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PubMed1995

Radiology and the courts: the first 100 years.

The authors examine the impact of legal decisions over the past 100 years on the practice of radiology. Eleven cases are reviewed that have national implications for radiology. Five themes emerged. (a) Radiology is a medical service, to be billed as such, rather than a hospital service. (b) Physicians and their organizations are subject to federal antitrust laws and regulations. (c) Applicability of state regulations to radiology practices depends on legislative intent and actual circumstances. (d) Hospitals and physician groups are entitled to make exclusive contracts for valid business purposes. Radiologists losing such contracts are entitled to due process before being deprived of staff privileges. (e) Physicians practicing in managed care plans remain liable for untoward patient results of adherence to plan protocols even if conformity to those protocols is a requirement for participation. As the practice of medicine becomes more complex, radiologists face additional legal challenges fashioned for a business environment.

History, 20th Century↗
PubMed1980

Hospital-based physicians: current issues and descriptive evidence.

Hospital-based physicians (HBPs) have been the recipients of considerable attention in health policy debates in recent years. This paper discusses issues and trends concerning HBPs and presents evidence on practice characteristics, compensation methods, and incomes of anesthesiologists, pathologists, and radiologists. Some comparisons with office-based MDs are included. The primary data source is composed of physician surveys sponsored by the Health Care Financing Administration and conducted by the National Opinion Research Center in 1977 and 1978. Findings generated from these surveys support past research showing that radiology is the most lucrative HBP specialty, followed by pathology and anesthesiology; hospital-based practice tends to be considerably more lucrative than office-based practice, taken as a whole. Survey findings are discussed in light of current policy developments in the health services sector.

Anesthesiology↗
PubMed2006

Disclosing conflicts of interest in clinical research: views of institutional review boards, conflict of interest committees, and investigators.

Strategies for disclosing investigators' financial interests to potential research participants have been adopted by many research institutions. However, little is known about how decisions are made regarding disclosures of financial interests to potential research participants, including what is disclosed and the rationale for making these determinations. We sought to understand the attitudes, beliefs, and practices of institutional review board chairs, conflict of interest committee chairs, and investigators regarding disclosure of financial interests to potential research participants. Several themes emerged, including general attitudes toward conflicts of interest, circumstances in which financial interests should be disclosed, rationales and benefits of disclosure, what should be disclosed, negative effects of and barriers to disclosure, and timing and presentation of disclosure. Respondents cited several rationales for disclosure, including enabling informed decision making, promoting trust in researchers and research institutions, and reducing legal liability. There was general agreement that disclosure should happen early in the consent process. Respondents disagreed about whether to disclose the amounts of particular financial interests. Clarifying the goals of disclosure and understanding how potential research participants use the information will be critical in efforts to ensure the integrity of clinical research and to protect the rights and interests of participants.

Attitude of Health Personnel↗
PubMed1982

Medicare program; payment for physician services furnished in institutional providers of services--HCFA. Proposed rule.

These proposed rules would, in part, implement section 1887 of the Social Security Act, which was established by section 108 of the Tax Equity and Fiscal Responsibility Act of 1982. We are proposing to revise the regulations that govern Medicare coverage and reimbursement for services of physicians who practice in institutional providers (hospitals and skilled nursing facilities). The proposed regulations would set forth basic criteria for reasonable charge payment for those services, and would clarify how reasonable charges would be determined for physician services furnished by physicians in a provider setting. The regulations also would specify the conditions under which Medicare will pay on a reasonable cost basis for physician services to providers, and would provide improved tests of reasonableness for Medicare carriers and intermediaries to follow in determining payment. In addition, the proposed regulations would establish more specific conditions for payment for the services of anesthesiologists, radiologists, and pathologists.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1997

A comparison of ibuprofen versus acetaminophen with codeine in the young tonsillectomy patient.

OBJECTIVE: To compare the use of ibuprofen with the use of acetaminophen with codeine for posttonsillectomy management. BACKGROUND: We were not satisfied with our traditional pain-management practice for tonsillectomy patients. We hoped to find a new approach for improved patient comfort and avoid scheduled, abusable drugs such as codeine. DESIGN: Intervention, prospective, randomized control trial. Follow-up was 1 month. SETTING: University referral center; institutional pediatric practice, ambulatory. PATIENTS: 110 children undergoing tonsillectomy with or without other procedures. Consecutive patients were offered participation. Enrollees were randomly assigned to one of two classes and analyzed with the initial assignment. No patients withdrew for adverse effects, although 12 in group 2 used codeine and 5 of those used acetaminophen, whereas 2 in group 1 received ibuprofen. INTERVENTIONS: Patients received either acetaminophen with codeine (group 1) or ibuprofen (group 2) for postoperative pain control. MAIN OUTCOME MEASURES: The main outcomes, determined before initiation of the study, were assessment of (1) postoperative bleeding, (2) pain, (3) efficacy of relief of pain by drug, (4) nausea, (5) emesis, (6) readmission to hospital, (7) average temperature, and (8) highest temperature after surgery. RESULTS: The only statistically significant difference is less nausea in patients receiving ibuprofen (p = 0.0049). Of note, no difference existed in postoperative bleeding, pain, or temperature control. CONCLUSIONS: Ibuprofen is at least as effective as acetaminophen with codeine for postoperative pain control in children after tonsillectomy.

Acetaminophen↗
PubMed1998

Variations in antimicrobial use and cost in more than 2,000 patients with community-acquired pneumonia.

PURPOSE: To assess the patterns of antimicrobial use, costs of antimicrobial therapy, and medical outcomes by institution in patients with community-acquired pneumonia. PATIENTS AND METHODS: The route, dose, and frequency of administration of all antimicrobial agents prescribed within 30 days of presentation were recorded for 927 outpatients and 1328 inpatients enrolled in the Pneumonia Patient Outcomes Research Team (PORT) multicenter, prospective cohort study. Total antimicrobial costs were estimated by summing drug costs, using average wholesale price for oral agents and institutional acquisition prices for parenteral agents, plus the costs associated with preparation and administration of parenteral therapy. Thirty-day outcome measures were mortality, subsequent hospitalization for outpatients, and hospital readmission for inpatients. RESULTS: Significant variation (P <0.05) in prescribing practices occurred for 17 of the 23 antimicrobial agents used in outpatients across 5 treatment sites, and for 18 of the 20 parenteral agents used in inpatients across 4 treatment sites. The median duration of antimicrobial therapy for treatment site ranged from 11 to 13 days for outpatients (P=0.01), and from 13 to 15 days for inpatients (P=0.49). The overall median cost of antimicrobial therapy was $12.90 for outpatients, and ranged from $10.80 to $58.90 among treatment sites (P <0.0001). The overall median cost of antimicrobial therapy was $228.70 for inpatients, and ranged from $183.70 to $315.60 among sites (P <0.0001). Mortality and hospital readmission for inpatients were not significantly different across sites after adjusting for baseline differences in patient demographic characteristics, comorbidity, and illness severity. Although subsequent hospitalization for outpatients differed by site, the rate was lowest for the site with the lowest antimicrobial costs. CONCLUSION: Variations in antimicrobial prescribing practices by treatment site exist for outpatients and inpatients with community-acquired pneumonia. Although variation in antimicrobial prescribing practices across institutions results in significant differences in antimicrobial costs, patients treated at institutions with the lowest antimicrobial costs do not demonstrate worse medical outcomes.

Anti-Infective Agents↗
PubMed1993

[Preventive cardiology in the Czech Republic. Present status and perspectives].

Despite their proclaimed goals, prevention campaigns were little effective in the past. Now it is time to discard those highly publicized programmes. Preventive cardiology can be successful in reducing the incidence and mortality only on condition the endeavor of the public health system is combined with a well functioning service of general practitioners and family physicians. The nationwide model of prevention should be translated into practice by institutes of public health and hygiene and should improve, mainly by redefining the dietary habits and smoking cessation programmes, the risk profile of the entire population. It should be remembered that even a minor change in the risk profile in the whole population has society-wide implications and entails a significant decrease in the number of clinically manifest cases of the disease. While secondary prevention after myocardial infarction will continue to be the responsibility of the cardiologist, individualized intervention in persons at high risk, as part of primary prevention, can be provided generally only on condition it is performed by the general practitioner and the family physician. All multi-level models designed to refer patients and persons at risk step by step, according to the degree of risk, up the health system, as proposed by socialist health care, are not practicable. Today, the general practitioner can consult the expert directly should the need arise. Successful prevention will depend on the standard and education of the general practitioner on the one hand, and the performance of public health institutions on the other.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiovascular Diseases↗
PubMed2006

Implementing patient safety practices in small ambulatory care settings.

BACKGROUND: Improving patient safety in the outpatient setting poses unique challenges for patient safety leaders in clinics and hospitals. Even though ambulatory care may be less technologically complex than inpatient care, it is often more complex logistically. METHODS AND MATERIALS: From October 2002 to May 2003, Gundersen Lutheran Medical Center developed a tool kit of best practices and conducted a collaborative to institute these best practices within a regional health care network. All clinics evaluated patient safety standards and enhanced medication-related practices. RESULTS: Improvements were demonstrated in medication list accuracy. A number of policies were instituted, and medical and nursing staffs were educated in patient safety issues. Improvements were sustained after one year. DISCUSSION: The collaborative model of improvement efforts was an effective model for improving patient safety in small group practices. Structural and process changes often do not require major changes in workflow or large technology installations. Many of the projects allowed for, or required, local assessment and management. However, within a large system of clinics, some of the improvements in this study--verbal order policy, methodology and/or technology for assessment of medication and allergy list accuracy, warfarin care--required systemwide efforts. The degree of difficulty of achieving improvements was surprisingly low and barriers were minimal.

Ambulatory Care Facilities↗
PubMed1994

Measuring physician attitudes toward cost, uncertainty, malpractice, and utilization review.

OBJECTIVE: To develop a reliable measure of physician attitudes postulated to influence resource utilization. DESIGN: Statements related to attitudes that may influence resource use were culled from the literature and informal discussions with physicians. SETTING: Academic medical center. PARTICIPANTS: All faculty and housestaff in internal medicine, pediatrics, family medicine, and surgery at an academic medical center were surveyed. The response rate was 59% (n = 428). RESULTS: Exploratory factor analysis of all internal medicine surveys revealed four prominent domains. These closely corresponded with our a-priori hypothesized domains and were interpreted as cost-consciousness, discomfort with uncertainty, fear of malpractice, and annoyance with utilization review. A replication of the analysis using 25 survey items and conducted on the remainder of the data (surgeons, pediatricians, and family practitioners) revealed a similar four-factor solution. Scales were constructed for each of the four domains. Cronbach's alpha ranged from 0.66 to 0.88. Discomfort from uncertainty and fear of malpractice were moderately correlated (r = 0.42); other scale-scale correlations were modest. Of the four attitude measures, only cost-consciousness was associated with lower self-estimates of resource use. Both annoyance with utilization review and fear of malpractice increased as the proportion of time spent in patient care increased. CONCLUSIONS: Although various physician attitudes and beliefs have been hypothesized to influence health services resource use, reliable and valid measures for most of these have not been developed. The authors developed a 19-item survey instrument designed to measure these attitudes reliably. The four scales developed in this study may help identify physician attitudes that are important determinants of physician decision making and help foster a better understanding of physicians' reactions and acculturation to different practice environments.

Academic Medical Centers↗
PubMed1997

Interdisciplinary professional practice leadership within a program model: BC Rehab's experience.

In restructuring from a departmental to a program management model, BC Rehab successfully developed the role of professional practice leader to address clinical standards of practice and other concerns related to individual disciplines. A review of the role of professional practice leader is presented. Practice leaders are in a unique position to promote interdisciplinary, client-focused service. Because practice leaders' mandates cross program boundaries, they are able to keep the broad scope and goals of rehabilitation in the forefront, offering a balance to the program-specific perspective. It is imperative for practice leaders to maintain connections to operational and clinical issues to avoid isolation.

Adolescent↗
PubMed2005

Value of the SAGES Learning Center in introducing new technology.

BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Learning Center is a group of educational "classrooms" designed to tutor meeting attendees on specific technology-intensive content areas. The objectives of the Robotics Station were to familiarize participants with basic laparoscopic skills as implemented with surgical robotic assistance and to help them explore the benefits and drawbacks of using robotics in their institutions. METHODS: Sixty-six volunteer surgeon attendees of the 2003 SAGES meeting representing a diverse group of backgrounds and possessing varying levels of surgical experience were directed through a series of drills on two different surgical robots. Each participant was directed through a series of three drills that practiced surgically relevant skills. Participants were given feedback on their performance. They then completed a 12-question computer-based questionnaire that surveyed their personal demographic backgrounds, their impressions of robotic surgery, and their opinions regarding the learning center's utility in educating them about new technology. RESULTS: Sixty-eight percent of participants had never used a surgical robot, and 89% had never used a robot clinically. Eighty-eight percent of respondents found one or both robots easier to use than they had expected, and 91% found that one or both robots made simple surgical tasks easier compared to standard laparoscopy. Sixty-four percent of participants stated that they were more likely to pursue purchase of a robotic system for use in their practice as a result of their exposure to robotics in the Learning Center. After completing the Robotics Station, 80% of surgeons believed that current surgical robots are of clinical benefit. However, 71% of participants stated that surgical robotic systems priced above $500,000 would not be financially viable in their practices. CONCLUSION: The structured learning environment used in the SAGES Learning Center fostered among participants a positive attitude toward surgical robotics. The format of their exposure to this technology at the Robotics Station also enabled participants to gauge the potential financial value of surgical robots in clinical practice. The SAGES Learning Center Robotics Station succeeded in exposing surgeons to surgical robotics in a way that helped them assess the value of this technology for their individual practices and institutions.

Adult↗
PubMed1994

Physician staffing patterns correlates of nursing home care: an initial inquiry and consideration of policy implications.

BACKGROUND: To determine, post-OBRA 1987, medical organization in nursing facilities (ie, medical director and staff profile, closing of medical staff, use of physician contract); structural correlates of medical organization; and links between medical organization, especially closed staffing, and medical care. METHOD: Mail survey of New York state nursing facility administrators (63% response). Survey consisted of open and closed end items that focused on facility and staff demographics, medical organization, and markers of medical care delivery, ie, physicians' daily presence, average response time to emergency calls, cross coverage for acute conditions and emergencies, attendance at care conferences, and offering of in-services. RESULTS: On average, facilities had 8.6 attending physicians, 32 residents per physician, 70% of residents cared for by non-staff physicians, no daily physician presence (60%), and no cross coverage. Most medical directors were from family (42%) or internal (55%) medicine, had a tenure of 7.5 years, did not have a certificate of added qualification in geriatrics (73%), and attended residents (66%). Forty-three percent of facilities had closed medical staffs, and 12% had physician contracts. Closed staffs were more likely in facilities that were larger, had more Medicaid residents, used physician extenders, and had more residents per nurse. Facilities with closed medical staffs had fewer physicians more residents per physician, and reported medical care practice patterns that would be associated with quality of care. These effects were independent of nursing and facility characteristics. Physician contract was unrelated to care. CONCLUSIONS: Medical organization and practice patterns emerge as important factors in considerations of nursing home quality. Results argue that, as in acute settings, limiting practice privileges in nursing homes may be a useful organizational strategy to improve quality of care.

Delivery of Health Care↗
PubMed2001

Introduction: promoting and maintaining a reflective professional staff in a hospital-based social work department.

Promoting and sustaining a staff of reflective social work practitioners requires a supportive departmental structure and culture. Providing such support is a particular yet necessary challenge to social work administrators in the current health care environment. This article discusses an array of administrative strategies employed in one hospital social work department to promote reflective social work practice. More specifically, it describes the role of practice-based research in enhancing worker reflectiveness.

Allied Health Personnel↗
PubMed1990

The independent practice of dental hygiene.

Dental hygienists are health care professionals specially trained and licensed to provide preventive oral health care and information to patients. In 49 of the 50 states, dental hygienists practice their profession under some type of supervision by a dentist. They are prohibited by state law from practicing independently in their own dental hygiene offices. The independent practice of dental hygiene and the controversial issues concerning dentists and dental hygienists are the issues examined in this article.

Alabama↗
PubMed1994

The effect of physician practice organization on efficient utilization of hospital resources.

OBJECTIVE: This study examines variations in the efficient use of hospital resources across individual physicians. DATA SOURCES AND SETTING: The study is conducted over a two-year period (1989-1990) in all short-term general hospitals with 50 or more beds in Arizona. We examine hospital discharge data for 43,625 women undergoing cesarean sections and vaginal deliveries without complications. These data include physician identifiers that permit us to link patient information with information on physicians provided by the state medical association. STUDY DESIGN: The study first measures the contribution of physician characteristics to the explanatory power of regression models that predict resource use. It then tests hypothesized effects on resource utilization exerted by two sets of physician level factors: physician background and physician practice organization. The latter includes effects of hospital practice volume, concentration of hospital practice, percent managed care patients in one's hospital practice, and diversity of patients treated. Efficiency (inefficiency) is measured as the degree of variation in patient charges and length of stay below (above) the average of treating all patients with the same condition in the same hospital in the same year with the same severity of illness, controlling for discharge status and the presence of complications. PRINCIPAL FINDINGS: After controlling for patient factors, physician characteristics explain a significant amount of the variability in hospital charges and length of stay in the two maternity conditions. Results also support hypotheses that efficiency is influenced by practice organization factors such as patient volume and managed care load. Physicians with larger practices and a higher share of managed care patients appear to be more efficient. CONCLUSIONS: The results suggest that health care reform efforts to develop physician-hospital networks and managed competition may promote greater parsimony in physicians' practice behavior.

Arizona↗
PubMed1982

Admitting applicants to skilled nursing facilities: social workers' role.

Social workers play a vital role in the screening and admission of applicants to skilled nursing facilities because they provide unique attention to patients' psychosocial as well as medical needs. This article reports on a study that investigates social workers' employment in nursing homes and their actual involvement in the admission process. It also details the practices and procedures used to screen, select, and admit applicants to the facilities.

Data Collection↗
PubMed2001

Mining treatment termination data in an adolescent mental health service: a quantitative study.

This study utilizes available clinical information from client records to explore patterns of termination from mental health treatment among adolescents at an urban outpatient mental health center. The analysis focuses on how and why adolescents terminate from treatment and identifies variables associated with "acknowledged" and "unacknowledged" terminations. Findings indicate that termination was acknowledged infrequently, often a brief process that occurred almost as frequently by telephone as in the context of treatment. Contrary to "practice wisdom" concerning treatment termination, adolescents who "dropped out" without a "clinical process" reported considerably more engagement in treatment than those who acknowledged the termination of treatment. Recommendations for a more "open door" policy and a more flexible practice with adolescents are discussed.

Adolescent↗