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At least 721 records · Page 40Linked to original sources
PubMed1994

Is there lead in the suburbs? Risk assessment in Chicago suburban pediatric practices. Pediatric Practice Research Group.

OBJECTIVE: This study was designed to determine: (1) the prevalence of elevated blood lead (BPb) levels (BPb > or = 10 micrograms/dL) in Chicago suburban children attending Pediatric Practice Research Group practices at 12 and 24 months of age, and (2) the efficacy of the Centers for Disease Control and Prevention (CDC) and Illinois lead exposure risk assessment questions. METHODS: Parents bringing their 1- and 2-year-old children for health supervision visits at pediatric practices completed questionnaires. BPb levels were drawn on children. Both questionnaire and an analyzable BPb level were obtained on 1393 subjects (79.2%). RESULTS: Only 2.1% of our sample had a venous BPb level > or = 10 micrograms/dL (0.48 mumol/L); no subjects had a level > or = 30 micrograms/dL (1.45 mumol/L). The CDC risk assessment questions had a sensitivity of .69 and specificity of .70. Due to the low prevalence of elevated BPb levels in this sample, CDC and Illinois screening strategies had high negative predictive values (.99) and low positive predictive values (.05 and .04, respectively). However, some of the subjects with BPb levels > or = 10 micrograms/dL were not at high risk by CDC and Illinois screening questions; 9 of 29 subjects with elevated lead levels (31%) did not respond affirmatively to any CDC risk assessment questions. The question best predicting an elevated BPb was the determination that the house the child lives in was built before 1960 (sensitivity = .83, specificity = .67). This question is not currently included in CDC or Illinois screening strategies. Screening based on the single question "Was your house built before 1960?" would have missed only five (17%) of the children with BPb levels > or = 10 micrograms/dL. Three of these five children were among the 17.1% of 1-year-olds and 26.3% of 2-year-olds in our sample who had moved. CONCLUSIONS: In this sample, children living in houses built before 1960 should be considered at high risk for high-dose lead exposure. Due to the high mobility of our sample, phrasing the question to include lifetime exposure (ie, Has your child ever lived in a house built before 1960?) should also be considered. Selective BPb testing of high-risk children in low-prevalence suburban areas using this question would miss few children with elevated BPb. Useful risk assessment questions in other areas and other populations may differ.

Centers for Disease Control and Prevention, U.S.↗
PubMed1996

The advanced practice nurse in collaborative practice.

Establishing interdisciplinary collaborative practice models is vital to the success of health care reform. Paramount in this assumption is the need to change the roles and relationships between nurses and physicians. To facilitate this change, the authors have prepared a model of collaborative practice based on the concepts of common purpose, professional contributions of practitioners, collegiality, communication, and client-focused practice.

Humans↗
PubMed1997

Risks of transfusion and organ and tissue transplantation: practical concerns that drive practical policies.

The risks and other adverse effects associated with blood transfusion and tissue and organ transplantation were reviewed retrospectively with the use of recent US activity data and published compilations of such events for both therapeutic modalities. In addition, practices that govern blood transfusion and transplantation, in light of regulations and standards of practice, and the practical factors that cause variations in the use of both therapies were compared and contrasted. These factors include availability, preservation and viability, life-saving vs life-enhancing effects, donor selection and qualification, donor-recipient pair matching, disease marker screening and transmission potential, immunopathologic considerations, and future alternative directions.

Communicable Diseases↗
PubMed1996

The advanced practice nurse and physician relationship: considerations for practice.

Although physician and nurse relationships have traditionally been a challenge, evolving changes in health care delivery offer the advanced practice nurse (APN) on opportunity to redefine the scope. Several issues will have an impact on this course. Initially, the condition of employment, as well as the physician's perception of the APN's role and the physician's commitment to role preservation, will be primary influences. Secondary factors include defining the role, scope of practice, and mechanisms for practice evaluation. This process will require and ongoing dialogue and selected strategies to develop and maintain physician relationships.

Humans↗
PubMed2001

Getting evidence into practice: the work of the Cochrane Effective Practice and Organization of care Group (EPOC).

Policy makers and continuing educators often face difficult decisions about which educational and quality assurance interventions to provide. Where possible, such decisions are best informed by rigorous evidence, such as that provided by systematic reviews. The Cochrane Collaboration is an international organization that aims to help people make well-informed decisions about health care by preparing, maintaining, and ensuring the accessibility of systematic reviews of the benefits and risks of health care interventions. International collaborative review groups prepare Cochrane reviews for publication in The Cochrane Library, a collection of databases available on CD-ROM and the World Wide Web and updated quarterly. The Cochrane Effective Practice and Organization of Care Group (EPOC) aims to prepare and maintain systematic reviews of professional, financial, organizational, and regulatory interventions that are designed to improve professional practice and the delivery of effective health services. EPOC has 17 reviews and 20 protocols published in Issue 3, 2000, of the Cochrane Library, with further protocols in development. We also have undertaken an overview of previously published systematic reviews of professional behavior change strategies. Our specialized register contains details of over 1,800 studies that fall within the group's scope. Systematic reviews provide a valuable source of information for policy makers and educators involved in planning continuing education and quality assurance initiatives and organizational change. EPOC will attempt to keep the Journal of Continuing Education in the Health Professions informed on an ongoing basis about new systematic reviews that it produces in the area of continuing medical education and quality assurance.

CD-ROM↗
PubMed2004

Integrating clinical practice guidelines into daily practice: impact of an interactive workshop on drafting of a written action plan for asthma patients.

INTRODUCTION: Written action plans (WAPs) are instructions that enable asthmatics to manage their condition appropriately and are recommended by current asthma clinical practice guidelines (CPGs). However, general practitioners (GPs) rarely draft WAPs for their patients. An interactive, case-based workshop for asthma, combined with an objective structured clinical examination (OSCE), was developed to increase GPs' knowledge and use of WAPs in Québec. METHODS: The study compared 24 GPs receiving an OSCE preworkshop and 12 months post-workshop (group 1) with 16 GPs receiving an OSCE preworkshop and at 6 and 12 months post-workshop (group 2). Participants received no feedback on their OSCE performance. During the workshop, which presented a preformatted tool to aid drafting of the WAPs, all 40 GPs worked individually and in small groups to answer questions on a hypothetical clinical case and then discussed the responses with a facilitator and an asthma specialist. RESULTS: Only group 2 GPs showed a significant improvement in knowledge of WAPs 12 months post-workshop (p = .01). The likelihood of prescribing WAPs to patients increased in group 2 to a degree approaching statistical significance (p = .070), and there was a borderline nonsignificant trend for prescribing practice to improve more among group 2 GPs than among group 1 GPs (p = .052). There was also a nonsignificant trend for 6-month OSCE to increase attendance at the 12-month OSCE. DISCUSSION: An interactive workshop employing a preformatted WAP tool and a reinforcing OSCE at 6 months yielded improved knowledge of WAPs at 1 year. Although originally developed as a form of evaluation, the OSCE appears to have formative value even when correction is not provided and may increase the effectiveness of continuing medical education interventions to enhance CPG implementation.

Adult↗
PubMed1990

Long-term patterns of general practice consulting behaviour: a qualitative 9-year analysis of general practice histories of a working-aged rural Finnish population.

The 9-year practice histories of 100 working-aged residents of the rural municipality of Kaavi in Finland were analysed. Based upon an analysis of these histories, an interview of the 81% who participated and the personal patient knowledge of the author from his work as a general practitioner for 7 years in the community, 78% of the persons studied could be classified into six categories in a qualitative typology of consulting patterns. The descriptive names of the categories, together with their proportionate sizes and the mean annual consultation rates within the categories were: (1) 'Healthy and competent' (16%; 1.03); (2) 'Contented returners' (12%; 3.28); (3) 'Information seekers' (8%; 4.08); (4) 'Support seekers' (15%; 4.62); (5) 'Drifters' (21%; 2.21) and (6) 'Those hard to convince' (6%; 3.59). The rest (22%; 1.15) could not be classified. The implications of the typology are discussed from two standpoints: (1) In view of the current Finnish debate on the need for fee deterrents for the use of public general practitioner's services. (2) The potentials and limitations of different broad strategies suggested for general practice.

Family Practice↗
PubMed2005

Treatment of depressive disorders in split versus integrated therapy and comparisons of prescriptive practices of psychiatrists and advanced practice registered nurses.

This study examined the differences in adherence to medication for the treatment of depressive mood disorders whether the patient was involved in split or integrated therapy and if the patient was being treated by a psychiatrist or an advanced practice registered nurse (APRNs) in psychiatry with prescriptive authority. The sample consisted of 122 adults ages 20-60 who carried a diagnosis of major depression, dysthymia, or bipolar II disorder, voluntarily treated in the private sector. Chi-square was the measure used to assess differences in adherence. Adherence was determined by documentation from chart reviews, retrospectively, of the prescriptions for psychotropic medication for a period of up to nine months for each patient included in the research. Six psychiatrists and six APRNs volunteered to collect data from their private practices. Findings demonstrated no statistically significant differences in patient's adherence to medication if they were in split or integrated treatment or if either psychiatrists or an APRN treated them. Psychiatrists used more of secondary class of antidepressants and more antianxiety agents than did the APRNs. The nurses spent more time with patients, using more integrated therapy, than did the psychiatrists.

Adult↗
PubMed2006

Context, automated decision support, and clinical practice guidelines: does the literature apply to the United States practice environment?

BACKGROUND: Context - the combined effect of factors such as physician type, clinical setting, and guideline characteristics - influences the ability of automated decision support (ADS) to improve physician compliance with clinical practice guidelines (CPGs). Our goal was to determine whether research about the utility of ADS for promoting CPG compliance is contextually applicable to United States physicians. METHODS: We extracted information about physicians, settings, and guidelines from all articles published in the last 10 years that describe original research about the use of ADS to promote CPG compliance. The extracted information was compared to the range of practice contexts seen in the United States. RESULTS: Nearly two-thirds (65.3%) of papers described studies conducted in an academic setting, but only 11% of physicians report academic affiliations (p<0.0001). Physician reimbursement structure is often not reported. Salaried physicians were explicitly included as subjects in 14% of articles, but make up 45% of US physicians (p<0.0001). There are little data about the generalizability of ADS research to emergency care settings (6% of articles), and nursing home or skilled nursing facilities (10% of articles). Finally, ADS has not been studied at all in several epidemiologically important disease categories. CONCLUSION: The literature does not adequately address some physician, setting, and guideline contexts. Before making policy or spending decisions based on the effectiveness of ADS, additional research is needed to determine whether ADS research can be generalized to under-represented contexts.

Decision Support Systems, Clinical↗
PubMed2006

Aggregation of qualitative studies--From theory to practice: Patient priorities and family medicine/general practice evaluations.

OBJECTIVE: Aggregation (i.e., meta-ethnography or meta-synthesis) of qualitative studies remains relatively rare and controversial. We have attempted this procedure within an investigation of patient priorities and evaluations of primary care in order to triangulate an instrument development process as well as explore associated dilemmas. METHODS: The procedures included a literature search of qualitative research on patient priorities and evaluations and creation of a framework for quality assessment of retrieved papers. The tool for the evaluation of quality in qualitative studies was piloted, refined, and applied to the retrieved literature. The articles were equally distributed between two teams in random fashion, and inter-rater agreement calculated. Finally, we formulated and applied a strategy for aggregation of data from included papers that allowed comparison to a systematic review of quantitative studies on the topic. RESULTS: Thirty-seven articles met inclusion criteria. Twenty-four of these articles were of sufficient quality to be included in the qualitative aggregation. Inter-rater agreement ranged from 0.22 to 0.77 and 0.38 to 0.60 for pair and assessor comparisons, respectively. The aggregation strategy enabled synthesis within sub-categories of the heterogeneous papers. CONCLUSIONS: We have devised a modestly reliable instrument to assess the quality of qualitative work. The procedure for quality assessment and aggregation appears to be both feasible and potentially useful, though both theoretical and practical problems underline the need for further refinement prior to widespread utilization of this approach. PRACTICE IMPLICATIONS: An instrument to assess the quality of qualitative work within the context of aggregation efforts is described. Calculating inter-rater reliability in this framework can support future quality assessments. A method of breaking a heterogeneous collection of included papers into sub-categories to enable aggregation of qualitative studies is applied and demonstrates its feasibility and potential usefulness.

Anthropology, Cultural↗
PubMed1997

The use of clinical practice guidelines (CPGs) to evaluate practice and control costs in ventriculoperitoneal shunt management.

BACKGROUND: As a step toward maximizing the quality and cost-effectiveness of neurosurgical care, we designed clinical practice guidelines (CPGs) for the management of VP shunt malfunctions and infections at a tertiary care pediatric teaching institution. The detailed CPGs determine the use of radiographic studies, laboratory tests, and invasive procedures in the management of this problem. One purpose of the CPGs is to provide clear clinical guidelines for the medical trainee, thereby reducing variability in care and unnecessary utilization of resources. METHODS: The CPGs were developed in stages over a 2-year period. The practice patterns in our institution for the management of shunt malfunctions and infections were articulated. They were compared with those published in the neurosurgical literature, and areas of clinical decision-making variability were identified. Preliminary guidelines were formulated, and data regarding patient care were prospectively collected. Based on this data, final CPGs were formulated and implemented. Total and itemized hospital charges for patients managed according to the CPGs were compared with those for patients in the 3 years before CPG implementation. RESULTS: CPG-managed patients had generally lower total and itemized charges as compared with control patients. Decreased charges per hospital day and charges for shunt films in the CPG group were statistically significant. CONCLUSIONS: The process by which the CPGs were developed and implemented, as well as the CPGs themselves, are described. We also present the clinical, demographic, and financial data that were prospectively collected for all patients managed within the CPGs over an initial 1-year period and compare it with data obtained for control groups of shunt malfunction patients admitted during the 3 years before implementation of the CPGs. We find a trend toward reduction of charges after implementation of the CPG.

Boston↗
PubMed2001

Practice patterns in the diagnosis and treatment of erectile dysfunction among family practice physicians.

OBJECTIVES: To examine the philosophies and practices of the family practitioner (FP) regarding the diagnosis and treatment of erectile dysfunction (ED). METHODS: A prospective study by questionnaire of a group of FPs was performed. The Spearman correlation coefficient and proportional odds regression analysis were used to measure the relationship between the continuous variable and ordinal-scale variables. The Goodman-Kruskal gamma test was used to measure the strength of the association between the ordinal-scale variables. RESULTS: Eighty-five FPs completed the questionnaire. All respondents had at least occasional discussions with their patients about ED. History taking, physical examination, and laboratory data were the most common tools used for diagnosis. Eighty-two percent of the FPs reported being either comfortable or somewhat comfortable in making a diagnosis of ED; 93% believed that only selected patients required more extensive diagnostic workups for ED. Sildenafil was the most commonly used agent. All physicians referred patients with ED to urologists at least occasionally. Most referred only after unsuccessful trials with sildenafil. The relationship between the degree of managed care penetration and the percentage of patients with ED referred for evaluation to a urologist was not statistically significant (P = 0.402). The relationship between the number of years in practice and the percentage of patients referred to a urologist for treatment or evaluation was found to be a negative, but statistically significant, relationship (P = 0.003). CONCLUSIONS: FPs are now diagnosing and treating ED on a routine basis. Referrals to urologists are likely to be made when they are no longer comfortable treating the problem.

Adult↗
PubMed2006

Positioning practices for ventilated intensive care patients: current practice, indications and contraindications.

To investigate the process of providing patient positioning in intensive care units (ICUs), a self-reported survey was distributed to a senior physiotherapist and a nurse in each of the 38 Level 3 Australian ICUs. The survey explored the rationales, aims, type, frequency and duration of directed patient positioning used, and perceived risks that may impede the implementation of an effective positioning regime. The response rate was 93%. Fifty nine respondents (83%) agreed that there is an accepted standard of care for the duration of a position change with ventilated patients. Of these respondents, 51 (86%) agreed that the standard is to turn patients every 2 hours, but this was only achievable "more than 50% of the time" in 47% (n=34) of ICUs. Educational and environmental issues were found to impact on positioning practices. Semi-recumbent and full side-lie positions were recommended in the management of a range of patient conditions. However, full side-lie was less commonly used than supine positioning. The prone and head down tilt positions were the least frequently utilised. Levels of agreement for precautions and contraindications to positioning patients into full side-lie and sitting were high. We conclude that, in Australia, experienced ICU physiotherapy and nursing staff are aware of evidence-based positioning practices and agree on indications and potential risk factors associated with positioning. However, educational and environmental resources are needed to improve the frequency and type of positioning used. Results from this survey can now be incorporated into educational tools to facilitate the safe use of positioning.

Attitude of Health Personnel↗
PubMed2000

Model of data structure and flow in general practice: a guide to evaluation of practice management software.

Despite its benefits, the computerisation of Australian general medical practices has been delayed, partly due to user concerns about the format of data dictated by available software and the portability of such data. This article proposes certain essential criteria for practice management software, which may provide a framework for its evaluation by users. A set of simple guidelines for database maintenance is also proposed. The author believes that users should become familiar with basic software architecture and drive the market to develop packages that conform to these minimal criteria.

Family Practice↗
PubMed2007

EPO adjustments in patients with elevated hemoglobin levels: provider practice patterns compared with recommended practice guidelines.

BACKGROUND: This study investigates provider practices regarding recombinant human erythropoietin (rHuEPO) dose when patient hemoglobin levels exceeded National Kidney Foundation-Dialysis Outcomes Quality Initiative target levels and reached 13 g/dL or greater (>or=130 g/L). METHODS: The study population (N = 167,796) was hemodialysis patients prevalent on January 1, 2003, who were on renal replacement therapy at least 90 days with Medicare as primary payer and rHuEPO claims in 2 or more consecutive months. Patient characteristics were obtained from the Centers for Medicare & Medicaid Services (CMS) Medical Evidence Report, and comorbid conditions were determined from Medicare claims. Providers and rHuEPO claims were linked by using CMS-assigned provider numbers and the CMS Annual End-Stage Renal Disease Facility Survey. Between-provider differences in patient characteristics were examined by using chi-square test, and provider effect on appropriate response, by using logistic regression. RESULTS: DaVita's percentage of monthly claims for patients with hemoglobin levels of 13 g/dL or greater (>or=130 g/L; 16.7%) and mean monthly rHuEPO dose (54,299 units) were highest. Dialysis Clinic Inc's percentage of such claims (2.0%) and mean monthly dose (38,687 units) were lowest. Dialysis Clinic Inc, Fresenius, and Renal Care Group had the highest percentage of recommended dose adjustments (mean, 70% of units); hospital-based units had the lowest (59%). By adjusted odds ratio, adjustments were 20% more likely for Dialysis Clinic Inc, Fresenius, and Renal Care Group compared with DaVita, National Nephrology Associates, hospital-based units, and independents (17% to 28% less likely). CONCLUSION: rHuEPO dose reduction practices are dependent on specific dialysis providers and whether units are hospital based or independent.

Adolescent↗
PubMed2000

Smokers over age 35 continue to receive oral contraceptives. Survey of patients in a family practice residency practice.

OBJECTIVE: To assess the frequency with which women over age 35 report both current oral contraceptive use and current cigarette smoking. DESIGN: Cross-sectional survey of women in a single practice setting. SETTING: Primary care teaching practice in a mid-sized US city. PATIENTS: 142 women aged 35-55 who had not reached menopause and had not had hysterectomy. MAIN OUTCOME MEASURES: Smoking status in current oral contraceptive users. RESULTS: 19 women (13%) were current oral contraceptive users and 46 (32%) were current smokers. Four of the oral contraceptive users (21%) reported current smoking. CONCLUSIONS: Despite reported cardiovascular risk, women who smoke continue to receive prescriptions for oral contraceptives. Physicians should redouble efforts to record smoking status and offer smoking cessation treatment to women over age 35 who smoke and wish to take oral contraceptives.

Adult↗
PubMed1993

Nutrition knowledge and practices of physicians in a family-practice residency program: the effect of an education program provided by a physician nutrition specialist.

The purpose of this study was to determine the effects of a nutrition-education program provided by a physician nutrition specialist in a family-practice residency program on residents' and faculty members' nutrition knowledge and nutrition-related patient care, their patients' perceptions of the importance of nutrition, and the physicians' dietary patterns. The nutrition specialist provided recommendations for nutrition patient-care practices to the physicians for 6 mo. Pre- and post-intervention assessments included 1) nutrition exams for physicians and patients, 2) patient questionnaires concerning attitudes towards nutrition, 3) chart reviews, and 4) diet records for physicians. The educational intervention caused a small but statistically significant (P < 0.01) increase in physicians' nutrition-knowledge scores and a significantly higher (P < 0.05) frequency of physicians discussing nutrition and recommending diets for their patients. Effects were greater among residents than among faculty members. The results suggest that a physician nutrition specialist can provide effective nutrition education within a residency program.

Diet Records↗
PubMed2000

Practice factors that influence antibiotic prescribing in general practice in Tayside.

A cohort design was used to evaluate antibiotic prescribing in relation to patient and general practice characteristics. The study included prescribing to all subjects resident in Tayside, from January to December 1994 and found 215217 antibiotic prescriptions dispensed to 118596 people. Training status of general practitioners (GPs) was found to be the characteristic most associated with prescribing. Adjusting for other GP characteristics had little effect on these results. Training practice status was the dominant factor associated with significant differences in rates of antibiotic prescribing, in class of antibiotic prescribed and in performance indicators of antibiotic prescribing.

Anti-Bacterial Agents↗