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PubMed2004

Perceptions around concordance--focus groups and semi-structured interviews conducted with consumers, pharmacists and general practitioners.

BACKGROUND: Achieving concordance by identifying beliefs about illness, treatment and medicine-taking should impact positively on behaviour and consumer satisfaction with respect to treatment, and health outcomes may be improved. OBJECTIVE: To explore, in the Australian context, beliefs and expectations of general practitioners (GPs), consumers and pharmacists in relation to concordance to allow further exploration of the implementation of principles of concordance in Australia. DESIGN: Qualitative analysis of focus group and semi-structured interview data. SETTING AND PARTICIPANTS: Focus groups were held with seven consumers and nine pharmacists and, in-depth, semi-structured interviews were held with 10 GPs between February and May 2003, in Brisbane (Australia). RESULTS: This explorative study identified a variety of issues. Consumers expressed the need for more input from health professionals - being given more information on their treatments and conditions, more time spent in discussion, and establishing a system where harmonious relationships between health professionals could take place, which would result in a more consumer-friendly health care system. The main issues voiced by the pharmacists were about the idea of organizing the health care system in a way that would accommodate more quality information sharing between all partners. GPs' issues included better and unlimited information-sharing, having more time to promote quality in health care and receiving remuneration for increased verbal contact with other health care professionals. Suggestions were made about ways to achieve concordance by improved information-sharing and shared decision-making. CONCLUSION: The data from this study will lead to the development of models to explore and attempt to incorporate principles of concordance in Australian pharmacy and medical practice.

Aged↗
PubMed1992

Gift or good? A contemporary examination of the voluntary and commercial aspects of blood donation.

The safety and ethical aspects of blood donation are examined in the light of current legislation and practice. The advantages and disadvantages of voluntary and paid donation are looked at in view of recent data concerning risk factors in various potential donor groups. It is concluded that voluntary, non-remunerated blood donation remains the safest and most ethical means of securing the blood supply.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Blood safety in developing countries.

This study, based on responses to a questionnaire, was undertaken to define problems in and formulate solutions for improving blood safety in developing countries as part of an effort to monitor the status of blood transfusion services globally. Despite improvements between 1988 and 1992, only 66% of developing countries (DGCs) and 46% of least developed countries (LDCs) screen all blood donations for antibodies to human immunodeficiency viruses; 72% DGCs and 35% LDCs test all donations for hepatitis B surface antigen and 71 and 48%, respectively, for syphilis. The antihuman globulin test is performed routinely in 62% DGCs and 23% LDCs, and inadequate quality assurance in all aspects of preparatory testing is a major weakness in many countries. The blood supply is usually insufficient: none of the LDCs and 9% of the DGCs collect 30 units or more per 1,000 of the population annually. Blood donor systems are totally voluntary and non-remunerated in 15% DGCs and 7% LDCs; 80% DGCs and 93% LDCs rely totally or partially on replacement donors and 25% of both groups on paid donations. The proportion of repeat donors is low (medians: 47% in DGCs, 20% in LDCs), and discard rates for collected blood are often high (up to 33%). Most of the blood collected is transfused as whole blood, and most DGCs and LDCs have inadequate supplies of plasma substitutes for management of acute haemorrhage. The reasons for these problems and suggested solutions are discussed.

AIDS Serodiagnosis↗
PubMed1998

Donor selection: the exclusion of high risk donors?

Selection of donors is an important means to improve the overall safety of the blood supply. Since the AIDS epidemic emerged and after the introduction of sensitive screening tests for HIV, it became clear that blood donations given in the infectious 'window' period, formed the most important risk for recipients of blood products. Therefore, selection criteria became more and more stringent to exclude these high risk donors. Means to exclude high risk donors are non-remuneration, including a clear policy to provide no incentives which can be readily converted to cash, the avoidance of replacement donations, the discouragement of 'HIV test seeking' donors, education and information of donors about HIV and other blood-borne infectious diseases and the in depth questioning about risk behaviour, orally as well as by questionnaires. Although this policy of donor selection is recognized by most blood centers in the world, the efficacy of this selection has not been well documented. Therefore in future, studies should be performed to base these selection criteria on evidence.

AIDS Serodiagnosis↗
PubMed2005

Experiences of female general practice registrars: are rural attachments encouraging them to stay?

OBJECTIVE: To establish whether a six-month rural attachment influenced female GP registrars' future plans to work in a rural area. Secondary aims include establishing the adequacy of postgraduate training in preparing the registrars for the attachment, opinions regarding rural practice and suggestions to improve the attachment. DESIGN: A six-page questionnaire was sent to eligible participants via state branches of General Practice Education Australia. SUBJECTS: Female GP registrars who undertook a six-month rural attachment during 2002. MAIN OUTCOME MEASURE: Whether the six-month rural attachment influenced female registrars to practise in the country. RESULTS: The rural attachment was a positive experience for 82% of participants. One-third were more likely, as a result of the attachment, to practise rurally in the future. In total, 14% were influenced against working rurally as a result of the attachment. Those who had previously resided or studied in a rural area were more likely to plan to work rurally. Level of vocational preparation was adequate for the majority with notable deficits in obstetrics and gynaecological procedural skills. Main negatives associated with the attachment included working long hours and social isolation. Recommendations for change focused on amending these issues along with improved child-care facilities and improved remuneration. CONCLUSION: The rural attachment is a predominantly positive experience for female registrars with the exception of professional and personal hardships associated with relocating to rural practice. The attachment dissuades only a small proportion of its female counterparts, which is promising considering the increasing role of female practitioners in the workforce.

Adult↗
PubMed2006

Factors influencing rural health care professionals' access to continuing professional education.

OBJECTIVES: The purposes of this study were to explore the perceived barriers and challenges to continuing professional education (CPE) access for Canadian health care professionals and to identify best practices for improving access to CPE. DESIGN: Key informant interviews and Web-based online surveys were conducted. PARTICIPANTS: Key informant interviews were conducted with national CPE accreditation bodies and health professional associations. An online survey was distributed to health professional education programs, as well as provincial professional associations, licensing and professional regulatory bodies. MAIN OUTCOME MEASURES: The perceived barriers and challenges to CPE access for Canadian health care professionals and best practices for improving access to CPE. RESULTS AND CONCLUSIONS: Geographic isolation and poor technological and telecommunications infrastructure were identified as key barriers to CPE delivery and access. Financial factors, such as funding to support travel or cost of attendance, were also identified as major challenges. Tele-education programming was identified as a best practice approach to improve CPE access, as were regional CPE activities and self-directed learning programs. Employer-sponsored initiatives, including staff coverage or locum support, remuneration for time off and paid travel expenses for CPE participation were also identified as best practice approaches.

Attitude of Health Personnel↗
PubMed2005

Reaching for the stars: career advancement and the registered nurse.

Clinical nursing has long struggled to secure the place of primacy it deserves in the profession's hierarchy of importance and worth. It is ironic that, even at the beginning of the 21st century, a clinical nurse is generally not as well-recognized, rewarded or remunerated as a colleague working in nursing management, education or research. Until the profession recognizes and takes serious action to remedy this situation, the crisis of recruitment and retention in nursing currently ravaging the globe is likely to continue. In this paper, I present a discursive account of an exciting initiative by a leading private, acute-care hospital which addresses this very problem. A new ladder for clinical nurse specialists (CNSs) introduces a rigorous and systematic approach to the appointment of three classifications of CNS, each requiring evidence of successively higher levels of competency, and which are accompanied by fiscal reward and stronger peer recognition.

Career Mobility↗
PubMed2006

National survey of spirometer ownership and usage in general practice in Australia.

OBJECTIVES AND BACKGROUND: Despite the lack of data, it is believed that spirometry is underutilized in general practice. The aim of the present study was to determine the availability of spirometry and the level of spirometry training in general practice throughout Australia and compare with international data. METHODS: In total, 5976 general practices throughout Australia were sent a questionnaire requesting details of spirometer ownership, usage and the level and source of spirometry training. To exclude response bias, a follow-up telephone survey was conducted of 160 practices that did not respond to the initial survey. RESULTS: Of practices 19.5% (1125) responded to the initial survey with 64.2% (722) of these owning a spirometer and 83.9% in the follow-up sample. Common reasons for not owning a spirometer were equipment cost (53.3%) and insufficient remuneration (32.8%). Most practices (67.0%) performed one or more tests per week. Practices commonly used spirometry to diagnose (89.5%) and manage (93.9%) asthma, assess breathlessness (83.4%) and to detect and manage other diseases such as COPD (77.7%). Spirometer accuracy was never checked using a syringe 77.8% of practices and 40% did not test a healthy subject as part of their quality assurance programme. Spirometry training was received most commonly through courses run by general practice organizations (38.2%), and the duration of training courses was <2 h in 40% of cases. CONCLUSION: Despite high spirometer ownership in general practice, the frequency of use is low. Low rates of verification of spirometer accuracy and performance suggest the need for reliable, stable spirometers to be available to general practitioners. Regular and more comprehensive training in spirometry is needed.

Australia↗
PubMed2006

Registered nurses as responsible clinicians under the New Zealand Mental Health (Compulsory Assessment and Treatment) Act 1992.

The objectives of this research were to determine how many registered nurses are working as 'responsible clinicians', under what phases of the legislation they are functioning, and to describe the enabling processes and barriers to nurses undertaking this statutory role. An anonymous descriptive survey was distributed to the 11 nurses who were currently responsible clinicians as well as five senior nurses selected from each of the 21 District Health Boards and the Auckland Regional Forensic Psychiatry Services (n = 121). The response rate was 88.4% (n = 107). The survey questioned respondents on statutory roles currently undertaken. Respondents were asked whether the responsible clinician role was a legitimate one for nurses and whether they were motivated to attain it. They were also asked which competencies of the role they believed they met, their perceptions of credentialing processes and the educational requirements needed to achieve the role. A descriptive statistical analysis was undertaken and open-ended questions were analysed using content analysis. Of the approximately 395 responsible clinicians nationally, 11 (2.8%) are nurses. Most nurses viewed the role as legitimate. However, many were unaware of competencies for the role and credentialing processes, and were somewhat ambivalent about achieving the role due to current workload, role conflict and lack of remuneration. Competency deficits were highlighted. There are grounds to encourage nurses as responsible clinicians given the intent of the legislation. This will require the promulgation of appropriate mental health policy, and a concerted effort by major stakeholders in mental health service delivery.

Adult↗
PubMed2004

Access to primary health care for Australian adolescents: how congruent are the perspectives of health service providers and young people, and does it matter?

OBJECTIVE: To explore the extent of congruence between the views of service providers and young people (on adolescents' health concerns, barriers to accessing health services and ideal service model) in order to improve and increase the appropriateness, quality and usage of primary health care services. METHODS: A qualitative data collection technique was used. During 2001/02, focus groups were conducted in urban and rural locations with adolescents (in and out of mainstream education), general practitioners, community health staff and youth health workers. RESULTS: Service providers and young people identified a similar range of health concerns for young people, with young people adding additional issues of great importance to them that service providers felt were not in their 'domain of treatment'. There was reasonable congruence in regard to 'ideal service model' with some differences relating to methods of information delivery. However, for 'barriers to accessing services' there were major discrepancies. CONCLUSIONS: While there is some common understanding between young people and service providers on certain aspects of health services, there are clearly areas where perceptions differ. This discrepancy matters because it may adversely affect the quality of provider-adolescent interaction and the willingness of adolescents to access services. IMPLICATIONS: To deliver optimal health services to young people, the differences in understanding regarding services need to be addressed. Strategies could include promotion to, and encouragement of, young people to seek help, continuing professional education of providers and changes in remuneration policies.

Adolescent↗
PubMed2006

Improving access to medicines among clients of remote area Aboriginal and Torres Strait Islander Health Services.

Despite unequivocally worse health, expenditure on Indigenous people through the Pharmaceutical Benefits Scheme (PBS) is considerably less than for other Australians. We report on the effectiveness of a program to supply PBS medicines to remote Aboriginal and Torres Strait Islander Health Services (ATSIHSs) under section 100 (s. 100) of the National Health Act 1953. THE PROGRAM: Under the special PBS arrangements (SPBSAs), approved ATSIHSs are able to order PBS medicine in bulk through local pharmacies and supply them as needed to patients on-site. The usual co-payment associated with PBS medicine is not charged and the pharmacist remuneration structure is different. METHODS: The project involved consultation with the evaluation reference group and other stakeholders at all stages. There were six main data collection components: public submissions; interviews with government and other key stakeholders; pharmacist survey; medicine utilisation and expenditure data; national ATSIHS minimum dataset; and case studies of ATSIHSs. RESULTS: These SPBSA potentially benefit 36% of the Aboriginal and Torres Strait Islander population. They have resulted in improved access to much-needed medicines, representing an increase of dollar 36.5 million in expenditure on Aboriginal and Torres Strait Islander people through the PBS between 2000/01 and 2002/03. They have further ensured that dollar 8.3 million of State and Territory expenditure formerly directed at medicine can be spent on prevention and primary care. CONCLUSION: Overall, the SPBSAs have been very successful and demonstrates an effective model for the development of Indigenous health policy.

Australia↗
PubMed1998

The misplace of litigation in medical practice.

Medical decision-making is based upon mathematical probability in determining the significance of variables involved. Truth is often not absolute and medical decisions often require reconsideration of information, reanalysis and possible change. Litigation based upon error negates the ordinary practice of medicine. Error is intrinsic to all human behaviour and contributed to by uncertainty concerning precision in diagnosis and treatment of some diseases, mood change affecting ability to process cognitive and analytic function, and adverse work environment. Error is an important process in learning and providing it is recognized and fully admitted is a creative process providing opportunity for improving medical practice. Litigation is based on proof of negligence. Negligence is defined as carelessness, which is a rare cause of human and medical errors. The law confuses error with negligence; error should not be the basis for litigation. Litigation based on error is counter-productive to the best practice and improvement of clinical medicine. The assessment of errors and negligence is limited by the method of choice of medical experts, the adversarial system often ignoring the intermediate position in favour of a yes-no answer, the selection of experts to favour the desired result rather than the real situation, the method of questioning of witnesses which discourages explanation and creative solution of disagreement, and the hierarchical system which does not allow exploration of the issues and creative solutions. The basis for financial compensation for ill health is relevant when this assists the sufferer to cope with the ill health. The ethical basis for compensation when ill health results from error by health care workers is not more valid than ill health resulting from biological or environmental factors. Human error is common normal behaviour, while biological and environmental causes of ill health are common errors of human biology and the environment. Unintentional human error should not be the basis of financial remuneration or punishment. This latter principle has been applied to all services between the customer and service supplier, which may lead to unnecessary mistrust, anxiety and alienation in modern society. Incapacity from injury or disablement is covered by damages payment in only a small percentage of permanent disability cases (1.5% in the U.K.). Universal insurance by government or private agencies e.g. as in motor accident insurance to include the 98% of the permanently disabled who are receiving no payment at present would be both preferable and fairer. The protection of barristers from litigation for negligence in court is based upon arguments that could apply to most other occupations, and are equally, if not more relevant to medicine. The legal system of settling claims for negligence by doctors needs to be replaced by an investigative system which seeks to explain the basis and cause of error, which would benefit the patient and the doctor, and improve medical practice. A creative process needs to replace a judgmental, rigid and punitive system. A committee involving specialist groups in selecting expert witnesses, a health counsellor and a patient representative may be most suitable. Criminal acts, where error is performed deliberately, assault or sexual misdemeanors, would still be subject to the common law.

Australia↗
PubMed1995

National survey of emergency medicine resident moonlighting. SAEM Inservice Examination Survey Task Force.

OBJECTIVES: To survey emergency medicine (EM) residents regarding moonlighting practices and perceptions for clarifying: 1) resident moonlighting remuneration; 2) any association of perceived educational debt with moonlighting income and hours; and 3) perceptions related to moonlighting (including motivations, impact on resident training, and potential medicolegal difficulties). METHODS: A confidential, voluntary survey was administered to all allopathic EM residents in the United States. This written survey was provided to residents at their in-service examinations. Completed forms were anonymously returned by residents or local administrative staff to a central site where all identifiers were removed prior to mailing en mass to the investigators. Comparisons between groups were made using chi-square tests and correlations were assessed using the Pearson correlation coefficient. RESULTS: Seventy-six percent (1,826/2,407) of the surveys were returned. There was a weak correlation (r = 0.11) between educational debt and moonlighting hours for residents in the second year and above, but no association of debt with moonlighting income. Most (88%) of the residents reported that their programs permitted moonlighting. Nearly half (49%) reported that they did moonlight in some way. Most (82%) thought moonlighting provided experience not available in the residency. Only 13 (2%) respondents stated they had been sued for malpractice while moonlighting. Most (66%) moonlighting respondents stated that they moonlighted for financial reasons, with educational debt the primary motivating factor. Of the moonlighting residents, 28% were unsure of their type of malpractice insurance coverage, and 9% had no coverage at all. CONCLUSIONS: Education about EM practice matters including the risks of moonlighting should begin early in residency, because moonlighting is widespread. Residents are vulnerable to medicolegal action while moonlighting and have insufficient knowledge of their malpractice insurance coverage. Although educational debt is perceived as a strong motivating factor for moonlighting, there is only a weak relationship between educational debt and moonlighting hours.

Analysis of Variance↗
PubMed2006

Challenges to dental access - England as a case study.

Access to dental services because of an insufficient workforce is a historic challenge faced by many developing countries. In recent years, however, it has become a major issue for many industrialized countries. The growing demand for cosmetic dentistry, an increase in patients' willingness to pay for dental treatment, and growing numbers of older dentate patients have all put pressure on dental systems. Ways of meeting these challenges and ensuring reasonable dental access will vary from country to country, but the solutions often lie in how the dental workforce is regulated. This case study of the dental reforms currently being implemented in England highlights progress at a particular point in time (Summer 2005). It is clear that it will take a number of years to find a new national dental payment system (the National Health Service) to replace the system which has changed little since 1948. However, the political pressure to address poor access to state-funded dental services calls for more immediate actions. The initial approach was to increase the dental workforce via international recruitment, and in the medium term to increase the number of dental students in training and to expand the numbers of other members of the dental team. An additional stratagem is to retain those already providing dental care under the National Health Service by the introduction of a new method of remuneration. England is trying to improve both access to care and the oral health of the population by creating a workforce more suitable to public demands and changing oral health needs.

Dental Health Services↗
PubMed2006

Limiting financial disincentives in live organ donation: a rational solution to the kidney shortage.

Availability of kidney transplantation is limited by an inadequate supply of organs, with no apparent remedy on the immediate horizon and increasing reliance on living donors (LDs). While some have advocated financial remuneration to stimulate donation, the National Organ Transplant Act (NOTA) of 1984 expressly forbids the offer of 'valuable consideration.' However, recent developments indicate some fluidity in the definition of valuable consideration while evolving international standards highlight deficiencies (particularly regarding long-term care and follow-up) in the current American system. Recognizing that substantial financial and physical disincentives exist for LDs, we propose a policy change that offers the potential to enhance organ availability as well as address concerns regarding long-term care. Donors assume much greater risk than is widely acknowledged, risk that can be approximated for the purpose of determining appropriate compensation. Our proposal offsets donor risk via a package of specific benefits (life insurance, health insurance and a small amount of cash) to minimize hazard and ensure donor interests are protected after as well as before nephrectomy. It will fund medical follow-up and enable data collection so that long-term risk can be accurately assessed. The proposal should be cost effective with only a small increase in the number of LDs, and the net benefit will become greater if removal of disincentives stimulates even further growth. As importantly, by directly linking compensation to risk, we believe it preserves the essence of kidney donation as a gift, consistent with NOTA and implementable in the United States without altering current legal statutes.

Costs and Cost Analysis↗
PubMed1998

Longitudinal study of career plans and directions of veterinary students and recent graduates during the first five years after graduation.

OBJECTIVES: To determine the patterns of work undertaken by veterinarians during the first 5 years after graduation, and to study the background to career decisions. DESIGN: Longitudinal study. POPULATION: Veterinarians (119) who started the veterinary course at the University of Queensland in 1985 and 1986, and who responded to a mailed questionnaire 5 years after they graduated. PROCEDURE: Questionnaires were completed in the first and fifth year of the veterinary course, and in the second and after the fifth year after graduation. The data were coded numerically and analysed using the SAS System for Windows. RESULTS: Most respondents (61%) planned to work in mixed practice and 61% entered mixed practice initially, but only 39% of these (26% of the total) remained in mixed practice after 5 years. Those who had grown up on a farm which derived primary income from animals were more likely to enter mixed practice, but half of this group had left mixed practice after 5 years. Most decisions to change career direction involved a move away from negative factors including inadequate private time and/or rewards, issues involving other people including the practice principal and sometimes clients, or aspects of the work itself. However, some cited positive reasons, including opportunities to learn, to help others or to travel. There were no significant differences between males and females in the numbers entering mixed practice or leaving it, or entering small animal practice, or in attitudes to many issues involving veterinarians. However, more females than males found their remuneration too small, and females did receive significantly smaller incomes than males. CONCLUSIONS: Most graduating veterinarians, especially those from farms with animals, seek to enter mixed practice initially. Negative experiences are mainly responsible for moves to small animal practice. Gender does not affect the distribution of young veterinarians between mixed and small animal practice.

Animals↗
PubMed2001

Veterinary practitioners in rural Australia: a national survey.

OBJECTIVES: To assess the attitudes of Australian veterinarians to issues related to rural veterinary practice. METHODS: A questionnaire was completed by 1367 AVA members, and the data were analysed using the SAS System for Windows 7.0. RESULTS: The country lifestyle and the type of work were seen as major advantages for rural practitioners, and long working hours and after hours demands coupled with sexist attitudes in the case of women, were seen as the main disadvantages. Remuneration, the tiring and often dangerous nature of the work, and social and professional isolation were also seen as major disadvantages. Personal qualities, including the ability to relate to rural people and to fit into rural communities were seen as the most important qualities for a veterinarian in rural practice. The future of rural practitioners was seen to be closely linked to their ability to contribute to the financial viability of the whole animal enterprise and to the fortunes of the rural industries. Companion animals were also seen as a key part of the future work of rural practitioners. CONCLUSIONS: Rural practitioners are characterised by a strong commitment to rural life and work, and they will increasingly be required to contribute to the financial viability of the whole animal enterprise. The full range of professional skills required are likely to be beyond the scope of the undergraduate veterinary course, but the internet and other modern forms of distance education should help practitioners to acquire relevant skills.

Animals↗
PubMed1987

The economic contribution of dental hygienists' activities to dental practice: review of the literature.

This article reviews studies of dental practice and essays on practice management that have included information on the economic contributions of oral hygiene services. Several studies found that these services were less remunerative than other services and recommended that dentists delegate these functions when possible. However, one study noted that performance time, as well as delegation, influenced practice productivity and also reflected the practice's concept of care. Some practice management authors indicated that poorly managed practices without an excess of patients do not benefit economically from hiring a hygienist; but for practices with good management capabilities and an excess of patients, a hygienist may be able to make a major contribution to practice productivity. The lower remuneration for hygiene services and the high percentage of practice time required to provide a complete prophylaxis once or twice a year to each patient led several authors to doubt that dentists would or could provide these services themselves. The data in the reported studies, however, are insufficient to support firm conclusions about the profitability of hygienists' activities in dental practice.

Dental Hygienists↗