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PubMed2002

Practice improvement methods: conceptual base, evidence-based research, and practice-based recommendations.

OBJECTIVES: To provide (1) an overview of the purpose of practice improvement methods and a conceptual base for the relationship between the various practice improvement methods; (2) an evidence-based review of the range of practice improvement methods; and (3) practice-based recommendations. DESIGN AND METHOD: Secondary research design using electronic literature search of PsycINFO database was carried out on eight practice improvement methods (PIMs) and the evidence for effectiveness presented. RESULTS: There is evidence of effectiveness in changing practice for each of the PIMs reviewed, and for some, there is also evidence of effects on patient outcomes. Each has strengths and weaknesses. However, the stronger conclusion from reviews is that use of multiple PIMs is more likely to impact clinical practice and patient outcomes than use of a single PIM. CONCLUSION: The development of PIMs should concentrate on combination and integration between methods to maximize their effectiveness.

Databases as Topic↗
PubMed2001

Towards evidence-based general practice in rural and remote Australia: an overview of key issues and a model for practice.

There is an extensive global move towards evidence-based practice intended to increase the quality and effectiveness of health care. However there are barriers and issues when rural general practitioners attempt to incorporate evidence-based medicine in their practice. Key issues affecting the uptake of evidence-based medicine by rural general practitioners include the gaps in the scientific evidence relevant to general practice, time limitations, and the cost of Internet access, geographical isolation from centres of evidence-based practice and limited training opportunities. General practitioner consultations may involve multiple, ill-defined problems and the patients' views about their treatment may conflict with an evidence-based treatment approach. Rural general practitioners may require additional supports to access information from research through Internet-based resources, accessible summaries of evidence or clinical practice guidelines. In addition a model to assist rural general practitioners use evidence-based medicine is suggested. This model may enable the clinical decision-making process to integrate clinical experience, patient preferences and an understanding of the rural context of practice with the best available evidence, to in turn produce best practice.

Journal Article↗
PubMed1990

[Statistical studies of student clinical practice. 1. Clinical practice of operative dentistry from 1983 to 1989].

Clinical practice has been assigned as a final and very important aspect of study and practice of dental education. In our university, the students are exposed the clinical practice from the latter term of fifth year. This report investigated the protocols of clinical cases from the first to the seventh class of graduates. The results obtained were as follows: 1) The graduates of first class averaged 9 clinical cases. This decreased with the years and the fourth class averaged 5.5 cases. From the sixth class simulator training and mutual practice among the students was introduced and the total average of seventh class was 5.1 cases. 2) The dental practice centers on restoration and 20 percent of all cases were amalgam fillings from the first to four the class. However this decreased from the fifth class and does not take place at present. Composite resin restorations increased. Cast restorations occupied 20 percent of all cases and the proportion hasn't changed. 3) Clinical cases of graduates of fifth class who were first to include treatment between students averaged 7 cases. Mutual treatment practice is useful because of the increase exposure to clinical practice.

Clinical Clerkship↗
PubMedDate not supplied

Effect of basic preventive health practices and mass media on the practice of breast self-examination.

To assess factors that affected utilization of breast self-examination in 160 women enrolled in masters degree programs--in nursing and in programs outside of health disciplines--a questionnaire sought information about 1) the relationship between practice of six basic preventive health measures and practice of breast self-examination, and 2) changes which occurred in women's practices of breast self-examination subsequent to the October 1974 mass media coverage of Mrs. Betty Ford's mastectomy. Descriptive data about other factors that influenced women's practice of breast self-examination were obtained. Findings indicated a relationship between positive practice of breast self-examination and positive practices of other preventive health measures in women of health and nonhealth orientation up to 35 years of age and under, but not in those over 35 years of age. Significantly increased breast self-examination practices in women of all ages were reported following Mrs. Ford's mastectomy. Implications favorable to the early detection of breast disease are suggested.

Breast Neoplasms↗
PubMed1994

Practice theories in nursing and a science of nursing practice.

The claim that knowledge about clients, client problems, and nursing therapeutics is enough to make nursing practice scientific is refuted on the basis that practice theories in nursing must encompass not only theories addressing these aspects but also those dealing with practice issues pertaining to the nurse-agent in action. A comprehensive framework specifying two dimensions of focus for practice theories is proposed to examine different types of practice theories in nursing and it is further used to frame a science of nursing practice as a subset of nursing science at large. Knowledge development for a science of nursing practice is then examined within four possible paradigms founded on different ontological and epistemological views.

Aged↗
PubMed1999

Manage indirect practice expense the way you practice medicine: with information.

PURPOSE: Surgeons are increasingly faced with the pressures of maintaining the highest quality of patient care, while at the same time maintaining financial viability. The purpose of this project was to provide a framework for analyzing practice costs for colorectal surgeons using an activity-based cost accounting model. METHODS: A survey of 11 practices that were diverse in terms of geography, managed care penetration, academic vs. private practice style, and case distribution was performed. In activity-based costing the assignment of typical costs such as staff salaries are assigned to the appropriate business process. The business processes employed in this study were service patients in the office, perform in-office procedures, schedule cases in facilities, service patients in the hospital, insurance authorization, maintain medical records, billing, collections, resolve billing disputes, interaction with third parties, maintain professional education, sustain and manage the practice, maintain the facility, teaching and research, and performing drug studies. The final step is to assign the cost associated with all appropriate business processes to the appropriate cost object. The cost objects in this study were defined as a charge office visit, no-charge office visit, charge hospital visit, in-office procedures, in-facility procedures, and performing drug studies. The data were then analyzed to allow a comparison of four similar practices within the study group. RESULTS: The data demonstrated that the cost of seeing a charge office visit ranged from $55 to $105. Similarly, the cost of seeing a no-charge office visit during the global period ranged from $43 to $100. The study analyzed possible explanations for the wide variability in these costs. CONCLUSIONS: It is essential that physicians clearly understand the sources of expenses generated by the operation of their practices. A clear comprehension of costs will lead colorectal surgeons to make appropriate decisions regarding such important issues as office staffing ratios, office square footage, and instrumentation acquisitions.

Colorectal Surgery↗
PubMed2005

[The actual role of general practice in the dutch health-care system. Results of the second dutch national survey of general practice].

A second Dutch National Survey of General Practice was carried out in 2001 with the aim of providing actual information about the role of general practice in the Dutch health-care system for researchers and policy makers. Data were collected on different levels (patients, general practitioners, practices) and included morbidity (self-report and presented to general practitioners), diagnostic and therapeutic interventions, doctor-patient communication, and background characteristics. Compared to 1987 (the first National Survey), Dutch general practitioners had organized their work more efficiently. Patients were less satisfied (78% satisfied) about the organizational aspects of general practice care than about the care actually provided (90% satisfied). Dutch general practitioners provide high-quality care: on average, their performance was in 74% of cases in accordance with national guidelines. Communication in general practice had become less social and more medically oriented compared to 1987. General practice still acts in a gatekeeper role; this is illustrated by 96% of contacts handled solely by the general practitioner.

Adult↗
PubMed2006

A cross-sectional study of secondary cardiac care in general practice: impact of personal and practice characteristics.

OBJECTIVE: To determine the impact of patient (age, gender, type of and time since diagnosis) and practice (rurality, number of partners, availability of practice nurse) characteristics on secondary cardiac care in general practice in a country without universal registration. METHODS: Medical and demographic data were gathered from the medical charts of 1611 eligible patients from 35 randomly selected practices. Eligible patients were aged under 80 years with a recorded history of acute myocardial infarction, percutaneous trans coronary arteriogram or angina. Self-report data about diet, exercise, smoking and alcohol consumption were provided from postal questionnaire (1084 patients responded; 69% response rate). RESULTS: Having an angina only diagnosis significantly decreased the likelihood of patients being prescribed aspirin (OR = 0.53; 95% CI = 0.40-0.69), lipid-lowering medication (OR = 0.55; 95% CI = 0.43-0.69) or ACE inhibitors (OR = 0.62; 95% CI = 0.48-0.81). Younger patients (OR = 1.05; 95% CI = 1.04-1.06) were also more likely to be prescribed lipid-lowering medication. Cholesterol was predicted by gender only, with females having significantly higher cholesterol (B = -0.41; 95% CI = -0.54 to -0.27). The number of missed opportunities for secondary cardiac care was greater among patients with angina only (B = 0.39; 95% CI = 0.19-0.60). The amount of variance explained by practice and patient variables overall for each of the measures was small, ranging from 2 to 6%. CONCLUSIONS: Practice size or location appears to have little impact on secondary cardiac care. The most consistent significant personal characteristic finding was that patients with a diagnosis of angina only were significantly less likely to receive aspirin, statins or ACE inhibitors and more likely to have more missed opportunities for secondary cardiac care.

Age Factors↗
PubMed1991

Faculty practice plans: the organization and characteristics of academic medical practice.

The contemporary academic medical center is a complex organization providing medical and other professional health education, biomedical and behavioral research, and a comprehensive range of patient care services. This paper presents data from the Association of American Medical Colleges' 1989 survey of 125 member faculty practice plans. The survey data showed that 62% of the 74 responding plans were units or associations within the medical school corporate structure. Plans were organized along a broad continuum from the autonomous, departmental model with decentralized governance and management to the group model with centralized governance and management. The growth of managed care, increased competition, and a greater reliance by the medical school on clinical practice income as a financing source are causing the practice plan to expand beyond billing of professional fees. The survey data showed that 75% of the practice plans operated satellite centers, and 61% planned to build new ambulatory care facilities in order to expand and improve services to patients. The practice plans also have adapted to changes in third-party reimbursement and are establishing mechanisms to negotiate managed care contracts involving multiple clinical departments to increase referrals and maintain patient shares; 86% of the plans participate in at least one managed-care organization. The role of the practice plan will continue to evolve in response to the needs of the academic medical center for a cooperative and supportive environment in which to conduct its traditional missions of teaching, research, and patient care.

Academic Medical Centers↗
PubMed2001

Assessing the impact of payment method and practice setting on German physicians' practice patterns.

This project determined the impact that a physician's practice setting and reimbursement method has on his or her practice behavior. Multivariate regressions that controlled for physician, patient, and practice characteristics were conducted. The primary data source was a questionnaire that sampled ambulatory physicians practicing in the state of Brandenburg, Germany. This research demonstrated that physicians paid on a fee-for-service basis differ significantly from practitioners paid a salary in captured utilization measures: more patient visits per week, including more follow-up visits; a decreased rate of hospitalization; and an increased likelihood of making house calls. A group practice setting demonstrated little impact when compared with a solo practice.

Adult↗
PubMed1995

Allocating census data to general practice populations: implications for study of prescribing variation at practice level.

OBJECTIVES: To assign census data to general practice populations and to test accuracy of different procedures for estimating the proportion of patients aged over 64. DESIGN: Patients' postcodes from patient register of one family health services authority and the directory linking postcodes to census enumeration districts were used to locate patients in their census area of residence. With different levels of census geography and four different allocation procedures, proportion of patients aged over 64 in each area was used to predict proportion of patients aged over 64 in each general practice. Predicted figures were compared with real figures from each practice register to assess accuracy of allocation methods. SETTING: Data from 1991 census and from 73 practices administered by one family health services authority. MAIN OUTCOME MEASURES: Actual and predicted proportions of patients aged over 64 in general practice populations. RESULTS: Correlations between actual and predicted proportions of patients aged over 64 were significant for all four allocation procedures--values of 0.66, 0.7, 0.84, and 0.84 were achieved (P < 0.0005). Predicted ranges of proportions of patients aged over 64, however, were well short of those that actually existed, and significant differences existed between predicted percentages and actual figures for all four methods. CONCLUSION: Although predicted values correlated with actual values, the failure of the allocation procedures to correctly predict values, especially at the extremes, casts doubt on the validity of similar techniques for allocating census variables to general practice populations.

Age Factors↗
PubMed2003

Evaluation of aid to diagnosis of pigmented skin lesions in general practice: controlled trial randomised by practice.

OBJECTIVES: To determine whether an aid to the diagnosis of pigmented skin lesions reduces the ratio of benign lesions to melanomas excised in general practice. DESIGN: Controlled trial randomised by practice. SETTING: General practices in Perth, Western Australia. PARTICIPANTS: 468 general practitioners in 223 practices. INTERVENTIONS: Intervention practices were given an algorithm and instant camera to assist with the diagnosis of pigmented skin lesions. All practices were given national guidelines on managing melanoma. MAIN OUTCOME MEASURES: Ratio of benign pigmented lesions to melanomas excised. Analyses conducted with and without inclusion of seborrhoeic keratoses. RESULTS: At baseline the ratios of benign to malignant lesions were lower in the intervention group than in the control group. During the trial period the ratios were higher in the intervention group (19:1 v 17:1 without seborrhoeic keratoses and 29:1 v 26:1 with seborrhoeic keratoses). After adjustment for patients' age, sex, and socioeconomic status, the ratio was 1.02 times higher (95% confidence interval 0.68 to 1.51, P = 0.94) in the intervention group when seborrhoeic keratoses were not included and 1.03 times higher (0.71 to 1.50, P = 0.88) when seborrhoeic keratoses were included. General practitioners in the intervention group were less likely than those in the control group to excise the most recent pigmented skin lesion they managed (22% v 48%, P < 0.001) and to refer the patient to a specialist (16% v 27%, P = 0.06). CONCLUSIONS: Provision of the algorithm and camera did not decrease the ratio of benign pigmented skin lesions to melanomas excised by general practitioners.

Algorithms↗
PubMed2001

Access to the evidence base from general practice: a survey of general practice staff in Northern and Yorkshire Region.

AIM: To identify and describe current methods of making health related research evidence accessible to general practice staff in the Northern and Yorkshire Region. METHOD: A postal survey questionnaire of general practice staff in the Northern and Yorkshire Region. RESULTS: At least one completed questionnaire was obtained from 70% of the general practices surveyed, and the individual response rate to the survey was 45%. Just under 60% of all respondents reported having no access to the NHS internet and just under 50% also reported having no access to the internet. All respondents in this survey reported greater access to paper based information than to electronic databases. However, this research provides evidence of differential access to information resources between different professions in general practice with GPs clearly having easier access than other professions to both paper based resources and electronic databases. 70% of all respondents said that they would need to be trained to use either a computer, the internet, or to search databases if the opportunity for easy access to any of these information services was available. CONCLUSIONS: At the time of this survey, general practices seemed to be struggling to set up the infrastructure and develop the skills that are necessary to make best use of available research evidence. In addition, there is a need for further investigation into the reasons why different professions working in the same practice setting have differential access to information resources available in primary care.

Computer User Training↗
PubMed1996

Comparison of appropriateness of cholesterol testing in general practice with the recommendations of national guidelines: an audit of patient records in 20 general practices.

OBJECTIVE: To compare the profiles of those patients selected by general practitioners for measurement of serum cholesterol with the recommended profiles for opportunistic cholesterol testing described in the national practice guidelines published by the Dutch College of General Practitioners. DESIGN: Retrospective audit of general practitioners' records. MATERIALS: Practice records of 3577 adult patients systematically sampled from 20 general practices. MAIN MEASURES: With criteria set by the national guidelines, the proportion of patients per practice (a) for whom cholesterol testing would be considered justified, and (b) for whom cholesterol testing would be considered unjustified, and the proportion of patients within each of these groups who had had a cholesterol measurement recorded. RESULTS: Cholesterol tests were performed on 415 (11.7%) of the 3577 patients. National guidelines on the management of hypercholesterolaemia state that a positive cardiovascular risk profile is an indication for cholesterol measurement. Just under one fifth (668) of the patients in this study were recorded as having a positive cardiovascular risk profile, but only 31% of these had had their cholesterol measured. Of the patients without recorded evidence of a positive cardiovascular risk profile cholesterol had been measured in 8%. Restricting the analyses to the age group 18-65 (n = 3060) of whom 12.5% had a positive risk profile, did not improve the results. In practices with a computerised information system 37% of patients with recorded evidence of a positive cardiovascular risk profile had had their cholesterol measured. CONCLUSIONS: Cholesterol testing was not targeted as selectively as recommended by the national guidelines. The major problem was failure to test those likely to benefit. Improving the targeting of cholesterol measurements would undoubtedly increase the workload of general practitioners. If the national guidelines are to have an effect on health promotion the first step must be to increase the proportion of patients with positive cardiovascular risk profiles who get their cholesterol tested. A major factor in successfully selecting cases seems to be that practices are equipped with a computerised medical information system.

Adolescent↗
PubMed1995

The concept of individualized hypertension care in general practice and outpatient clinics. The general practitioner hypertension practice study (III).

OBJECTIVE: To examine test ordering practice among general practitioners and hospital medical specialists according to the concept of individualized hypertension care. DESIGN: Mailed hypothetical case histories, with reference panels to categorize tests. SETTING: Uppsala-Orebro region in mid-Sweden. SUBJECTS: General practitioners (N = 90) and hospital medical specialists (N = 69) in randomly sampled primary health care centres and hospitals. MAIN OUTCOME MEASURES: Test ordering scores. RESULTS: 84% of invited GPs and 72% of specialists participated. According to reference panel standards, primary care physicians performed 75% of obligatory tests and specialists 88%. Superfluous tests constituted a larger proportion of the practice of hospital specialists (11-28%) than GPs (2-12%) in the six cases. Summarized examination scores revealed a wide practice variation within and between the two physician categories, specialists scoring significantly higher in three cases. Standardization of practice was more common among specialists, and differed significantly regarding serum potassium test, chest X-ray and ECG. Both groups deviated from current guidelines by omitting metabolic parameters. CONCLUSION: There is considerable practice variation in individualized hypertension care, which might influence treatment outcome. Practice audit and continuing medical education could contribute to care standardization according to guidelines.

Adult↗
PubMed1991

Nurse-physician collaborative practice: the clinical nurse specialist in a radiation oncology private practice.

The role of the clinical nurse specialist (CNS) has been established and described in some detail. The majority of these specialists practice in academic centers or large hospitals, often in concert with a group of their peers and with strong administrative support for the advanced practice role. Changes in the healthcare system, particularly the recent trend toward the establishment of freestanding cancer centers, have opened new practice opportunities for advanced nursing practitioners. This article describes the transition of a radiation oncology CNS from a university hospital to a collaborative practice in a private radiation oncology setting. The CNS describes important steps in this process, including negotiation of role functions and benefits, maintenance of professional commitments, and collaborative practice issues. Comments from the radiation oncologist, along with speculation on the future of the practice, also are included.

Communication↗
PubMed1990

The effect of independent practice association plans on use of pediatric ambulatory medical care in one group practice.

We compared the use of pediatric ambulatory medical care of 640 children who switched from a traditional Blue Cross plan to more comprehensive independent practice association plans with that of matched patients who remained with Blue Cross in one large, suburban pediatric practice in Rochester, NY. A quasi-experimental, retrospective cohort design was used. Use of pediatric ambulatory medical care by patients in the independent practice association plan and control patients was determined by medical chart review for 1 year before and 1 year after each patient's switch. During the baseline year, patients who would join the independent practice association plan already had 19% more acute-illness visits than control patients. During the second year, patients in the independent practice association plan averaged 42% more acute-illness visits, 22% more well child-care visits, 93% more chronic-illness visits, 27% more after-hours visits, 53% more weekend visits, 185% more laboratory studies, and 70% more referrals. The shift toward independent practice association plans in this open-market setting increased use of ambulatory medical care for pediatric patients.

Ambulatory Care↗
PubMed1988

The effect of a rural preceptorship during residency on practice site selection and interest in rural practice.

Rural areas of the United States face serious shortages in health care personnel. This report evaluates the effect of a rural preceptorship during the second or third year of a family practice residency on interest in rural practice and on practice site selection. A majority of participants (n = 123) felt that this experience influenced their choice of a practice site. Furthermore, a large majority felt that it increased their interest in rural practice opportunities. Rural preceptorships during residency are a timely solution to increase the number of family physicians interested in rural practice.

Attitude of Health Personnel↗