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PubMed1988

Improving pediatricians' compliance-enhancing practices. A randomized trial.

Previous evaluations of continuing medical education (CME) have yielded conflicting results regarding its effects on physician knowledge, performance, and subsequent patient outcomes. Poor adherence by mothers to prescribed pediatric regimens is a separate, but well-documented, problem. In the present study we assessed the ability of CME to: (1) increase the knowledge of pediatricians about compliance-enhancing strategies; (2) increase the performance of these practices by pediatricians; and (3) improve mothers' compliance with antibiotic regimens for their children's otitis media. Ninety pediatricians were randomly assigned to either a control group or one of two CME interventions: tutorial plus printed materials or mailed printed materials only. Following the interventions, data on compliance and on reported behaviors of pediatricians were gathered from a random sample of mothers (N = 771) whose children were being treated for otitis media. Findings indicated that CME increased physician knowledge and compliance-enhancing practices and resulted in improvement in mothers' adherence to therapy.

Child↗
PubMed2004

Does academic dishonesty relate to unethical behavior in professional practice? An exploratory study.

Previous research indicates that students in engineering self-report cheating in college at higher rates than those in most other disciplines. Prior work also suggests that participation in one deviant behavior is a reasonable predictor of future deviant behavior. This combination of factors leads to a situation where engineering students who frequently participate in academic dishonesty are more likely to make unethical decisions in professional practice. To investigate this scenario, we propose the hypotheses that (1) there are similarities in the decision-making processes used by engineering students when considering whether or not to participate in academic and professional dishonesty, and (2) prior academic dishonesty by engineering students is an indicator of future decisions to act dishonestly. Our sample consisted of undergraduate engineering students from two technically-oriented private universities. As a group, the sample reported working full-time an average of six months per year as professionals in addition to attending classes during the remaining six months. This combination of both academic and professional experience provides a sample of students who are experienced in both settings. Responses to open-ended questions on an exploratory survey indicate that students identify common themes in describing both temptations to cheat or to violate workplace policies and factors which caused them to hesitate in acting unethically, thus supporting our first hypothesis and laying the foundation for future surveys having forced-choice responses. As indicated by the responses to forced-choice questions for the engineering students surveyed, there is a relationship between self-reported rates of cheating in high school and decisions to cheat in college and to violate workplace policies; supporting our second hypothesis. Thus, this exploratory study demonstrates connections between decision-making about both academic and professional dishonesty. If better understood, these connections could lead to practical approaches for encouraging ethical behavior in the academic setting, which might then influence future ethical decision-making in workplace settings.

Behavior↗
PubMed2003

Influences on the variation in prevalence of type 2 diabetes between general practices: practice, patient or socioeconomic factors?

BACKGROUND: The prevalence of type 2 diabetes is known to vary between countries, districts and general practices. The influence of early detection and screening on the variation of prevalence between general practices has not previously been investigated. AIM: To test the hypothesis that the prevalence of type 2 diabetes is associated with awareness of and screening for diabetes within general practices and to explore other factors that may explain the variation in prevalence between practices. DESIGN OF STUDY: Cross-sectional study of general practices. SETTING: Forty-two general practices in Newcastle and North Tyneside; 20% random sample of patients with type 2 diabetes (n = 1056). METHOD: Factors thought to be associated with the variation of type 2 diabetes prevalence were collected from general practices through practice managers, medical records, and patient questionnaire. Pearson's correlation coefficient was used to quantify the association, and variables significant at the 5% level were entered into a multiple linear regression model. RESULTS: There was a wide inter-practice variation in age/sex standardised type 2 diabetes prevalence (range = 0.69% to 2.73%; P < 0.001). There was no significant association between the prevalence of type 2 diabetes and the proportion of patients detected outside primary care or the proportion of patients detected through screening, accounting for only 2% and 3% of the variation in type 2 prevalence between practices, respectively. The mean Townsend deprivation score accounted for 42% of the variation in type 2 diabetes prevalence between practices, with more deprived practices having a higher prevalence. CONCLUSION: This study suggests that socieconomic deprivation, rather than detection through screening or awareness of diabetes, accounts for much of the variation in prevalence of type 2 diabetes between practices.

Adolescent↗
PubMed2001

Role of conventional angiography in evaluation of patients with carotid artery stenosis demonstrated by Doppler ultrasound in general practice.

BACKGROUND AND PURPOSE: Previous studies have suggested that patients with carotid stenosis who are candidates for endarterectomy can be effectively identified on the basis of carotid Doppler ultrasound alone. Before widespread acceptance of this policy, the accuracy of carotid Doppler ultrasound outside selected centers and clinical trials needs to be evaluated. We performed a 12-month prospective study to evaluate the accuracy of Doppler ultrasound in identifying patients for carotid intervention in general practice settings. METHODS: Each patient referred to our endovascular service for diagnostic angiography to evaluate for carotid stenosis was interviewed and examined by a neurologist. Subjects consisted of symptomatic patients with >/=50% stenosis and asymptomatic patients with >/=60% stenosis by Doppler ultrasound. Information pertaining to demographic and cerebrovascular risk factors and the results of the carotid Doppler ultrasound were recorded. The severity of stenosis on angiograms was measured with North American Symptomatic Carotid Endarterectomy Trial criteria by a blinded observer. The results of both studies were compared to determine the relative accuracy of ultrasound results. RESULTS: Of 130 patients (mean age, 69+/-8.8 years) who met Doppler ultrasound criteria, 22 (17%) and 8 patients (6%) were found to have 30% to 49% or <30% stenosis by angiography, respectively. The positive predictive value of carotid Doppler ultrasound for identifying appropriate symptomatic candidates for carotid intervention (angiographic stenosis >/=50%) was 80%, with a false-positive value of 20%. The positive predictive value of carotid Doppler ultrasound for identifying appropriate asymptomatic candidates for carotid intervention (angiographic stenosis >/=60%) was 59%, with a false-positive value of 41%. Carotid endarterectomy or angioplasty and stent placement were undertaken subsequently in 60 (46%) of the patients. In 94 patients who underwent cerebral angiography alone, no complications were observed. CONCLUSIONS: The present accuracy of carotid Doppler ultrasound in general practice does not justify its use as the sole basis of selecting appropriate patients for carotid intervention. Given the relatively low rate of associated morbidity with present day techniques, additional confirmatory studies such as angiography should be performed in every patient before a decision regarding intervention is made.

Aged↗
PubMed1996

A comparison of patients attending general dental practices employing or not employing dental hygienists.

Previous studies have shown that dental practices employing dental hygienists provide a more periodontally oriented mix of dental services. Little is known about differences in the characteristics of patients who attend these practices, and whether these reflect the orientation of service delivery. In this study, a comparison was made between patients attending private general dental practices employing hygienists and patients attending practices without hygienists in Adelaide, South Australia. A questionnaire was mailed to 2391 patients, and valid responses were received from 632 patients attending 12 practices employing hygienists, and 1052 patients attending 22 practices not employing hygienists. Bivariate analysis of the responses comparing the two groups of patients was conducted using ANOVA for continuous variables and chi-square statistics for categorical variables. A multiple logistic regression model was developed to identify characteristics of patients attending practices with hygienists. Examination of significant (p < 0.05) findings revealed that patients attending practices with hygienists had a higher socio-economic status, had a more preventive pattern of use of services, had better knowledge of periodontally related topics and it was more likely that the dental profession was their main source of information of these topics. These findings indicate that patient profiles do reflect the orientation of service delivery within dental practices and raise the question of whether the dental practice alters the patient's knowledge and behaviour or whether certain patients selectively seek care from practices with hygienists.

Adult↗
PubMed2005

Defensive medicine among high-risk specialist physicians in a volatile malpractice environment.

CONTEXT: How often physicians alter their clinical behavior because of the threat of malpractice liability, termed defensive medicine, and the consequences of those changes, are central questions in the ongoing medical malpractice reform debate. OBJECTIVE: To study the prevalence and characteristics of defensive medicine among physicians practicing in high-liability specialties during a period of substantial instability in the malpractice environment. DESIGN, SETTING, AND PARTICIPANTS: Mail survey of physicians in 6 specialties at high risk of litigation (emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology) in Pennsylvania in May 2003. MAIN OUTCOME MEASURES: Number of physicians in each specialty reporting defensive medicine or changes in scope of practice and characteristics of defensive medicine (assurance and avoidance behavior). RESULTS: A total of 824 physicians (65%) completed the survey. Nearly all (93%) reported practicing defensive medicine. "Assurance behavior" such as ordering tests, performing diagnostic procedures, and referring patients for consultation, was very common (92%). Among practitioners of defensive medicine who detailed their most recent defensive act, 43% reported using imaging technology in clinically unnecessary circumstances. Avoidance of procedures and patients that were perceived to elevate the probability of litigation was also widespread. Forty-two percent of respondents reported that they had taken steps to restrict their practice in the previous 3 years, including eliminating procedures prone to complications, such as trauma surgery, and avoiding patients who had complex medical problems or were perceived as litigious. Defensive practice correlated strongly with respondents' lack of confidence in their liability insurance and perceived burden of insurance premiums. CONCLUSION: Defensive medicine is highly prevalent among physicians in Pennsylvania who pay the most for liability insurance, with potentially serious implications for cost, access, and both technical and interpersonal quality of care.

Defensive Medicine↗
PubMed2002

Comparison of the performance of three diagnostic algorithms for regular broad complex tachycardia in practical application.

The authors previously proposed a Bayesian approach to the electrocardiographic diagnosis of regular broad complex tachycardia (BCT), which can be due to VT or supraventricular tachycardia with aberrant conduction (SVTAC). They also published an account comparing the theoretical merits in the design of two of the most commonly used diagnostic algorithms for the same purpose, those of Brugada et al. and Griffith et al. In this study, a direct head-to-head comparison was performed on the practical performances of the three algorithms in this study. A set of 111 ECGs showing regular BCT (77 VT, 34 SVTAC) whose diagnoses were confirmed by electrophysiological study was shown to five internists in general medicine at a district general hospital. The observers were asked to comment on whether the ECG criteria in the three algorithms tested were fulfilled or not, and a computer program then derived the corresponding diagnoses. The sensitivity and specificity for VT achieved by the Brugada algorithm were 92% and 44%, 92% and 44% by the Griffith algorithm, and 97% and 56% by the Bayesian algorithm. The Bayesian algorithm achieved a higher sensitivity and specificity than the other two algorithms, but the differences are not statistically significant (P = 0.6583 and P = 0.5334, respectively). The Brugada, Griffith, and Bayesian algorithms show comparable performances in terms of overall sensitivity and specificity when tested in practice. Of the three algorithms, the Griffith algorithm excels in simplicity and is the easiest to implement in practice. The Bayesian algorithm achieved slightly higher values for sensitivity and specificity than the Brugada and Griffith algorithms but may be more suitable for automated computer-aided diagnosis of ECG due to its complexity.

Algorithms↗
PubMed1993

Contextual interference in movements of the same class: differential effects on program and parameter learning.

Contextual interference effects in motor learning usually were not found when the tasks to be learned presumably required the same generalized motor program (GMP) and differed only with regard to the movement parameters (see Lee, Wulf, & Schmidt, 1992; Magill & Hall, 1990). Thus, tasks requiring different motor programs (e.g., different relative timings) seemed to be a prerequisite for random practice to be more effective than blocked practice. However, the previous studies (that did not find random/blocked differences) used global error measures that confounded errors in relative timing and errors in absolute timing. In the present study, subjects practiced three movement patterns that had the same relative timing (requiring the same GMP) but different overall durations (requiring different parameters). Errors in relative timing and in absolute timing were assessed separately. The results indicate that random practice is more effective for the learning of relative timing (GMP learning) and less effective for the learning of absolute timing (parameter learning) than blocked practice. Preliminary ideas as to the reasons for this effect are discussed.

Journal Article↗
PubMed1995

Paediatric appendicectomy in NSW: changes in practice over time and between groups.

The present study examined patterns of appendicectomy among 0- to 14-year-old children in New South Wales between 1986 and 1989/90. The study, which used routinely collected hospital separation data, showed that the overall rate of appendicectomy in this age group in 1989/90 was 2.5 per 1000 which was a significant (P < 0.01) reduction on the 1986 rate. The rate of appendicectomy with histologically confirmed appendicitis was 1.8 per 1000 in 1989/90 which was significantly (P < 0.01) lower than the corresponding rate for 1986. The proportions of appendicectomies with perforation (10% in 1989/90) and without acute appendicitis ('negative' appendicectomy; 28% in 1989/90) were comparable to previous Australian and overseas reports and changed little during the study period. Differences in the rates of appendicectomy and of perforated appendices were found between geographic areas. However, the area-specific rates of perforation were not systematically associated with the corresponding rates of negative appendicectomy. The proportion of negative appendicectomies was higher among female than male children (35% of females compared with 25% of males in 1989/90). The youngest age group (0-4 years) had the highest proportion of perforations: 27% compared with 13% in the 5-9 year and 8% in the 10-14 year age groups. We conclude that appendicectomy is now performed less frequently in NSW than in previous years. Surgical practice in relation to appendicectomy in NSW provides outcomes that compare favourably with previous Australian and overseas experience. Although the proportion of perforations is relatively low, the comparatively high proportion of perforations in the youngest age group is of concern.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2006

Critical care outreach: the need for effective decision-making in clinical practice (part 2).

As the extension of nursing into roles previously within the domain of medicine and the demand for evidence based practice continue to increase, the quality of decision making becomes imperative. Making accurate decisions is essential, both for the practitioner and for the patient, especially in the provision of critical care outreach (CCOR), to improve outcomes of care. With changes in health care delivery and increased accountability for practitioners' decisions, it is important to understand more about how clinical decisions are made and what factors influence them in order to inform practice. The previous paper outlined the theoretical background of clinical decision making and the knowledge that underpins practice in CCOR. In this paper, the authors, a Nurse Consultant in CCOR and a research fellow, examine the process of a practitioner's decision making in the practice of CCOR, through a collaborative reflective account of a case study. From this, recommendations are made about the future development of CCOR practitioners and services.

Aged↗
PubMed1990

Consistent and varied memory/visual search: is there an interaction between age and response-set effects?

Interactions of stimulus consistency and response-set were examined after extensive consistent (CM) and varied mapping (VM) practice for young (mean age 20) and old (mean age 74) adults. The experiment examined whether reduced response complexity would lead to equivalent consistent mapping search performance across age groups. Subjects received 2,240 training trials each for CM and VM versions of a hybrid memory/visual search task. During training two response conditions were used: (1) respond only when a target was present (Yes-only responding) and (2) respond only when a target was absent (No-only responding). Following initial training, subjects were transferred to the opposite response condition. During training the function relating reaction time to memory-set size differed between age groups only with CM practice, replicating age-related effects previously found for extensive CM practice. Response reversal (e.g., Yes-only to No-only) after training led to age-related transfer effects for both CM and VM search. Importantly, the transfer data suggest age-dependent controlled processing effects.

Adolescent↗
PubMed1975

Patient morbidity and some patterns of family practice in southeastern Ontario.

Over a 7-month period the trial version of the International Classification of Health Problems in Primary Care (ICHPPC) was studied. Ten community physicians reported 28 399 encounters wtith 11 437 patients. The overall distribution of health problems was comparable to that found in other North American studies. Some differences between the morbidity distributions in urban and rural practices varies from those of previous Canadian studies. Other differences between practices appeared to be related to the interests and training of the individual physicians. The workload of the physicians varied considerably. Many of the encounters involved problems for which there may be minimal benefit from medical intervention, and there was a large discrepancy in the frequency of follow-up visits for specified stable chronic health problems. The implications of these interpractice variations in the altering field of health care are discussed.

Anxiety↗
PubMed1989

Full-time women general practitioners--an invaluable asset.

It has been said that women doctors do not fulfil the same role as men doctors in general practice. This is inaccurate as previous studies of workload in general practice have not excluded from the analyses women principals who are part time, that is, have a less than full profit share at parity. In a postal questionnaire to 501 women principals 308 (62%) replied, of whom 143 (46%) were full time with respect to profit share. Respondents were asked to record aspects of workload over a four-week period for themselves and three of their full-time men partners. Analysis of their responses showed that they did an equal workload to their full-time men partners in terms of number of surgeries, length of surgeries and number of home visits. Equal numbers of full-time women did out-of-hours work as their men partners and the number of nights and weekends on-call as well as use of deputies were similar. The analysis also showed that full-time women did more specialized clinics than men, thus emphasizing the special role of women doctors in preventive care.

Employment↗
PubMed2000

Regular inhaled salbutamol and asthma control: the TRUST randomised trial. Therapy Working Group of the National Asthma Task Force and the MRC General Practice Research Framework.

BACKGROUND: Previous work has suggested that the long-term regular use of inhaled beta2-agonist bronchodilators might lead to a deterioration in asthma control. The aim of TRUST (The Regular Use of Salbutamol Trial) was to study the effects of regular use of inhaled salbutamol, the most widely prescribed bronchodilator in the UK, on the control of asthma. METHODS: A randomised, double-blind, placebo-controlled trial was undertaken in 983 patients with asthma being treated at least twice a week with short-acting beta2-agonist, alone or in combination with inhaled steroids (2 mg or less) daily. Patients were aged 18 years and over and were recruited from 115 general practices in the UK. 90% (881) of the patients used inhaled corticosteroid therapy, and all patients continued to use their usual inhaled beta2-agonist for symptomatic relief. Patients were randomised to receive 400 microg salbutamol or matched placebo via a Diskhaler four times per day for 12 months. The primary outcome measure was rate of exacerbations of asthma, with criteria based on data from diary cards completed daily by each patient, treatment with additional corticosteroids, or both. FINDINGS: There were no differences in the annual rate, timing, or duration of exacerbations between the two groups. The mean morning peak expiratory flow was similar for the two groups. The mean evening peak expiratory flow (p<0.001) and the diurnal variation (p<0.001) were greater, and the use of rescue bronchodilator was less (p<0.001), in the group receiving regular salbutamol. INTERPRETATION: There was no evidence that regular use of inhaled salbutamol 400 microg four times daily for a year increased the exacerbation rate of asthma in the population studied.

Administration, Inhalation↗
PubMed1977

Cumulative radiation effect. Part VI: simple nomographic and tabular methods for the solution of practical problems.

In five previous papers, the concept of the Cumulative Radiation Effect (CRE) has been presented as a scale of accumulative sub-tolerance radiation damage. The biological effect generated in normal connective tissue by fractionated or continuous radiation therapy given in any temporal arrangement is described by the CRE on a unified scale of assessment, so that a unique value of the CRE describes a specific level of radiation effect. The basic methods of evaluating CREs were shown in these papers to facilitate a full understanding of the fundamental aspects of the CRE-system, but these methods can be time-consuming and tediuous for complex situations. In this paper, simple nomographic and tabular methods for the solution of practical problems are presented. An essential feature of solving a CRE problem is firstly to present it in a concise and readily appreciated form, and, to do this, nomenclature is introduced to describe schedules and regimes as compactly as possible. Simple algebraic equations are derived to describe the CRE achieved by multi-schedule regimes. In these equations, the equivalence conditions existing at the junctions between schedules are not explicit and the equations are based on the CREs of the constituent schedules assessed individually without reference to their context in the regime as a whole. This independent evaluations of CREs for each schedule results in a considerable simplification in the calculation of complex problems. The calculations are further simplified by the use of suitable tables and nomograms, so that the mathematics involved is reduced to simple arithmetical operations which require at the most the use of a slide rule but can be done by hand. The order of procedure in the presentation and calculation of CRE problems can be summarised in an evaluation procedure sheet. The resulting simple methods for solving practical problems of any complexity on the CRE-system are demonstrated by a number of examples.

Connective Tissue↗
PubMed2004

Fielding incognito standardised patients as 'known' patients in a controlled trial in general practice.

BACKGROUND: Incognito standardised patients (SPs) have only been used to represent new patients so far. The few trials with incognito SPs provide little detail on the method used for fielding them. OBJECTIVE: To establish the feasibility of introducing SPs as 'known' patients (i.e. patients who have previously visited the practice) into practices, to indicate the required practice preparations, and to describe the various aspects of using SPs in a pretest/post-test design. METHODS: We used incognito SPs as known patients in a controlled trial to assess the practice behaviour of 49 trainees. The SPs received a 2-day training in role playing and completing checklists. We compiled comprehensive practice information folders of each practice to be visited. Real personal data and faked medical data of SPs were inserted in the filing system of each practice to be visited. Apart from SP roles with slightly different reasons-for-encounter and different SPs, the same training protocol, checklists and practice information folders were used in the post-test. RESULTS: The SPs carried out 287 visits in 50 practices. All practices prepared the patient records for the SP visits in a fairly authentic practice style. Trainees detected the SP in 74 visits. The main reasons for detection were imperfections in patient records and aspects of SP roles or role playing. CONCLUSION: Fielding incognito SP visits as known patients was feasible but labour-intensive. Preparing the SP patient records and familiarising SPs with the interior of practices represented new elements in the use of SPs. The pretest/post-test format made their use more efficient instead of complicating it.

Clinical Competence↗
PubMed1996

The preparedness of pediatricians for emergencies in the office. What is broken, should we care, and how can we fix it?

OBJECTIVES: To determine the frequency of emergencies in pediatric practices, assess office emergency preparedness, and explore practitioner's reasons for levels of preparedness. DESIGN AND SETTING: Telephone survey of pediatric offices in Fairfield County, Connecticut. SAMPLE: Fifty-one (98%) of 52 offices participated, representing 481 staff. RESULTS: More than 2400 emergencies are seen each year in the pediatric offices, with a median of 24 emergencies per practice annually. Forty-two (82%) of the practices averaged at least one emergency per month, 13 (25%) experienced more than 50 emergencies annually, and seven (14%) experienced more than 100 emergencies annually. Of all eligible staff, 14% were certified in basic life support and 17% in pediatric advanced life support. The following emergency equipment was missing from offices: oxygen, 14 (27%); intravenous catheters, 14 (27%); bag-valve-mask, 15 (29%); nebulizers, 17 (33%); epinephrine 1:10 000, 27 (53%); and intravenous fluids, 28 (55%). Thirty-seven (73%) of offices had the minimum recommended equipment and training for status asthmaticus management; only 17 (33%) of offices had similar preparation for each of the six other emergencies. High-level emergency preparedness was rare. The perceptions of office pediatricians are that office emergencies are rare, and emergency preparedness is difficult to achieve because practices are too busy and the expense and time commitment are too great. CONCLUSIONS: Emergencies are common in pediatric practices, but problems in the emergency preparedness of practices persist despite previous studies with similar findings, and publication of guidelines. Perceptions of practitioners suggest that not enough effort has been devoted to increasing practitioner awareness of these problems. Greater awareness might result by emphasizing practical instruction in residency and continuing medical education courses, and by publication of guideline summaries.

Adolescent↗
PubMed1991

Establishing a family practice: a model to determine economic feasibility.

The availability of adequate health care is a major concern of urban and rural citizens. Community leaders and hospital administrators attempting to recruit family physicians and health care providers considering a specific community need a method by which they can evaluate a community's potential for supporting a first or additional primary care physician. To develop this method, a detailed survey of family practices geographically dispersed throughout Oklahoma was conducted in 1989. Data collected from family physicians and their administrative staff reflected the volume of ambulatory and hospital visits and the direct and indirect costs of the practice over the previous 12 months. Using the fixed and operating cost data, as well as number of patient visits and patient care revenue, we designed a model to project the economic feasibility of establishing a family practice in a specific community. This model can be used to project the number of visits a community can generate for a prospective family physician, as well as the direct and indirect costs, gross revenue, and net income of the practice.

Adolescent↗