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PubMed1995

Variation in use of breast-conserving surgery in Lombardia, Italy.

The extent of variation in the use of breast-conserving surgery was analyzed using the 1990 and 1991 hospital discharge data of Lombardia, Italy. The proportion of patients undergoing breast-conserving surgery for unilateral breast cancer was estimated for each of the 10 geographic areas (9 provinces plus metropolitan Milano) in which the region is divided. Overall, the rate of use was 41% of 3,225 patients in 1990, and 45% of 3,736 patients in 1991. In both study years, patient age was strongly correlated with the likelihood of undergoing conservative surgery, with younger women more frequently treated with this approach. In each province, patients treated at centers located in the main city had a greater probability (OR, 1.54; 95% CI, 1.37-1.69) of having conservative surgery. This procedure was also more often used in private hospitals (OR, 1.59; 95% CI, 1.20-2.08) where care is paid at the point of consumption by patients, directly or through their private insurance. The observed variation in the use of the conservative procedure across the 10 regional areas was greater than that expected by chance alone (p < .0001), with rates ranging from 29% to 60%. This pattern persisted even after adjusting for the relevant patient and hospital characteristics. Despite the relatively large body of scientific evidence, it appears that the surgical management of breast cancer is more dependent on physicians' attitudes in each geographic area than on individual patients' characteristics.

Adolescent↗
PubMed2000

Treatment choices for extremely preterm infants: an international perspective.

OBJECTIVE: To compare treatment choices of neonatal physicians and nurses in 11 European countries for a hypothetical case of extreme prematurity (24 weeks' gestational age, birth weight of 560 g, Apgar score of 1 at 1 minute). STUDY DESIGN: An anonymous, self-administered questionnaire was completed by 1401 physicians (response rate, 89%) and 3425 nurses (response rate, 86%) from a large, representative sample of 143 European neonatal intensive care units. Italy, Spain, France, Germany, the Netherlands, Luxembourg, Great Britain, Sweden, Hungary, Estonia, and Lithuania participated. RESULTS: Most physicians in every country but the Netherlands would resuscitate this baby and start intensive care. On subsequent deterioration of clinical conditions caused by a severe intraventricular hemorrhage, attitudes diverge: most neonatologists in Germany, Italy, Estonia, and Hungary would favor continuation of intensive care, whereas in the other countries some form of limitation of treatment would be the preferred choice. Parental wishes appear to play a role especially in Great Britain and the Netherlands. Nurses are more prone than doctors to withhold resuscitation in the delivery room and to ask parental opinion regarding subsequent treatment choices. CONCLUSION: An extremely premature infant is regarded as viable by most physicians, whereas after deterioration of the clinical conditions decision-making patterns vary according to country. These findings have implications for the ethical debate surrounding treatment of infants of borderline viability and for the interpretation and comparison of international statistics.

Adult↗
PubMed1993

Women in pediatrics: the experience in Quebec.

OBJECTIVES: To compare the practice patterns of female pediatricians in Quebec with those of their male counterparts and to identify specific factors influencing these practice patterns. DESIGN: Matched cohort questionnaire survey. SETTING: Primary, secondary and tertiary care pediatric practices in Quebec. PARTICIPANTS: All 146 female pediatricians and 133 of the 298 male pediatricians, matched for age as well as type and site of practice; 119 (82%) of the female and 115 (86%) of the male pediatricians responded. MAIN OUTCOME MEASURES: Demographic and family data as well as detailed information about the practice profile. RESULTS: The two groups were comparable regarding demographic data, professional work and patient care. Compared with the male respondents, the female pediatricians were younger and saw more outpatients. The mean number of hours worked per week, excluding on-call duty, was 40.5 (standard deviation [SD] 12.4) for the women and 48.9 (SD 12.0) for the men (p < 0.001). The female pediatricians were more likely than their male counterparts to have spouses who were also physicians (40%) or in another profession (45%). The female pediatricians without children worked significantly fewer hours than the male pediatricians with or without children (p < 0.001). Children (p = 0.006), but not the number of children (p = 0.452), had a significant effect on the number of hours worked by the female pediatricians. CONCLUSION: The duality of the role of female physicians as mothers and professional caregivers must be considered during workload evaluations. If the same style of practice and the increase in the proportion of female pediatricians continue, about 20% more pediatricians will be needed in 10 years to accomplish the same workload.

Adult↗
PubMed1998

A study of referral patterns among Queensland general medical practitioners to chiropractors, osteopaths, physiotherapists and others.

BACKGROUND: In Queensland, Australia, patients with work-related injuries must receive a referral from a general medical practitioner to receive treatment from such "nontraditional" practitioners as physiotherapists, chiropractors or osteopaths, even though these nontraditional practitioners are primary care providers outside of the workers' compensation system. The Chiropractors' Association of Australia (Queensland Branch) (CAAQ) believed that injured workers wishing to receive chiropractic care stood little chance of obtaining a medical referral. On the other hand, the General Manager of the Workers' Compensation Board of Queensland maintained that injured workers had little difficulty obtaining such a referral for chiropractic care. OBJECTIVE: To canvass general medical practitioner attitudes and referral patterns to chiropractors, osteopaths, physiotherapists and other nontraditional practitioners (naturopaths). DESIGN: A descriptive study in which 1509 general medical practitioners in private practice in Queensland were invited to respond to a mailed questionnaire. The sample represented 50% of all such practitioners in Queensland. RESULTS: A 52% response rate was obtained with 784 (638 male, 142 female general practitioners) questionnaires returned. Respondents' ages ranged from 27 to 79 yr. The respondents' years in practice ranged from 1 to 55 yr. The survey showed that attitudes and referral patterns were distinctly different depending on the nontraditional practitioner group in question. CONCLUSION: The survey results confirm that general medical practitioners are highly unlikely to have professional dealings with chiropractors and osteopaths, including referral of patients to said providers, even if the patient requests such a referral, and that general medical practitioners are much more likely to have professional dealings with physiotherapists than with any of the other nontraditional groups considered.

Adult↗
PubMed1995

History of treatment received by patients with TMD: a preliminary investigation.

A retrospective investigation of 257 patient records from a university-based facial pain center for patients with temporomandibular disorders examined the "natural history" of patients with temporomandibular disorders for consultation and treatment of their complaints. Data were obtained on a variety of demographic variables, referral patterns, types of providers seen for consultation, and the types of diagnostic tests ordered by these providers. Results showed that patients with temporomandibular disorders see more than three providers prior to their referral to a tertiary care center, that a considerable proportion of those providers are physicians, that patients reported undergoing a variety of diagnostic tests, and that patients reported receiving a variety of diagnoses for their condition. Results also showed that patients who initially consulted a physician were somewhat more likely to be referred to another physician, while patients who consulted a dentist were highly likely to be referred to another dentist.

Adult↗
PubMed1996

Patterns of hospital care and physician perspectives from an Italian, Japanese, and USA hospital.

Many studies have compared different countries' health care systems at the macro level. Less has been done to analyze care provided for patients with specific diseases and to compare physician attitudes concerning factors that influence patient care. This study compares severity of illness and length of hospital stay for patients admitted for diabetes mellitus, cholecystitis, or appendicitis at three teaching hospitals in Italy, Japan, and the United States. Physicians caring for patients with these diseases were surveyed to assess their opinions of the adequacy of resources available at their hospital, perceived administrative pressures concerning resource use, and interactions with patients and their families that relate to admission and discharge decisions. The severity of the patient mix was consistently higher in the U.S. hospital than in the Italian or Japanese hospitals. Controlling for diagnosis, severity of illness, surgery, age, and presence of co-morbid conditions, the U.S. hospital consistently had the shortest stays and the Japanese hospital the longest. Japanese physicians were more likely than U.S. or Italian physicians to report insufficient resources, such as nurses, to provide quality care, but less likely to report administrative pressures interfering with patient care. Differences in hospital utilization may reflect variation in clinical practices, availability of resources, barriers to access to care, organizational differences at the national and hospital level, and patient and family preferences.

Adult↗
PubMed1995

Medical specialists prefer to withdraw familiar technologies when discontinuing life support.

OBJECTIVE: To assess how members of different specialties vary in their decisions about which form of life support to withdraw. The hypothesis was that each specialty would be more comfortable withdrawing its "own" form of life support relative to other forms and other specialties. DESIGN: Mail survey. SETTING: 24 medical centers. PARTICIPANTS: 225 specialists in six specialties and 225 comparison physicians randomly matched according to percentage of time devoted to clinical practice. MEASUREMENTS: The six specialties were linked with six life-sustaining technologies related to their special expertise: 1) pulmonologists with mechanical ventilation, 2) nephrologists with hemodialysis, 3) gastroenterologists with tube feedings, 4) hematologists with blood products, 5) cardiologists with intravenous vasopressors, and 6) infectious disease specialists with antibiotics. The subjects ranked different forms of life support in the order in which they would prefer to withdraw them. They also expressed their preferences in response to hypothetical clinical vignettes. RESULTS: In five of the six specialties, the specialists had a relative preference for withdrawing their "own" form of life support, compared with the preferences of the comparison physicians. Overall, the physicians tended to prefer withdrawing a form of life support closely linked with their own specialty. CONCLUSIONS: Just as some specialist physicians tend to reach for different technologies first in treating patients, they also tend to reach for different technologies first when ceasing treatment. Specialists' preferences for different ways to withdraw life support not only may reflect a special understanding of the limits of certain technologies, but also may reveal how ingrained are physicians' patterns of practice.

Anti-Bacterial Agents↗
PubMed1992

Adolescent medicine practice in urban Pittsburgh--1990.

Adolescent medicine has emerged as a discipline in the present era with few key curricular or skill areas clarified and little consensus regarding the acceptance and interest generated in pediatricians by this area. This investigation was undertaken to ascertain present adolescent medicine practice patterns in Pittsburgh, Pennsylvania. The data generated are intended to serve as a basis for future comparisons. The methodology was a questionnaire design, with 178 (54%) of the questionnaires returned and subjected to analysis. The results indicated that 6% of pediatricians actually limit their practices to patients 16 years of age or younger, and 65% limit their practices to patients younger than 19 years of age. Most practices (64%) do not have a gynecological table. Only 20% of practices offer clinical services which would match the needs of adolescent patients, such as the prescription of oral contraceptives, counseling for homosexuality, or treatment of dysfunctional uterine bleeding. Most interestingly, pediatricians report seeing few adolescents with drug and alcohol problems or sexually transmitted diseases. These data provide the basis for future investigations.

Adolescent↗
PubMed2005

Child and adolescent psychiatry in The Netherlands: patterns of practice 7 years later.

OBJECTIVE: The aim of the study was to investigate capacity, demographic composition, and patterns of practice of Dutch child and adolescent psychiatrists, and to compare these findings with the results of a similar investigation in 1996. METHOD: A postal survey was sent out to all Dutch child and adolescent psychiatrists. RESULTS: In comparison with 1996, there is an increase in Dutch child and adolescent psychiatry (CAP) capacity. CAP has moved towards being a predominantly female specialty, usually practised as a mono-specialism, rather than combined with adult psychiatry. CAP as a rule is practised within institutions, rather than in private practice. CONCLUSION: The threat of a stark decline in Dutch CAP capacity starting in the year 2006, predicted in 1996, is lifted. The consequences of the findings are discussed in a European perspective.

Adolescent↗
PubMed2000

Economics of using pharmacists as advisers to physicians in risk-sharing contracts.

An educational program designed to help physicians control the overall cost of drugs and total health care is described, along with its effectiveness at one managed health care plan. Prime Therapeutics, Inc., developed and manages an ongoing physician education program designed to help primary care physicians control drug and total health care costs. Physician education initiatives in the program are developed by using peer-reviewed literature; selections of preferred drugs are based on evidence of their safety, efficacy, uniqueness, and cost-effectiveness. For a typical educational initiative, a pharmacist meets with the physicians identified as being among the top 20% of prescribers of high-cost drugs addressed by the initiative and delivers a 20-minute presentation. One-on-one meetings with the physicians are then held quarterly to review their prescribing. Each physician is shown comparisons with the prescribing patterns of other physicians in the organization. The clinic chooses to present the clinicwide data as either blinded or nonblinded data. The program was evaluated by comparing per member per month (PMPM) total health care and drug costs for 1996 and 1997 at 12 general medicine clinics in a managed health care plan. Five clinics received no interventions, three clinics allowed the initial presentation and the quarterly face-to-face meetings, and four clinics allowed only the presentation and barred ongoing meetings. In general, the clinics with more interaction between pharmacists and physicians had lower PMPM costs for total health care and drugs than the clinics with less interaction. Pharmacists acting as advisers to primary care physicians in general medicine clinics helped lower PMPM costs for drugs and total health care.

Health Care Costs↗
PubMed2000

Use of hormone replacement therapy to reduce the risk of osteopenia in adolescent girls with anorexia nervosa.

PURPOSE: To assess how commonly hormone replacement therapy (HRT) and other measures are prescribed for the treatment of osteopenia in children and adolescents with anorexia nervosa (AN). METHODS: A self-administered questionnaire was distributed and completed by allopathic and osteopathic physician members of the Society for Adolescent Medicine at its 1998 annual meeting. The questionnaire was also mailed and E-mailed between March 1998 and February 1999. Descriptive statistics included percentages and measures of central tendency. RESULTS: The questionnaire was completed by 394 of the 1029 physicians surveyed (38.3%). Of the 268 respondents who treated patients with AN under the age of 18 years, 77.6% prescribed HRT. The decision to prescribe HRT was influenced by patient's age but not by bone mineral status. Among those who prescribed HRT, additional therapies included increased caloric intake (89.4%), weight gain (82.2%), increased calcium intake (84.1%), a change in exercise patterns (59.1%), and vitamin D supplementation (37.0%). Only 59 (22.0%) did not use HRT as a treatment modality. One-third of nonprescribers cited the lack of evidence of efficacy of HRT in preventing osteopenia. More recent medical graduates were less likely to prescribe HRT. CONCLUSIONS: This survey suggests that practitioners caring for adolescent females with AN commonly prescribe HRT for the treatment of osteopenia despite the paucity of evidence demonstrating that it effectively prevents or reverses bone loss associated with this disorder.

Adolescent↗
PubMed1999

The effect of doctor ethnicity and country of qualification on prescribing patterns: an ecological study.

OBJECTIVE: To assess the effect of doctor ethnicity and country of qualification on prescribing patterns. DESIGN: Ecological study. SETTING: 90 Family Health Services Authorities in the U.K. RESULTS: Being an Asian doctor and qualifying from the Indian subcontinent contributes to 5% of the observed variation seen in the frequency of prescribing, but not the cost. The major determinant of variation in prescribing is deprivation, which accounts for 14% of the cost and 32% of the frequency of prescribing. CONCLUSIONS: Being an Asian doctor and qualifying from the Indian subcontinent contributes to the frequency, but not the cost of prescribing variation. As this study was at the FHSA level, 'ecological fallacy' exists and further research is advocated at the individual doctor level.

Adult↗
PubMed2006

[The impact of two continuing education models on competence for hypertension diagnosis and treatment of community physicians].

OBJECTIVE: To compare the impact of two different continuing education models: traditional model and a new model entitled "problem-oriented and case-based" mutual pattern and "train the trainer" course, on improving hypertension diagnosis and treatment competence of community physicians. METHODS: A total of 632 physicians from 22 district and community hospitals in Haidian district (new model) and 20 district and community hospitals in Chaoyang district (traditional model) in Beijing were trained during July to October 2002. The survey was carried out before and 2 years after training with examination questionnaire. RESULTS: The competence evaluated as a score (maximal 100) for hypertension diagnosis and treatment of physicians was similar in physicians before training from the two districts. Post training, the score significantly increased from 40.0 to 47.4 (P < 0.01) in physicians from Chaoyang district and from 40.5 to 70.5 (P < 0.01) in physicians from Haidian district and the final score for physicians from Haidian district is significantly higher than that for physicians from increased from Chaoyang district (P < 0.01). CONCLUSION: The new model is more efficient for improving community physician's competence for diagnosing and treating hypertension.

Adult↗
PubMed1994

Innovation in high risk drug therapy.

The aim of this study was to identify predictors of the early adoption of high risk drugs by specialists with the expectation that the processes of innovation in this domain differ from those identified for general medical practice. One hundred and fifty-six specialists provided information regarding their awareness and use of each of eight target drugs, selected for their riskiness, and discussed in detail their adoption of one of them. General innovative behaviour, as assessed by awareness and use of the target drugs, as well as early first news of the particular drug discussed, were predictable from formal and informal contact with colleagues. However, the results indicate that two types of contact with colleagues are clearly distinguishable, as an information source and as an information seeker, which are independent and which show different patterns of prediction. Early use of the drug discussed was largely independent of the potential predictors. It is argued that first use of high risk drugs is determined by two factors, preparedness to prescribe the new drug and the presentation of particular circumstances which are appropriate for its use, only the first of which is predictable from the variables ordinarily thought to be involved in innovation. Therefore, if innovation is to be identified with stable characteristics of the practitioner, then this concept must be redefined in terms of knowledge and judgement rather than in terms of a particular behavioural event.

Adult↗
PubMed1993

Practice patterns and the adequacy of residency training in consultation medicine.

OBJECTIVE: To describe consultation practice patterns of graduates of an internal medicine residency program and to determine whether they consider themselves to be adequately trained to practice in the area of internal medicine consultations. DESIGN: The authors surveyed graduates of the internal medicine residency program at the University of California, San Diego, School of Medicine from 1980 to 1989. Respondents described their practice types and the mechanics of consultations they currently perform, as well as the adequacy of their training in and frequency of encountering 74 clinical problems in the area of internal medicine consultation. Topics were categorized as Group I: excessive training; Group II: adequate training, frequently encountered; Group III: adequate training, infrequently encountered; Group IV: inadequate training, frequently encountered; and Group V: inadequate training, infrequently encountered. SETTING: University teaching hospital. PARTICIPANTS: Of 214 graduates, 91 returned surveys adequate for analysis. RESULTS: Internists prefer verbal communication with their colleagues and seeing surgical patients in the office prior to admission. Residents perceive that they have been excessively trained in preoperative evaluations of the asymptomatic and chronically ill adult and in several postoperative complications. Topics seen frequently in clinical practice but inadequately taught include: issues in convalescence and rehabilitation from surgical procedures, use of psychotropic medications, and management of eating disorders. CONCLUSIONS: To prepare residents for practice, program directors in consultation medicine might consider incorporating outpatient preoperative evaluation assessments, encouraging a liaison between surgeons and internists, and modeling verbal communication among colleagues. Consideration should be given for more didactic training for Group IV topics.

Adult↗
PubMed1990

The impact of the fee-for-service reimbursement system on the utilisation of health services. Part II. Comparison of utilisation patterns in medical aid schemes and a local health maintenance organisation.

This study reports the results of a retrospective analysis of the use of a range of inpatient and outpatient services by the members of a health maintenance organisation (HMO), in which most providers are salaried, and by the members of three medical aid schemes in which providers are paid on a fee-for-services basis. The analysis shows significantly higher utilisation of all services by medical aid scheme members than by HMO members. Medical aid scheme patients saw all doctors 33% more often than their HMO counterparts. For general practitioners and specialists specifically, the differences were 36% and 18% respectively. Doctors looking after medical aid scheme beneficiaries ordered 133% more radiological procedures and 14% more pathological investigations than did those caring for HMO beneficiaries. Hospital utilisation was also higher for medical aid patients. While quality of care is difficult to measure, there are no reasons to suspect that significant differences in quality exist between the two systems described here. One factor that may contribute to the higher utilisation rates in the medical aid group is the higher average income of this group. However, these results also demonstrate that providers working in the fee-for-service system are likely to increase the supply of services compared with providers who are salaried. The different methods of reimbursement are compounded by the different practice settings in which these groups of doctors work; the HMO generates an awareness of costs that is absent from the independent practice, 'third-party payment' system of the medical aid schemes.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical Laboratory Techniques↗
PubMed2006

Vitamin E: patterns of understanding, use, and prescription by health professionals and students at a university teaching hospital.

BACKGROUND: Vitamin E is a generic term used to describe the many derivatives of tocol and tocotrienol. It is the major lipid-soluble antioxidant in the skin and has been used as treatment for many skin conditions, including scarring. Studies have shown that vitamin E provides no benefit to the cosmetic outcome of scars. METHODS: The authors constructed and distributed a questionnaire among staff and students at their institution. Their aim was to determine patterns of use and prescription of vitamin E among staff and students and to determine the understanding of the properties and biological functions of vitamin E. RESULTS: Questionnaires were completed by 208 staff and students, including 110 nonconsultant hospital doctors (52.89 percent), 61 nurses (29.33 percent), and 27 medical students (12.98 percent). Nearly 68 percent thought that vitamin E could be of use in improving the cosmetic appearance of scars, while 25 percent actually recommended vitamin E to patients to improve the cosmetic outcome of scars. Just under 40 percent were aware of the biological function of vitamin E, while 16.35 percent thought vitamin E had absolutely no effect on scarring. Of respondents, 21.64 percent had used vitamin E for their own scars; 31.11 percent of these said it was suggested by a doctor, while 6.67 percent said a pharmacist suggested it. CONCLUSIONS: Without scientific basis, health professionals continue to recommend vitamin E for use on scars. Such recommendations should not be made in the absence of evidence-based medicine.

Antioxidants↗
PubMed1997

Attitude survey of adverse drug-reaction reporting by health care professionals across the European Union. The European Pharmacovigilance Research Group.

OBJECTIVES: This survey was conducted to assess the attitudes of medical practitioners in the European Union regarding their national spontaneous reporting scheme, to identify reasons for under-reporting and to determine what steps might be effective in increasing reporting rates. National spontaneous reporting schemes rely on health care professionals reporting individual cases of suspected ADRs to a central or regional agency. National schemes, however, vary considerably and reporting rates and patterns differ between member states. Accumulating evidence suggests that doctors' attitudes to national ADR reporting schemes are significant determinants of reporting rates. METHODS: A self-administered questionnaire and letter of invitation was sent to a random sample of approximately 1% of medical practitioners in each of nine EU member states (Denmark, France, Ireland, Italy, the Netherlands, Portugal, Spain, Sweden and the UK). One month later, a reminder letter and a second copy of the questionnaire was sent to the non-responders (except Denmark and Italy). RESULTS: Response rates, and the percentage of responders who stated that they had reported previously an ADR, varied substantially between countries. Issues that appeared to discourage reporting included lack of availability of report forms; the address or telephone number of the reporting agency; lack of information on how to report; and not having enough time to report. Issues which did not apparently discourage reporting included concern about patient confidentiality; fear of legal liability or appearing foolish; reluctance to admit that harm had been caused to a patient; and ambition to collect and publish a personal series of cases. CONCLUSIONS: The results of this survey demonstrate some of the advantages and disadvantages of transnational, multilingual studies of this type, but indicate that there is scope for the further development of such techniques and their use on a wider basis in the EU and elsewhere.

Adverse Drug Reaction Reporting Systems↗