70-79, 80-89, and ≥90years). Predictors of 30-day survival were identified using multivariable analysis.Results: Altogether, 11,396 patients were included in the study. Thirty-day survival was 28% for patients aged 70-79 years, 20% for patients aged 80-89 years, and 14% for patients aged ≥90years. Factors associated with higher survival were: patients with an initially shockable rhythm, IHCA at an ECG-monitored location, IHCA was witnessed, IHCA during daytime (8 a.m.-8 p.m.), and an etiology of arrhythmia. A lower survival was associated with a history of heart failure, respiratory insufficiency, renal dysfunction and with an etiology of acute pulmonary oedema. Patients over 90 years of age with VF/VT as initial rhythm had a 41% survival rate. We found a trend indicating a less aggressive care with increasing age during cardiac arrest (fewer intubations, and less use of adrenalin and anti-arrhythmic drugs) but there was no association between age and delay in starting cardiopulmonary resuscitation (CPR). In survivors, there was no significant association between age and a favourable neurological outcome (CPC score: 1-2) (92%, 93%, and 88% in the three age groups, respectively).Conclusions: Increasing age among the elderly is associated with a lower 30-day survival after IHCA. Less aggressive treatment and a worse risk profile might contribute to these findings. Relatively high survival rates among certain subgroups suggest that discussions about advanced directives should be individualized. Most survivors have good neurological outcome, even patients over 90 years of age. [ABSTRACT FROM AUTHOR]

Objective: We aim to compare patients' perspectives on communication with their hospital physicians (HPs) and primary care physicians (PCPs) on patients' dietary and herbal supplements (DHS) use.Methods: We conducted a cross-sectional prospective study among in-patients using structured questionnaires on DHS use. Multivariate logistic regression models assessed variables influencing doctor-related reasons for patients' nondisclosure of supplement use.Results: Of 452 DHS users identified, 133 (29.4%) used herbs and 319 (70.6%) used non-herbal supplements. DHS users reported that PCPs were more aware of DHS consumption than HPs (70.1% vs. 34.1%, P<0.0001). PCPs initiative to detect supplement use was higher compared with HPs (P<0.0001). Doctor-related reasons for non-disclosure of DHS use were more prominent in a hospital setting. Multivariate logistic regression model suggested association between older patient age and doctor-related non-disclosure (p=0.03). DHS use was recorded in only 33 patients medical files.Conclusions: Doctor-patient communication concerning DHS use is significantly poorer during hospitalization compared with primary-care settings. A significant barrier for in-hospital disclosure is doctor-related.Practice Implications: Continuity of care between community and hospital physicians regarding patients' DHS use should be improved due to the safety implications of such use. Educating physicians on DHS and improving communication could bridge this gap. [ABSTRACT FROM AUTHOR]

Healthcare service in itself is one of the most crucial, most sensitive services in the world. Advancement in healthcare infrastructures, equipment and manpower are rapid day by day. "Healthcare service providers", the definition is changing from commonly perceived "doctors" to "doctors plus managers". The healthcare practice has changed all its way from individual practice to communal, organised hospital systems; resources are pooled in a common place; where patients expect for every kind of treatment once they enter the common roof. However, the hospital only can understand the role the doctor and manager play together for quality healthcare services. The two now cannot be separated despite of several disparities that appear between them. There should always be an effort to bridge the gap between them which appears between them despite serving the common goal. Doctor manager collaboration including collaboration of education system shall bring the real bond between them to understand each other, understand system and pace for their common goal. [ABSTRACT FROM AUTHOR]

Background: Policy dialogues are critical for developing responsive, effective, sustainable, evidence-informed policy. Our multidisciplinary team, including researchers, physicians and senior decision-makers, comprehensively evaluated The Winnipeg Central Intake Service, a single-entry model in Winnipeg, Manitoba, to improve patient access to hip/knee replacement surgery. We used the evaluation findings to develop five evidence-informed policy directions to help improve access to scheduled clinical services across Manitoba. Using guiding principles of public participation processes, we hosted a policy roundtable meeting to engage stakeholders and use their input to refine the policy directions. Here, we report on the use and input of a policy roundtable meeting and its role in contributing to the development of evidence-informed policy. Methods: Our evidence-informed policy directions focused on formal measurement/monitoring of quality, central intake as a preferred model for service delivery, provincial scope, transparent processes/performance indicators, and patient choice of provider. We held a policy roundtable meeting and used outcomes of facilitated discussions to refine these directions. Individuals from our team and six stakeholder groups across Manitoba participated (n = 44), including patients, family physicians, orthopaedic surgeons, surgical office assistants, Winnipeg Central Intake team, and administrators/managers. We developed evaluation forms to assess the meeting process, and collected decision-maker partners' perspectives on the value of the policy roundtable meeting and use of policy directions to improve access to scheduled clinical services after the meeting, and again 15 months later. We analyzed roundtable and evaluation data using thematic analysis to identify key themes. Results: Four key findings emerged. First, participants supported all policy directions, with revisions and key implementation considerations identified. Second, participants felt the policy roundtable meeting achieved its purpose (to engage stakeholders, elicit feedback, refine policy directions). Third, our decision-maker partners' expectations of the policy roundtable meeting were exceeded; they re-affirmed its value and described the refined policy directions as foundational to establishing the vocabulary, vision and framework for improving access to scheduled clinical services in Manitoba. Finally, our adaptation of key design elements was conducive to discussion of issues surrounding access to care. Conclusions: Our policy roundtable process was an effective tool for acquiring broad input from stakeholders, refining policy directions and forming the necessary consensus starting points to move towards evidence-informed policy. [ABSTRACT FROM AUTHOR]

A well-functioning Doctor-Manager relationship plays a crucial role in the success of a healthcare organization. As the healthcare industry gets more competitive and corporatized, it often leads to friction between these two professionals due to their difference in work cultures; creating discontent. This discontent among the doctors and the managers hampers the efficiency of a healthcare organization. This article attempts to shed some light on both doctor as well as manager's perspective on the issue of their dissatisfaction. We also aim to explain how the gap between these two professionals can be bridged and consider some strategies that might help in tackling this problem. [ABSTRACT FROM AUTHOR]

The article focuses on relationship between healthcare organizations and physicians with compliance to the Stark Law, which prohibits physicians to refer Medicare patients to the same entity for health services.

Background: The increasing pervasiveness of mobile technologies has given potential to transform healthcare by facilitating clinical management using software applications. These technologies may provide valuable tools in sexual health care and potentially overcome existing practical and cultural barriers to routine testing for sexually transmitted infections. In order to inform the design of a mobile health application for STIs that supports self-testing and self-management by linking diagnosis with online care pathways, we aimed to identify the dimensions and range of preferences for user interface design features among young people. Methods: Nine focus group discussions were conducted (n = 49) with two age-stratified samples (16 to 18 and 19 to 24 year olds) of young people from Further Education colleges and Higher Education establishments. Discussions explored young people's views with regard to: the software interface; the presentation of information; and the ordering of interaction steps. Discussions were audio recorded and transcribed verbatim. Interview transcripts were analysed using thematic analysis. Results: Four over-arching themes emerged: privacy and security; credibility; user journey support; and the task-technology-context fit. From these themes, 20 user interface design recommendations for mobile health applications are proposed. For participants, although privacy was a major concern, security was not perceived as a major potential barrier as participants were generally unaware of potential security threats and inherently trusted new technology. Customisation also emerged as a key design preference to increase attractiveness and acceptability. Conclusions: Considerable effort should be focused on designing healthcare applications from the patient's perspective to maximise acceptability. The design recommendations proposed in this paper provide a valuable point of reference for the health design community to inform development of mobile-based health interventions for the diagnosis and treatment of a number of other conditions for this target group, while stimulating conversation across multidisciplinary communities. [ABSTRACT FROM AUTHOR]

Background: Health decision-making requires evidence from high-quality data. As one example, the Discharge Abstract Database (DAD) compiles data from the majority of Canadian hospitals to form one of the most comprehensive and highly regarded administrative health databases available for health research, internationally. However, despite the success of this and other administrative health data resources, little is known about their history or the factors that have led to their success. The purpose of this paper is to provide an historical overview of Canadian administrative health data for health research to contribute to the institutional memory of this field. Methods: We conducted a qualitative content analysis of approximately 20 key sources to construct an historical narrative of administrative health data in Canada. Specifically, we searched for content related to key events, individuals, challenges, and successes in this field over time. Results: In Canada, administrative health data for health research has developed in tangent with provincial research centres. Interestingly, the lessons learned from this history align with the original recommendations of the 1964 Royal Commission on Health Services: (1) standardization, and (2) centralization of data resources, that is (3) facilitated through governmental financial support. Conclusions: The overview history provided here illustrates the need for longstanding partnerships between government and academia, for classification, terminology and standardization are time-consuming and ever-evolving processes. This paper will be of interest to those who work with administrative health data, and also for countries that are looking to build or improve upon their use of administrative health data for decision-making. [ABSTRACT FROM AUTHOR]

Background: With the introduction and implementation of a variety of government programs and policies to encourage adoption of electronic medical records (EMRs), EMRs are being increasingly adopted in North America. We sought to evaluate the completeness of a variety of EMR fields to determine if family physicians were comprehensively using their EMRs and the suitability of use of the data for secondary purposes in Ontario, Canada. Methods: We examined EMR data from a convenience sample of family physicians distributed throughout Ontario within the Electronic Medical Record Administrative data Linked Database (EMRALD) as extracted in the summer of 2012. We identified all physicians with at least one year of EMR use. Measures were developed and rates of physician documentation of clinical encounters, electronic prescriptions, laboratory tests, blood pressure and weight, referrals, consultation letters, and all fields in the cumulative patient profile were calculated as a function of physician and patient time since starting on the EMR. Results: Of the 167 physicians with at least one year of EMR use, we identified 186,237 patients. Overall, the fields with the highest level of completeness were for visit documentations and prescriptions (>70 %). Improvements were observed with increasing trends of completeness overtime for almost all EMR fields according to increasing physician time on EMR. Assessment of the influence of patient time on EMR demonstrated an increasing likelihood of the population of EMR fields overtime, with the largest improvements occurring between the first and second years. Conclusions: All of the data fields examined appear to be reasonably complete within the first year of adoption with the biggest increase occurring the first to second year. Using all of the basic functions of the EMR appears to be occurring in the current environment of EMR adoption in Ontario. Thus the data appears to be suitable for secondary use. [ABSTRACT FROM AUTHOR]

In an effort to meet the challenges of the post-health reform marketplace, hospitals have accelerated the practice of employing physicians. Despite this trend, many hospitals require their employed physicians to also maintain membership and privileges on the medical staff--the self-governing entity comprised of fellow physicians that oversees the practice of medicine within the hospital setting. Recent case law identifies at least two salient issues that will likely arise from physicians' dual roles as hospital employee and medical staff member and be a point of negotiation and litigation: (1) the applicability of "due process" rights, which are typically afforded in medical staff peer review actions, to employment termination actions, and (2) the obligation to report employment termination actions to the federal government's National Practitioner Data Bank, a central database for information about medical staff peer review actions and other incidents that may reflect on physicians' competence and quality of care. This article examines how and why these issues may become points of contention and proposes various practical solutions to avoiding or mitigating such conflicts. [ABSTRACT FROM AUTHOR]

Hospitals and physicians have been working together for years in providing specialized health services. However, hospital-physician relationships are considered lukewarm at the best. We build on psychological contract theory to develop an in-depth understanding of how physicians ( N = 15) and hospital executives ( N = 15) in Belgium experience and interpret obligations in their working relationship. Our analysis yielded a rich understanding of mutual obligations and areas of ambiguity. Two major themes emerged from the analysis. A distinction should be made between administrative obligations (adequate support and responsive decision making) and professional obligations (clinical excellence and physician autonomy). Two areas of ambiguity could be identified reflecting both dimensions. An economic trade-off exists in the day-to-day interaction and therefore views on how the care should be organized differ. In addition, the extent to which medical decisions should take into account the corresponding impact on hospital finance varies. [ABSTRACT FROM AUTHOR]

Background: Hospitals face increasingly competitive market conditions. In this challenging environment, hospitals have been struggling to build high-quality hospital–physician relationships. In the literature, two types of managerial strategies for optimizing relationships have been identified. The first focuses on optimizing the economic relationship; the second focuses on the noneconomic dimension and emphasizes the cooperative structure and collaborative nature of the hospital-physician relationship. We investigate potential spillover effects between the perceptions of physicians of organizational exchange and their customer-oriented behaviors. Methods: A cross-sectional study was conducted on 130 self-employed physicians practicing at six Belgian hospitals. Economic exchange was measured using the concept of distributive justice (DJ); noneconomic exchange was measured by the concept of perceived organizational support (POS). Our outcomes consist of three types of customer-oriented behaviours: internal influence (II), external representation (ER), and service delivery (SD). Results: Our results show a positive relationship between DJ and II (adjusted R2 = 0.038, t = 2.35; p = 0.028) and ER (adjusted R2 = 0.15, t = 4.59; p < 0.001) and a positive relationship between POS and II (adjusted R2 = 0.032, t = 2.26; p = 0.026) and ER (adjusted R2 = 0.22, t = 5.81; p < 0.001). No relationship was present between DJ (p = 0.54) or POS (p = 0.57) and SD. Organizational identification positively moderates the relationship between POS and ER (p = 0.045) and between DJ and ER (p = 0.056). The relationships between POS and II (p = 0.54) and between DJ and II (p = 0.99) were not moderated by OI. Professional identification did not moderate the studied relationships. Conclusion: Our results demonstrate that both perceptions of economic and noneconomic exchange are important to self-employed physicians' customer-oriented behaviours. Fostering organizational identification could enhance this reciprocity dynamic. [ABSTRACT FROM AUTHOR]

BACKGROUND: Discharge against medical advice (DAMA) has been associated with increased morbidity and re-admission of the patients who have been DAMA. The present study aims to evaluate the prevalence of DAMA and to determine the associated factors for DAMA. METHODS: A cross-sectional study was conducted from April 2012 to September 2012 in 17 hospitals in Tabriz, Iran. Data collection was performed using a two-part checklist including demographic factors, information about hospital and DAMA reasons. The profile of all DAMA patients was studied. RESULTS: The overall DAMA rate among hospitals was 5.7%. The highest DAMA rates were from private and educational hospitals, 10.8% and 9.6% respectively. The lowest rates were from social security hospitals with 2.5%. In this study, sex, age, month and health insurance were significant predictors of DAMA. CONCLUSION: In comparison to other studies, relatively higher rates of DAMA in this study show the need for conducting additional studies to define the causes of DAMA and to devise appropriate interventions to decrease DAMA rate. Determining DAMA rate and its determinants can play an important role in early detection of these at-risk patients and in instituting appropriate intervention. [ABSTRACT FROM AUTHOR]

Ethics consultation is a commonly applied mechanism to address clinical ethical dilemmas. However, there is little information on the viewpoints of health care providers towards the relevance of ethics committees and appropriate application of ethics consultation in clinical practice. We sought to use qualitative methodology to evaluate free-text responses to a case-based survey to identify thematically the views of health care professionals towards the role of ethics committees in resolving clinical ethical dilemmas. Using an iterative and reflexive model we identified themes that health care providers support a role for ethics committees and hospitals in resolving clinical ethical dilemmas, that the role should be one of mediation, rather than prescription, but that ultimately legal exposure was dispositive compared to ethical theory. The identified theme of legal fears suggests that the mediation role of ethics committees is viewed by health care professionals primarily as a practical means to avoid more worrisome medico-legal conflict. [ABSTRACT FROM AUTHOR]

Background: There have been few empirical studies into what non-medical factors influence physicians and nurses when deciding about admission and discharge of ICU patients. Information about the attitudes of healthcare professionals about this process can be used to improve decision-making about resource allocation in intensive care. To provide insight into ethical problems that influence the ICU admission and discharge process, we aimed to identify and explore ethical dilemmas healthcare professionals are faced with. Methods: This was an explorative, descriptive study using qualitative methods (individual and focus group interviews). We conducted 19 individual interviews and 4 focus group interviews with nurses and physicians working in the ICU or the general ward of 10 Dutch hospitals. Results: The ethical problems in the context of ICU admission and discharge can be divided into problems concerning full bed occupancy and problems related to treatment decisions. The gap between the high level of care the ICU can provide and the lower care level in the general ward sometimes leads to mutual misunderstandings. Our results indicate that when professionals of different wards feel there is a collective responsibility and effort to solve a problem, this helps to prevent or alleviate moral distress. ICU patients' wishes are often unknown, causing healthcare professionals to err on the side of more treatment. Additionally, the highly technological nature of intensive care appears to encourage over-treatment. Conclusions: It is important for ICUs and general wards to communicate and cooperate well, since there is a mutual dependency for optimal patient flow between the different departments. Interventions that improve the understanding and cooperation between these wards may help mitigate ethical problems. The nature of the ICU environment makes it important for healthcare professionals to be aware of the risk of over-treatment, reflect on why they do what they do, and be mindful of a possible negative impact of over-treatment on their patients. Early discussion of a patient's wishes with regard to treatment options is important in preventing over-treatment. [ABSTRACT FROM AUTHOR]