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Data from the actual private practices of two dentists were compared with respective data from the participation of the same two dentists in a laboratory model of private practice conducted in the University of North Carolina Dental Research Center. The findings show that a laboratory model can be established which accurately reflects the major parameters of an actual private practice.
The Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society develop practice parameters as strategies for patient management based on analysis of evidence regarding risks and benefits. This parameter reviews published literature relevant to the decision to begin treatment after a child or adolescent experiences a first unprovoked seizure and presents evidence-based practice recommendations. Reasons why treatment may be considered are discussed. Evidence is reviewed concerning risk of recurrence as well as effect of treatment on prevention of recurrence and development of chronic epilepsy. Studies of side effects of anticonvulsants commonly used to treat seizures in children are also reviewed. Relevant articles are classified according to the Quality Standards Subcommittee classification scheme. Treatment after a first unprovoked seizure appears to decrease the risk of a second seizure, but there are few data from studies involving only children. There appears to be no benefit of treatment with regard to the prognosis for long-term seizure remission. Antiepileptic drugs (AED) carry risks of side effects that are particularly important in children. The decision as to whether or not to treat children and adolescents who have experienced a first unprovoked seizure must be based on a risk-benefit assessment that weighs the risk of having another seizure against the risk of chronic AED therapy. The decision should be individualized and take into account both medical issues and patient and family preference.
The study examines attitudes of family practice residents toward social work collaboration in their practices. Residents valued social work services highly, and almost three-fourths want a social worker in practice with them. Residents valued the broad range of services offered by social workers, and over half could see no disadvantages to such collaboration.
The practice guideline 'Acute cough' from the Dutch College of General Practitioners stresses the fact that a cough of less than 3 weeks' duration seldom heralds serious pathology. However, for sound reassurance of patients presenting with a cough of short duration, the general practitioner needs to know much about the signs and symptoms connected to low-prevalence serious pathology in these patients. The practice guideline distinguishes upper and lower respiratory tract infections and defines serious lower respiratory tract infection. The diagnostic value of symptoms and laboratory findings like a sedimentation rate or C-reactive protein in order to make such distinctions, is not explained in detail. Antibiotics are reserved for serious lower respiratory tract infection with the exception of acute bronchitis, croup and bronchiolitis, which can be treated without antibiotics. Recommendations for treatment of acute bronchiolitis with bronchodilators or corticosteroids, and croup with corticosteroids are based on consensus. This practice guideline can be considered as a clear and valuable piece of work for all physicians in primary and secondary care.
Clinical practice guidelines can improve health care outcomes, but they are only as effective as their implementation. We present a framework for implementing practice guidelines that begins by identifying the forces driving and restraining the adoption of the guideline. Strategies for changing physician behavior that strengthen the driving forces and weaken the restraining forces can then be incorporated into a comprehensive implementation program. Nine strategies for changing physician behavior are presented, based on a review of the literature and organizational experience at Group Health Cooperative of Puget Sound. In designing an implementation strategy, it is essential that the resources allocated to implementation are commensurate with the improvement in outcomes expected from the successful implementation of the guideline. All implementation programs should include plans for measuring outcomes to allow for continuing improvement. Guideline implementation, evaluation and improvement efforts are most likely to be successful when they are part of an explicit, evidence-based process for evaluating and improving clinical practice.
To maintain control over healthcare delivery and financial decisions, as well as increase access to capital markets, some group practices are forming their own physician practice management companies. These companies should be organized to balance the expectations of physicians with the values of capital markets. This organization should include retained earnings, financial reporting in accordance with generally accepted accounting principles (GAAP), predictable earnings and cash flow, physician ownership and leadership, and incentives for high-quality management. Three large, primary care and multispecialty clinics that merged to form a new physician practice management company increased their access to capital markets and improved their overall financial position, which will help them achieve long-term survival.
OBJECTIVE: To determine the views and practices of Victorian general practitioners (GPs) on the early detection of colorectal cancer (CRC). METHODS: A 1995/1996 quantitative mail survey was used to determine GP knowledge and practice in relation to CRC screening and diagnosis in asymptomatic and symptomatic patients. This includes the amount of investigation, the type and process of diagnostic testing and attitudes to CRC screening. RESULTS: GPs are investigating symptomatic patients but few asymptomatic patients. In general, only patients in the increased risk groups are being investigated. Colonoscopy is the most common method of examination. Most GPs prefer faecal occult blood tests (FOBTs) to be interpreted via laboratory and endoscope procedures to be performed by a specialist. CONCLUSION: GPs were unlikely to screen asymptomatic patients unless there is a family or personal history of CRC or adenomatous polyps. Colonoscopy is the preferred practice for examining such patients. The use of FOBTs for screening standard risk asymptomatic patients was lower than recent research recommends. If population screening for CRC is endorsed, professional and public education in CRC tests, particularly for asymptomatic standard risk patients would be required. Patient initiated screening was highly favoured, supporting the need for public awareness programs.
A survey of family practice physician assistants (PAs) in Iowa was undertaken to determine the frequency with which they utilized specific clinical skills. A response was received from 55 of 77 (74%) PAs surveyed. Average age of respondents was 42 years (range, 35 to 50). Respondents had, on average, been practicing for 13 years, mostly in family medicine; on average, they saw 25 patients a day. All reported providing patient education, prescribing and dispensing medication, interpreting radiographs, referring patients, and providing a wide range of services similar to their physician counterparts in Iowa. In regard to 62 activities identified, few differences emerged among respondents when population setting was considered--except that PAs who work in communities of fewer than 10,000 residents often perform a wider range of services than those who work in larger communities. Activities that have been ranked as important by Iowa family practice physicians in other surveys were also the clinical skills that PAs in this survey reported performing most often. This study supports mounting evidence that PAs are an important aspect of primary care delivery across society. Their activities in the delivery of care are similar to those that the physicians with whom they are most closely associated consider important.
OBJECTIVE: To integrate evidence based medicine with the experience and expectations of consumers and GPs in the development of clinical practice guidelines for acute respiratory infections (ARI) in young children. METHOD: Focus groups and workshops were held with 21 GPs and 27 patients of young children involved in a 2 year randomised controlled trial. RESULTS: The acceptability of the guideline development process for participants was determined. Barriers were identified which would impede clinical change, including: inadequate time; lack of knowledge; fear of patient dissatisfaction; and fear of poor health outcome. CONCLUSION: This paper details a process of guideline development that addresses the realities of general practice in Australia and the concerns of consumers. We identified potential barriers to change and integrated intervention strategies with the evidence to produce realistic clinical practice guidelines.
OBJECTIVE: To explore to what extent female rheumatologists perceived that gender had an influence on their professional practice or on their choice of specialty. METHODS: We collected data from 29 female rheumatologists and used qualitative and quantitative methods to describe the findings. RESULTS: Three groups of respondents were identified (cluster analysis). Most of these rheumatologists perceived that gender influenced the way they practiced, although the specific weights of the topics were different in the 3 groups. Gender also influenced these physicians' choice of specialty field. CONCLUSION: The differences in practice style may have a potential effect on health systems as feminization of the medical profession increases.
OBJECTIVE: To assess influenza vaccination status and influenza vaccination practices of family physicians in Quebec. DESIGN: Mail survey of a random sample of 1000 family physicians. SETTING: Family practices in the province of Quebec. PARTICIPANTS: Of 1000 Quebec family physicians sent questionnaires, 550 responded. After excluding physicians who worked only in institutions, had no patients older than 65 years, or did clinical work less than 20% of the time, 379 respondents were eligible for the study. MAIN OUTCOME MEASURES: Vaccination status of family physicians in 1996 and professional practices based on six clinical and administrative activities pertaining to influenza vaccination. RESULTS: Prevalence of vaccination was 35.5% (95% confidence interval 30.8% to 40.4%) among responding physicians and was higher among those 60 years and older, those with a chronic condition, and those perceiving high peer pressure to get vaccinated. Most respondents frequently assessed the current influenza vaccination status of their patients, risk factors for influenza-related complications, and contraindications to the vaccine. They also frequently provided education about influenza and its vaccine, recommended vaccination, and administered the vaccine. Only a few reported assessing prior influenza vaccinations or recording vaccination status regularly. Finally, vaccinated physicians recommended the vaccine more frequently to their patients than unvaccinated physicians did. CONCLUSION: Promotion programs focusing on peer influence could increase vaccination of family physicians. This could in turn improve vaccination coverage of elderly patients.
Exemplified by studies on the predictive value of standardised history taking of angina pectoris, part 2 of this contribution describes the different significance of medical diagnostics in dependency from different levels of the health care system (general practice, cardiologic drop-in clinic, university hospital). Because of different prevalences (pre-test probability) and in spite of exactly the same symptoms the probability of actual coronary heart disease is highly different. The specific post-test probability can be explained and calculated by Bayes' theorem. It becomes evident why general practitioners have to be cautious in adopting recommendations, if those recommendations are based on studies which were done with patients in specialised health care settings. As a consequence from the reflections and empirical findings presented, it becomes better comprehensible what general practice is not and which perspectives for research, education and practice are resulting.
OBJECTIVE: To determine whether patients with hypertension in general practice are diagnosed and treated according to the criteria of the Dutch College of General Practitioners guidelines. DESIGN: Retrospective, descriptive. METHOD: Using data from 9 general practices belonging to the general practice research network of the Academic Medical Centre St Radboud, Nijmegen, the Netherlands, all intake data of newly diagnosed hypertensive patients were collected. Three periods (1983-1991, 1992-1996 and 1997-2001) were studied and compared to the 1991 and 1997 versions of the guidelines. RESULTS: During the study period, 1959 patients with hypertension were registered. In 4% of the men and 3% of the women the hypertension criteria of the time were not met. These figures decreased during the course of the research period. Mean blood pressure at diagnosis was above 160/100 mmHg, even in patients with diabetes. The additional risk factors were recorded increasingly frequently (cholesterol level, smoking behaviour, body-mass index). In 1991, 63% were treated with medication (the other 37% only received lifestyle advice). During the last period, 86% received medication, while the indication to prescribe medication according to the guidelines increased from 40% to 81%. The increase may be ascribed to the new guideline recommendation of one risk factor as an indication to treat patients with mild hypertension instead of two. CONCLUSION: Almost all patients in whom the participating general practitioners diagnosed hypertension fulfilled the criteria. The difference in threshold values for diagnostic measurements and medicinal treatment means that people with mild hypertension are not always registered and consequently risk being forgotten by their general practitioner.
Standards of care and professional performance are the backbone of dermatology nursing practice as well as the basis for professional growth and development. The goal of developing Dermatology Nursing Standards of Clinical Nursing Practice is to gain formal recognition for the practice of dermatology nursing.
There is evidence that patients with atrial fibrillation (AF) are not being anticoagulated according to the published guidelines. Difficulty in identifying such patients may partly explain this. In this study, we examined the yield of different methods for detecting people with AF in a single general practice: hospital discharge letters, referrals to cardiology, staff recall of cases, records of relevant prescriptions from the local pharmacist and similar records from the GMS Payments Board. A review of all files of patients over 45 was undertaken as the definitive method of case identification. Recommended anticoagulation guidelines were applied using structured patient interviews. The practice population was 5,473. Sixty-eight patients with AF were identified giving a practice prevalence of 1.2%. The GMS Payment Board records for the prescribing of all specified medications was the most sensitive method (58.8%) with a positive predictive value of 21.6%. Of nine patients without cognitive impairment at consultation, four (44.4%) opted to change to the recommended treatment. Reluctance of patients to adopt current treatment guidelines points to the need for further work in this area.
A transient ischaemic attack (TIA) can be seen as an attack of angina of the brain. In the first weeks following a TIA there is a sizeable risk of subsequent stroke. After this period, this increased risk tapers off and an elevated risk of cardiovascular disorders remains, with the emphasis on its cardiac component. The management of a patient with a TIA in general practice focuses on these two risk periods. The long-term cardiovascular risk can easily be reduced by prescribing aspirin, an established procedure in general practice. The immediate threat of obstruction of the carotid artery may, as was only recently firmly established, be averted by a timely referral for additional diagnostics and, when needed, carotid desobstruction. This part of TIA management in general practice, however, is hampered by the current waiting periods for these procedures.
The purpose of this study was to compare the prescribing practices among family practice, pediatric, and internal medicine third-year residents in an inner city ambulatory care setting. A four-month chart audit was made for the prescriptions provided for asthma, osteoarthritis, congestive heart failure, and upper respiratory infection patients by these residents. In general, family physicians prescribed medications that were not different from those used by internists and pediatricians. However, there were significant (p less than 0.01) differences in the number of visits and prescriptions among the specialties. The prescribing practices of the study group differed from a national survey of private practitioners in several drug categories.
This paper presents results from two studies of primary care residency programs. Study I was a survey of preventive cardiology attitudes and practice-related intentions of internal medicine and family medicine residents from throughout the United States. Study II consisted of an examination of family medicine residents' perceptions regarding preventive practices and a series of 1,528 medical record reviews of their related assessment and counseling practices. The specific aims were to examine residents' perceptions about their residency programs and to determine the percentages of patients who were assessed for and, if necessary, counseled for coronary heart disease prevention. Results indicated that internal and family medicine residents believe that they should be prepared by their residency training to offer these services and that their residencies were preparing most of them to do so. While they report that they intend to assess and counsel patients in these areas, they do not seem to be doing so. The medical record reviews strongly indicated that they are not providing these services at the recommended levels, especially for assessment of and counseling for smoking and blood cholesterol levels.