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PubMed2004

Breast cancer treatment in clinical practice compared to best evidence and practice guidelines.

There is sparse evidence on community practice patterns in treating women with breast cancer. This study compared care of women with breast cancer with evidence from meta-analyses and US National Comprehensive Cancer Network (NCCN) clinical guidelines. Records of 4395 women with breast cancer were abstracted from practices of 19 surgeon oncologists in six specialty practices in the Philadelphia region during 1995-1999. Patients were followed through December 2001. Low-frequency data were obtained on all patients. All other data were from a random sample of 464 women, minimum of 50 patients per practice. Actual care provided was compared to NCCN guidelines and results of meta-analyses. Fewer than half the women received treatments reflecting meta-analysis results or NCCN guidelines, by disease stage/TNM status. Adherence to either standard varied from 0% for LCIS to 87% for stages IIA or IIB node positive. There are multiple interactive reasons for low adherence to guidelines or meta-analyses results, including insufficient health system supports to clinicians, inadequate organisation and delivery systems and ineffective continuing medical education. The paucity of written information from patient records on physician/patient interactions limits the understanding of treatment decisions.

Adult↗
PubMed2001

Practice patterns versus practice guidelines in pediatric otitis media.

OBJECTIVE: To study the practice patterns of physicians and their adherence to an evidence-based practice guideline (PG) on pediatric otitis media with effusion. We hypothesized that overall knowledge of the recommendations from the guidelines would be less than 75%, and that specialist physicians would have better knowledge of the recommendations than generalist physicians. METHODS: We performed a survey study of 1167 otolaryngologists, pediatricians, and pediatric otolaryngologists. Each physician was sent a 6-item survey asking about their practice patterns and treatment preferences for young children with otitis media with effusion. We compared responses between different specialties. RESULTS: The overall response rate was 48%. Only 8 (1.4%) of the 558 responding physicians answered all 6 items congruent with the PG. Overall, pediatricians, otolaryngologists, and pediatric otolaryngologists had similar total scores, but different scores on individual items. CONCLUSIONS: These results indicate that the practice patterns of pediatricians, otolaryngologists, and pediatric otolaryngologists differ from the recommendations of an evidence-based PG. In particular, 2 items covering key treatment recommendations were answered in agreement with the PG by fewer than half of the physicians. It is not clear from this study whether these discrepancies were due to poor dissemination or knowledge concerning the PG, or disagreement with its recommendations.

Child↗
PubMedDate not supplied

Confronting actual practice with practice guidelines in oncology.

Improving health care quality requires the availability of data to identify and eliminate unnecessary variations in the care process. Variations can be caused by an ineffective implementation of research findings or by obstacles to the translation of research into clinical practice. The analysis of current patterns of care by the use of routine data from electronic patient records or clinical registries may help highlight these deficiencies in actual care. The growing infrastructure of information technologies and the knowledge about clinically relevant variations of routine practice may help us understand the mechanisms that are impeding the translation of research into practice. There is a need to scrutinize these variations of practice and the barriers to guideline implementation. We think that an understanding and open discussion of such reasons may help, to continuously improve the quality of patient care. This process facilitates efforts and strategies to implement evidence-based medicine in the daily routine.

Data Collection↗
PubMed2000

Setting national standards for practice equipment. Presence of equipment in Estonian practices before and after introduction of guidelines with feedback.

BACKGROUND: During the last few years quality assurance has received increasing attention in Estonian health care as well as in family medicine, which is a new speciality in Estonia (since 1993). The modest equipment that district doctors (former primary care doctors) had at their disposal, appeared inadequate considering family doctors' work tasks. AIM: To determine the type of equipment available in primary care practices before setting a standard, and 1 year after the minimal standard of practice equipment was introduced. To follow how well family doctors adhere to this standard. METHOD: A questionnaire was sent to a random sample of district doctors (n=157) in 1992 and to all family doctors practising as independent contractors in 1998 (n=376). Quality of equipping was assessed against the standard set by consensus of the representatives of Family Doctors' Society, based on the country's needs and family doctor's job description. RESULTS: The level of primary care doctors' office equipment in 1992 was quite low. However, by the spring of 1998, substantial improvement of the equipment in family doctors' practices was estimated. The number of doctors possessing instruments for otorhinolaryngological, ophthalmological and gynaecological work as well as for taking care of children had increased two- to three-fold. About one-half of the family doctors reported that they had all the instruments listed in the standard. CONCLUSIONS: Setting a national standard helps to improve practice equipment--an important structural aspect of quality of care. Although improvement of equipment alone cannot guarantee quality of care, it may provide an important first step towards promoting it.

Data Collection↗
PubMed1995

Treatment preferences, return visit planning and factors affecting hypertension practice amongst general practitioners and internal medicine specialists (the General Practitioner Hypertension Practice Study)

OBJECTIVES: To study clinical practice and attitudes in hypertension care amongst general practitioners (GPs) and hospital internal medicine specialists. DESIGN: Mailed case report questionnaires. SUBJECTS: Ninety GPs and 69 internal medicine specialists at randomly selected primary health care centres and hospital outpatient departments. MAIN OUTCOME MEASURES: Case-bound treatment preferences, treatment goals and return visit planning, and views on factors influencing practice. RESULTS: The participation rate was 84% and 70%, for GPs and internal medicine specialists, respectively. GPs more often proposed nonpharmacological therapy (P < 0.05), solely and as a complementary treatment, and prescribed more calcium antagonists (P < 0.001), whilst internal medicine specialists prescribed more ACE inhibitors (P < 0.001). Personal experience guides practice more than national consensus and economy, more so with increasing time since specialization. CONCLUSIONS: GPs and internal medicine specialists in Sweden report a hypertension practice closely related to each others' and to the intentions of national guidelines.

Family Practice↗
PubMed1996

Practicality of recording patient ethnicity in general practice: descriptive intervention study and attitude survey.

OBJECTIVE: To assess the feasibility of recording patient ethnicity in primary care using the Office of Population Censuses and Surveys classification. DESIGN: A descriptive intervention study and attitude survey in random samples of adults and primary care staff in randomly selected practices. SETTING: Eight practices in Lincolnshire and seven in Leicester. SUBJECTS AND METHODS: When patients were asked their ethnicity by general practitioners, nurses, or receptionists data were collected for 863 of a possible 880 patients. Of 750 patients sent a questionnaire about their attitudes towards the collection of such data 489 responded. Ninety five primary care staff completed a similar questionnaire. MAIN OUTCOME MEASURES: Time taken to record a patient's ethnicity; attitudes of patients and staff towards such recording, including who should ask, who can respond for others, and whether data can be shared with secondary care. RESULTS: Recording the data took less than a minute for three quarters of patients, but even this would need an average of a week of receptionist time per general practitioner. 72% of patients and 57% of staff agreed that ethnic data could be shared with secondary care, and 73% of patients and 60% of staff felt that the data should probably be collected in general practice. CONCLUSIONS: Ethnicity recording in general practice is feasible and acceptable. Nevertheless, the role of ethnic data in assessing health need in primary care, an adequate recording system, and evidence that recording offers benefits greater than the costs need to be established.

Attitude↗
PubMed2004

The investigation of short stature: a survey of practice in Wales and suggested practical guidelines.

AIM: To survey the investigation of short stature in Wales and suggest guidelines to improve practice. METHODS: Questionnaires were circulated to paediatricians and consultant clinical biochemists or consultant chemical pathologists at 13 Welsh hospitals where children with short stature are investigated. RESULTS: A 100% response was obtained from laboratory and clinical staff. Clinicians screened 1-50 patients each year (median, 10). Growth hormone (GH) deficiency was subsequently diagnosed in 0-30% (median, 10%) and GH treatment started in 30-100% (median, 100%) of patients. Five paediatricians and eight laboratories had written investigative protocols. Investigation of GH secretion was initiated in some centres before a complete clinical evaluation was carried out. Various screening tests for GH deficiency, including insulin-like growth factor 1 (IGF-1), random GH, and exercise tests were used. The clonidine stimulation test was used to assess the GH axis in most centres but eight different protocols were described. GH was measured in four Welsh laboratories using two automated immunoassay methods. However, nine different ranges of cutoff values for defining abnormal GH responses were quoted, and in three centres laboratories and paediatricians quoted different cutoffs. CONCLUSION: This survey demonstrates the need for practical guidelines for the investigation and management of short stature in children, agreed by paediatricians and their laboratory colleagues. The guidelines should encompass the initial clinical investigation, assessment of the GH-IGF-1 axis (using standardised protocols), and provision for the transition to adult management. This article presents practical guidelines based on published points for good practice.

Child↗
PubMed2000

Clinical practice guidelines vs actual clinical practice : the asthma paradigm.

In recent years, a multitude of practice guidelines, statements, position papers, and "best practices" have been promulgated for a number of disease entities by a variety of medical societies and managed care organizations. In the case of asthma, for example, the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) initially published guidelines for the diagnosis and management of asthma in 1991; these recommendations were updated in 1997. However, health-care providers have not widely and consistently adhered to these guidelines. Several recent publications suggest that this underutilization of the NIH asthma guidelines may in part be related to a lack of understanding. This lack of understanding appears to span the spectrum of physicians in private practice, physicians working in health maintenance organizations, as well as university-affiliated physicians. Moreover, both primary-care physicians and "asthma specialists" share deficits in their knowledge base. To compound the problem, patients with asthma also demonstrate poor adherence to the guidelines. This poor adherence is evident irrespective of the patient's socioeconomic status. These types of data clearly indicate a need for further educational programs directed to both physicians and patients. However, as with the development and promulgation of any practice guideline, physicians need to be convinced that there exists compelling evidence from well-controlled clinical trials, for example, or from evidence-based medicine, to substantiate implementation of these guidelines.

Adult↗
PubMed1992

On content of practice. An Icelandic multicentre study, population, practices and contacts.

To establish data on the content of Icelandic family practice, a prospective practice audit was made of all Icelandic health centres with computerized contact data from 1 January to 31 December 1988. The study comprised 17 community health centres in Iceland and their target populations, 13 rural and four urban. The main subjects for study were population characteristics, practice sizes, types of health care providers, and contacts. The study population, 50,865 subjects, comprised 20.2% of the Icelandic population. Rural and urban populations were different and are described separately. The 17 health centres had a mean of 1,152 subjects/doctor. The target population had a total of 257,188 contacts: 155,526 rural contacts, 5.1/subject (3.3 office-, 1.1 phone-, and 0.4 home-contacts); 101662 urban contacts, 5.1/subjects (2.8 office-, 1.6 phone-, and 0.4 home-contacts). During 1988, 88.9% of the rural target population made contact. These data are comparable to data from other countries; the observed office and home contact rates were similar, but phone-calls were more frequent. Computer systems in family practice provide a feasible way to collect data on a regular basis for epidemiological purposes and for performance review.

Community Health Centers↗
PubMed1996

Practice management agreements: the core of the MSO-group practice alliance.

Physician group practices increasingly are negotiating practice management agreements with management service organizations (MSOs). Understanding the issues surrounding the creation and implementation of practice management agreements is critical to maintaining a successful MSO-group practice relationship. The scope of the management commitment must be established and the agreement must provide sufficient flexibility to allow the physicians and MSO to mutually benefit from market-place changes.

Contract Services↗
PubMed1988

Comparison of practice patterns and job satisfaction of entry level PharmD and BS level graduates in hospital and community practice.

Controversy has and continues to exist over whether schools of pharmacy should make the PharmD the universal entry level pharmacy degree. Proponents argue that doctorate status would enhance pharmacy's professional image and society would benefit from doctoral-level training. Opponents counter that, given the present health care system, society can place only a small percentage of pharmacists in positions requiring training at the doctorate level and, further, placing pharmacists with highly developed clinical skills in positions not requiring such skills will lead to both frustration and loss of clinical skills. The present study investigated the following research questions with regard to community and hospital pharmacy practice: (i) do job activities of entry level PharmD graduates differ from those of BS graduates; and (ii) does the job satisfaction of entry level PharmD and BS graduates differ? Questionnaires were mailed to randomly selected California entry level PharmD graduates and Georgia BS graduates to elicit responses regarding practice patterns and job satisfaction. Response rates were 68 percent for PharmD and 62.5 percent for BS respondents. The subsequent data revealed that both PharmD and BS respondents devoted the greatest portion of their time to drug distribution in both practice settings. Minimal differences were noted in other work activities in either on practice setting. No differences in job satisfaction were found.

California↗
PubMed1999

Update of geriatric psychiatry practices among American psychiatrists: Analysis of the 1996 National Survey of Psychiatric Practice.

Using data from the 1996 National Survey of Psychiatric Practice from the American Psychiatric Association (APA), the authors updated information on psychiatrists who are high geriatric providers (HGPs). In 1996, HGPs comprised 18% of the sample. Only 23% reported no geriatric patients in their practice, a 51% reduction from 1988-89; the proportion of HGPs is increasing. HGPs were more often male, minority, international medical school graduates, certified in geriatric psychiatry, and not medical school-affiliated. HGPs worked longer hours/week in direct patient care, had more patient visits/week, and saw more new patients/month, spending more time in hospitals and nursing homes and less time in office-based practice, and seeing more patients with mood disorders, psychotic disorders, and other disorders. Medicare was a proportionally higher payment source. Older psychiatrists were likely to have more patients over age 65. Tracking practice activities of HGPs may help inform policy discussion regarding staffing needs for geriatric patients with late-life mental disorders.

Aged↗
PubMed1975

An economic perspective on dental practice: the economics of increasing practice size.

Group dental practice is a form of organization which can show substantial professional and public benefits. Part of the support for group practice is derived from an extrapolation of the theory of economies of scale. Applied to dentistry, the theory holds that as practices grow they will be able to use their resources more efficiently than do smaller practices, and lower, thereby, the average costs of producing dental services.

Costs and Cost Analysis↗
PubMed2000

Preventive services in the primary care practices of the Practice Partner Research Network.

Despite the emphasis of primary care on preventive services over the past decade, and the reminder systems that are available to promote the provision of these services, many patients still do not receive needed services. This study describes the preventive services that the primary care practices of the Practice Partner Research Network (PPRNet) monitors, and documents adherence to them. Preventive services monitored in PPRNet practices and the levels of adherence to them vary by practice and service. The lower-than-desired levels of adherence offer opportunities for improvement interventions.

Data Collection↗
PubMed2001

Care of the secondary patient in family practice. A report from the Ambulatory Sentinel Practice Network.

BACKGROUND: Care of a secondary patient (an individual other than the primary patient for an outpatient visit) is common in family practice, but the content of care of this type of patient has not been described. METHODS: In a cross-sectional study, 170 volunteer primary care clinicians in 50 practices in the Ambulatory Sentinel Practice Network reported all occurrences of care of a secondary patient during 1 week of practice. These clinicians reported the characteristics of the primary patient and the secondary patient and the content of care provided to the secondary patient. Content of care was placed in 6 categories (advice, providing a prescription, assessment or explanation of symptoms, follow-up of a previous episode of care, making or authorizing a referral, and general discussion of a health condition). RESULTS: Physicians reported providing care to secondary patients during 6% of their office visits. This care involved more than one category of service for the majority of visits involving care of a secondary patient. Advice was provided during more than half the visits. A prescription, assessment or explanation of symptoms, or a general discussion of condition were provided during approximately 30% of the secondary care visits. Secondary care was judged to have substituted for a separate visit 60% of the time, added an average of 5 minutes to the visit, and yielded no reimbursement for 95% of visits. CONCLUSIONS: Care of a secondary patient reflects the provision of potentially intensive and complex services that require additional time and are largely not reimbursed or recognized by current measures of primary care. This provision of secondary care may facilitate access to care and represent an added value provided by family physicians.

Adolescent↗
PubMed2001

[Analysis of expert reports from a general practice expert in disciplinary cases and malpractice claims against family practitioners (1994-2000): a lesson for clinical practice].

Of the reports issued by a general practice expert for disciplinary and malpractice cases in the period 1994 to August 2000, 76 were analysed, with the emphasis on the more serious cases. Infectious diseases and cardiovascular diseases together formed 42% of the cases judged. The starting point of the analysis was the practice of an 'average general practitioner'. On the basis of jurisprudence and general practice literature, failure to diagnose a rare illness was not automatically regarded as reproachable but failing to estimate the seriousness of a situation was. In the first place it was checked whether or not general practitioner had adequately estimated the seriousness of the situation by paying due attention to the alarm signals and risk factors and in the case of diagnostic doubts by ensuring adequate follow-up. According to the analysis, 41% of the cases clearly exhibited reproachable conduct. This figure was twice as high when a locum was working at a practice. Two-thirds of the primary errors were due to the seriousness of the situation not being adequately estimated as a result of too little attention being paid to alarm signals and risk factors as well as a failure to ensure adequate follow-up. On the basis of the analysis it is advised that the use of a locum should be regarded as a risk situation: better information can be made available by means of an electronic patient file and unequivocal agreements for drawing up reports. For each consultation, the GP must systematically check whether there are alarm signals or risk factors. In the case of diagnostic doubts the clinical picture should be actively followed up by means of clear follow-up appointments at definite times. In the guidelines of the Netherlands Society for General Practitioners, explicit attention should be given to alarm signals and risk factors. In medical training and ongoing professional education, systematic training should be provided in the recognition of serious situations and rare diseases/complications.

Adult↗
PubMed2005

Expanding access to the management of HIV/AIDS through physicians in private practice: an exploratory survey of knowledge and practices in two Nigerian states.

Over the past few years, the cost of antiretroviral drugs has continued to decline. A significant proportion of people in Nigeria seek medical care primarily in the "for profit" private sector. The complexity of managing HIV and AIDS has led to debates on whether care should only be restricted to trained and accredited experts in HIV care. This research studied the knowledge and practices of physicians in private practice in two Nigerian states on the management of patients with HIV/AIDS using an anonymous self-administered questionnaire eliciting knowledge and attitudinal information. This is to ascertain their preparedness to manage HIV positive patients. The doctors were found to be poorly informed on practical issues in the management of HIV patients. These included the need to confirm their patient's HIV status, where to do the confirmation and where to refer such patients for counselling. Most of them referred to the mass media as their primary source of information. There is an urgent need for pro-active planning to prepare physicians in private practice for increasing demands in the management of HIV/AIDS in Nigeria. Organising a nation-wide training programme that would lead to ongoing accreditation programme is a way of achieving this. The formulation of guidelines for managing both clinical and non-clinical aspects of HIV/AIDS should be prioritised.

Clinical Competence↗
PubMed1983

Using private practice settings for academically intensive family practice clerkships.

The Department of Family Medicine and Practice at the University of Wisconsin has designed and conducted an academically intensive third-year three-month family practice clerkship based in private practice settings. This experience differs from more traditional preceptorships in the amount of academic structure and quality control applied to the student's learning experience. This clerkship has demonstrated that extramural experiences can be as academically intensive and carefully monitored as traditional, referral-hospital-based clerkships in family practice or other basic medical disciplines. Increases in the level of continuity of care occur over the entire 12 weeks.

Clinical Clerkship↗