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PubMed2005

Use of the transtheoretical model in the medication use process.

OBJECTIVE: To review articles published during the past 10 years relating to the transtheoretical model (TTM) and the medication use process, focusing on prescribing, dispensing, and using prescription and nonprescription medications for legitimate purposes. DATA SOURCES: MEDLINE, Cochrane database, PsychINFO, International Pharmaceutical Abstracts, and PubMed were searched from 1995 to August 2004 using the key terms models, psychological; prescriptions, drug; drugs, nonprescription; models, theoretical; self medication; patient compliance; medication compliance; decision making; drug therapy and behavior change. Additional searches included the following terms: pharmacists, community; TTM; transtheoretical model, pharmacy services, new practice patterns and physician practice patterns. STUDY SELECTION AND DATA EXTRACTION: Studies with empirical application of any aspect of TTM were included. Abstracts were reviewed by both authors, and data were independently abstracted including, for example, specific aspects of TTM used or tested, context for model use or setting, and results and authors' suggestions for future use of TTM. The reviewers came to consensus on all abstracted information. DATA SYNTHESIS: Eleven articles were identified that contained TTM and drug use; however, only 5 were empirical applications. There were 2 types of applications of TTM in medication use: measurement of stage of change regarding adherence and prediction of adherence using TTM concepts. A 1- and 2-item measure of adherence stage of change have been validated. Medication adherence stage of change varied by type of drug. The pros and cons of taking the medicine and stage of change were useful in predicting adherence. No intervention studies to improve adherence were identified. CONCLUSIONS: TTM has not been used extensively to examine the medication use process. Without further research, no clear recommendation can be provided as to the effectiveness of TTM in improving the drug use process, but it remains promising.

Drug Therapy↗
PubMed1991

Using data describing physician inpatient practice patterns: issues and opportunities.

Information on physicians' inpatient practice patterns is becoming increasingly available through state data systems. This article describes the kind of information that is becoming publicly available, provides illustrations of how these data can be used, and discusses issues and potential problems that may occur in using the data.

Health Services Research↗
PubMed1999

Physician practice style patterns with established patients: determinants and differences between family practice and general internal medicine residents.

BACKGROUND AND OBJECTIVES: This paper examines the practice style patterns of family practice and internal medicine residents for established patient visits. METHODS: New adult patients (n = 509) were prospectively and randomly assigned to family practice or internal medicine clinics at a university medical center and followed for 1 year of care by resident physicians. Initial and return visits were videotaped, and physician practice styles were analyzed using the Davis Observation Code (DOC). RESULTS: Resident physicians' practice styles with established patients during return visits were associated with various factors, depending on the DOC cluster of behaviors studied. These factors include patient gender, age, income, physical and mental health status, level of pain, number of return visits, and physician practice style displayed during the initial encounter. Family practice return visits had a greater emphasis on preventive services and counseling, compared with internal medicine return visits. Internists spent more visit time using technically oriented behaviors. CONCLUSIONS: Patient variables, as well as baseline physician behavior, have an important influence on physician practice styles during return patient visits. There are measurable differences in the established practice styles between family practice and internal medicine resident physicians, which may reflect differences in professional training programs.

Adult↗
PubMed1996

The measurement of physician work and alternative uses of the resource based relative value scale.

On January 1, 1992, the Medicare program implemented a new payment system for physician services based on the Resource Based Relative Value Scale (RBRVS). The RBRVS has been widely accepted as a rational and systematic approach to measuring the resource costs associated with physician services. In addition to deriving physician payment rates, the RBRVS provides a useful metric that allows the measurement and comparison of provider utilization rates and productivity across physicians performing a varied mix of services. In this study we describe the measurement of physician work, discuss alternative ways in which work values can be used to monitor physician service utilization (e.g., profiling physician practice patterns), measure physician productivity, and determine physician compensation.

Efficiency↗
PubMed2001

The evaluation of physician patterns of practice in cardiac patients at two British Columbia tertiary referral hospitals.

OBJECTIVE: To evaluate the patterns of care in patients hospitalized with acute coronary syndrome or congestive heart failure. DESIGN: A pilot study - retrospective chart review. SETTING: Two British Columbia tertiary referral teaching hospitals. PATIENTS: One hundred patients admitted with stable angina, acute ischemic syndrome or congestive heart failure at each hospital. RESULTS: Patient profiles showed that women at both hospitals were significantly older and had significantly longer lengths of stay than men. Patterns of practice were comparable except when it came to lipid testing and lipid-lowering agents being prescribed to patients at the time of discharge. At hospital A, patients were more likely to have a lipid profile performed compared with patients at hospital B. CONCLUSIONS: The addition of lipid testing to the clinical pathway for patients with myocardial infarction led to more patients at hospital A having a lipid profile performed. The routine assessment of lipid profiles in patients admitted for acute ischemic syndromes led to more aggressive pharmacological treatment with hydroxy-methyl-glutaryl coenzyme A reductase inhibitors - agents that are known to reduce mortality and recurrent infarction. Methods to improve treatment are proposed to help reduce morbidity and/or mortality in patients with ischemic heart disease and congestive heart failure.

Aged↗
PubMed1996

Site of service, anesthesia, and postoperative practice patterns for oculoplastic and orbital surgeries.

PURPOSE: Variations in physician practice patterns, particularly with reference to cost-intensive resource utilization, are increasingly being scrutinized. However, little information is currently available regarding physician practice patterns for oculoplastic surgery. METHODS: The authors surveyed members of the American Society of Ophthalmic Plastic and Reconstructive Surgery regarding their most common site of service, type of anesthesia, and first postoperative week of follow-up for 15 selected eyelid, lacrimal, and orbital procedures. RESULTS: The majority of eyelid and lacrimal surgeries are currently performed on an out-patient basis (hospital out-patient, ambulatory surgery center, or office), typically using local anesthesia, with or without sedation. Regional differences were noted. Physicians in western states showed a greater tendency toward office-based surgery for procedures such as blepharoplasty and ptosis repair. Orbital procedures were performed more frequently as a hospital inpatient surgery, under general anesthesia. Patterns of follow-up within the first postoperative week varied considerably for most procedures. Compared with admitting practices in 1987, an obvious trend toward out-patient surgery was noted. CONCLUSION: Variations in practice patterns will assume greater importance as the pressure for cost-containment increases. Total costs are affected by physician choices for site of service and type of anesthesia. This study allows surgeons who perform oculoplastic procedures to compare their practices with a national group specializing in such surgery. Further outcome-oriented studies are needed to develop practice guidelines for "preferred patterns" of care.

Anesthesia↗
PubMed2002

The impact of perceived barriers on primary care physicians' screening practices for female partner abuse.

OBJECTIVES: Our purpose was to examine primary care physicians' screening practices for female partner abuse in different clinical situations and to investigate the relationship between perceived barriers and screening practices. METHODS: A cross-sectional survey was mailed to Alaska physicians practicing in the following specialties: family practice, internal medicine, obstetrics/gynecology and general practice. RESULTS: The survey response rate was 80 percent (305/383). The majority (85.7%) of primary care physicians screened often or always when a female patient presents with an injury, but they rarely screened at initial visits (6.2%) or annual exams (7.5%). More than one-third of respondents estimated that 10% or more of their female patients had experienced some type of intimate partner abuse. Several barriers to screening described in the literature were not predictive of physicians' screening practice patterns. Physicians' perceptions that abuse is prevalent among their patients and physicians' beliefs that they have a responsibility to deal with abuse were the only variables independently associated with screening at initial visits and annual exams. The only variable predictive of screening when a patient presents with an injury was physicians' perceived prevalence of abuse. CONCLUSION: Primary care physicians have not integrated screening for partner abuse into routine care. Strategies to increase awareness of the high prevalence of abuse in the primary care setting and to educate providers on the negative health effects of victimization can help physicians to acknowledge their responsibility in addressing abuse and the importance of screening at routine visits. Further rigorous studies are needed to identify and evaluate predictors of screening for abuse.

Adult↗
PubMed1994

Analyzing patterns-of-treatment data to provide feedback to physicians.

Physicians' practice patterns can be influenced through feedback programs. The purpose of this article is to define a methodology that provides the feedback information necessary to affect physicians' practice patterns, using data collected by a large multispecialty physician group and individualized feedback plans for primary care physicians.

Diagnosis-Related Groups↗
PubMedDate not supplied

Patient characteristics and practice patterns of physicians using homeopathy.

BACKGROUND: The use of homeopathy is growing in the United States, but little is known about practice patterns of physicians using homeopathy and the patients who seek homeopathic care. MATERIALS AND METHODS: Data for consecutive patient visits to 27 doctors of medicine and doctors of osteopathy using homeopathy in 1992 were collected and compared with the National Ambulatory Medical Care Survey of 1990. RESULTS: Patients seen by the homeopathic physicians were younger, more affluent, and more likely to present with long-term complaints. Physicians using homeopathic medicine surveyed spent more time with their patients, ordered fewer tests, and prescribed fewer pharmaceutical medications than physicians practicing conventional medicine. CONCLUSIONS: While definite conclusions cannot be made based on this survey, we have documented that the use of diagnostic testing and conventional medications by physicians who use homeopathy to treat common chronic conditions is well below that of conventional primary care physicians. These findings, if associated with comparable clinical outcomes, suggest a potential for substantial cost savings. Further studies documenting outcomes, cost benefits, physician decision-making, and patient satisfaction will be required to further explore this subject.

Adolescent↗
PubMedDate not supplied

Practice patterns of family physicians in practice-based research networks: a report from ASPN. Ambulatory Sentinel Pratice Network.

BACKGROUND: Practice-based research networks are growing and undertaking larger and more complex studies to inform the clinical practice of family physicians. We describe a study that compares clinical behaviors of physicians in the Ambulatory Sentinel Practice Network (ASPN), a large national practice-based research network, with those from the National Ambulatory Medical Care Survey (NAMCS). METHODS: A survey, replicating NAMCS, was conducted among 129 family physician members of ASPN. Nested logistic regression was used to determine which services could predict ASPN membership after adjustment for common and easily observed patient and physician characteristics. RESULTS: Of 20 specific patient services, only 4 were predictive of membership in ASPN. Of these 4, 2 were screening or diagnostic services; ASPN physicians were 1.18 times more likely to obtain a blood pressure measurement and 0.60 times as likely to order a culture for streptococcal pharyngitis. ASPN physicians were 2.30 times more likely to provide family planning counseling and 1.66 times more likely to provide smoking cessation counseling after adjusting for patient smoking status. CONCLUSIONS: We conclude that there are minimal differences in the practice patterns of family physicians participating in a large national practice-based research network and those included in the probability sample of NAMCS. Additional work is needed to examine further those characteristics of the phenomena observed in practice-based research network research that might affect generalizability of results to the larger community of practicing family physicians.

Community Networks↗
PubMed1995

[Patient listing system--grouping of patients and workload of physicians. Patterns in general practice in the municipality of Trondheim].

To assess the impact of patient mix on general practitioners' work-load within a list patient system, a "key" was constructed for computing expected use of general practitioners' services by patients on a doctor's list. The key was based on empirically observed variations in consultation rates for different age and sex-groups. Computations were made for 90 general practitioners in Trondheim. Expected patient weight varied in accordance with the proportion of women and of old patients on the doctor's list. The mean expected use of consultations was approx. 6% higher for patients on female doctor's lists relative to patients on male doctors' lists. The difference between the patients of male and female doctors respectively was far less than previously expected. This is explained by the fact that female doctors - compared with their male colleagues - usually have more children and fewer old people on their list of patients.

Adolescent↗
PubMed2001

Clinical aspiration-related practice patterns in the intensive care unit: a physician survey.

OBJECTIVE: To characterize physician practice patterns regarding the clinical, microbiological, and antimicrobial-related events of suspected or documented aspiration and aspiration pneumonia within the intensive care unit. DESIGN: National mail survey. SETTING: University medical center. STUDY POPULATION: Critical care physician members of the Society of Critical Care Medicine. INTERVENTIONS: Survey questionnaire. MEASUREMENTS AND MAIN RESULTS: The response rate was 645 (32%) of 2,000 mailed surveys; analysis of data represents completed questionnaires from 605 respondents. Intensivists (42.3%), pulmonologists (22.6%), and surgeons (21.6%) represent the majority of respondents. Altered level of consciousness (67.9%) in the intensive care unit was identified as the predominant predisposing factor for aspiration pneumonia. Sixty-four percent of physicians used sputum specimens, rather than protected specimen brushes or bronchoalveolar lavage, as the diagnostic source of bacterial cultures in cases of suspected aspiration pneumonia. Microbiological assessment of aspiration pneumonia revealed the absence of any predominant pathogen, although Staphylococcus aureus and Pseudomonas aeruginosa were cited in 40.1% of combined responses, whereas anaerobes represented the fifth most prevalent cultured bacteria. In cases of suspected and confirmed aspiration, 51.9% and 77.7% of respondents, respectively, would prescribe an antimicrobial agent in the absence of a definitive infectious process, with administration of dual antimicrobial therapy increasing from 28.9% to 46.0% in suspected vs. confirmed cases of aspiration. In the treatment of aspiration pneumonia, 27.6% of physicians preferred pathogen-specific therapy, whereas the remainder (72.4%) selected an empirical antibiotic regimen based on prior clinical experience. Overall, a beta-lactam/beta-lactamase inhibitor, followed by a cephalosporin, aminoglycoside in combination, or clindamycin, was most often selected for empirical therapy of all defined aspiration-related clinical diagnoses. CONCLUSIONS: Our study revealed a divergent approach to antimicrobial treatment of cases of aspiration in the intensive care unit. Further investigation is warranted to determine why empirical antimicrobials are initiated frequently for noninfectious stages of aspiration.

Adult↗
PubMed1997

Variations between family physicians and obstetricians in the evaluation and treatment of preterm labor.

BACKGROUND: The purpose of this study was to examine and compare the approaches of family physicians and obstetricians when evaluating and managing women with preterm contractions or labor. METHODS: A survey questionnaire examining physician practice characteristics was sent to a random sample of specialists in obstetrics and family practice in 10 states. Responses were received from 54% of individuals in active practice. RESULTS: When asked their three most common treatment strategies for women with preterm labor, family physicians were more likely than obstetricians to select beta-agonists and hydration. Obstetricians were more likely to include magnesium sulfate and nifedipine in their treatment plans. For women with preterm contractions and no change in cervix, obstetricians were more likely to select either of the two short-term tocolytic therapies, while family physicians were more likely to select less aggressive therapy approaches. When adjusted for the facility in which they practiced and the number of years of experience, family physicians were nearly one half as likely as obstetricians to use tocolytics to treat women who had contractions but no cervical changes. CONCLUSIONS: In general, obstetricians were more likely to select more aggressive therapy for women with premature contractions without changes in cervix. Since it is unlikely that patient preferences would influence the choice of strategies for preterm labor, it is likely that these results reflect true differences in physician practice patterns based on physician specialty.

Adrenergic beta-Agonists↗
PubMed1999

Appropriateness of psychostimulant prescription to children: theoretical and empirical perspectives.

OBJECTIVES: 1) To consider study designs for evaluating how appropriately stimulant medications are prescribed to children. 2) To investigate appropriateness by seeking evidence of consensus around how stimulant management should be undertaken, collecting and reviewing evidence of actual physician practice in relation to use of stimulants, and evaluating the closeness of fit between recommended and actual practice. METHOD: Electronic databases and other published and unpublished material were searched for the decade 1987-1997 to identify 1) authoritative recommendations for medical management of attention-deficit hyperactivity disorder (ADHD) and 2) surveys of physician practice. Available information was analyzed qualitatively for commonalities and trends and for concordance between recommendations and practice. RESULTS: Despite differences in emphasis between experts, common themes were identifiable regarding prerequisites and follow-up for use of stimulants. Overall, it was rare to find physician practice in accordance with expert recommendations more than 70% of the time, suggesting that management may be suboptimal in at least 30% of children treated with medication for ADHD. Across surveys, consistent differences appear in physician practice patterns related to practice type. Management by specialist consultants approximates standards recommended by experts, while management by primary care practitioners diverges from these standards. CONCLUSIONS: There are grounds for concern about the quality and appropriateness of medical management for children with ADHD. The methodology used in this study holds promise for wider application, with planning and refinement. There is a need to find ways to improve care for children with ADHD provided by primary care physicians.

Attention Deficit Disorder with Hyperactivity↗
PubMed1993

Teaching risk management to physicians.

In summary, the risk manager should take an active role in educating the medical staff. The seven areas discussed can serve as a checklist for the risk manager and, of course, can be expanded. The risk management strategies described should be encouraged to become a part of physicians' daily practice patterns. Physicians then will be better prepared to help their patients deal with adverse outcomes as well as feel more comfortable about the medical-legal environment in which they practice.

Communication↗
PubMed1988

Differences in physician prevention practice patterns for white and minority patients.

A telephone survey of 120 randomly selected primary care physicians in New York City was completed in October, 1984 (response rate = 90%) concerning physicians' recommendations for health promotion and disease prevention. Responses from physicians with 50% or more Black and Hispanic patients were compared with responses from physicians with 50% or more White patients. The former were found to be less likely to follow guidelines from nationally recognized organizations for health promotion and disease prevention, although they were just as likely to value the importance of prevention in primary care. For example, physicians with predominantly Black and Hispanic patient populations were significantly less likely to recommend screening mammography (7% versus 23%) or recommend influenza vaccination for patients 65 or older (48% versus 74%) when compared with physicians with predominantly White patient populations. Factors that appeared to contribute to the difference in prevention practice patterns include physician training and education, the socioeconomic status of the patients, and the time physicians spend with patients. Differences in quality of preventive care provided to minority patients may be an additional factor in the disparity between the health status of White and non-White Americans.

Attitude of Health Personnel↗
PubMed1993

Gender differences in the treatment of patients with acute myocardial infarction. A multihospital, community-based perspective.

OBJECTIVE: As part of a community-wide study examining temporal trends in the incidence and survival rates of acute myocardial infarction, we examined differences between the sexes in overall utilization rates and changes over time, therein, of various therapies used in the management of acute myocardial infarction. DESIGN: Nonconcurrent prospective study. PATIENTS: Three thousand three hundred sixty-one men and 2119 women hospitalized with validated acute myocardial infarction in 16 hospitals in the Worcester, Mass, metropolitan area during 1975, 1978, 1981, 1984, 1986, 1988, and 1990. RESULTS: After controlling, by means of a logistic regression analysis, for a variety of patient-related factors that could affect physician prescribing patterns, women were significantly more likely to receive diuretics during hospitalization for acute myocardial infarction, whereas men were significantly more likely to receive antiplatelet agents, lidocaine, and other antiarrhythmic agents. No statistically significant differences were seen between men and women with regard to the use of anticoagulants, beta-blockers, calcium channel blockers, digoxin, nitrates, and thrombolytic agents. Marked increases over time (1975 through 1990) were seen in the use of anticoagulants, antiplatelet agents, beta-blockers, lidocaine, and nitrates in each of the sexes, while declines were seen in the use of digoxin and diuretics. Use of thrombolytic therapy increased between 1986 and 1990, whereas use of calcium channel blockers decreased over this period for both men and women. CONCLUSIONS: The results of this multihospital, population-based, observational study suggest that physician practice patterns in the pharmacologic treatment of men and women hospitalized with acute myocardial infarction are very similar.

Aged↗
PubMed1990

Practice guidelines and professional autonomy in a universal health insurance system: the case of tissue plasminogen activator in Ontario.

Ontario's universal health insurance system has placed few constraints on the clinical and economic autonomy of medical doctors. Although fees are standardized, most physicians remain in private fee-for-service practice and thereby retain control of the mix and volume of services. Utilization review is minimal. While organized medicine has argued that health care is 'under-funded', the government is pressing for better use of extant resources through firmer management of the medical services sector. The Ontario Medical Association (OMA), the major bargaining agent for doctors in the province, has accordingly sought to protect professional autonomy by developing voluntary self-regulatory approaches that obviate the need for external controls over physician practice patterns. Part of this strategy is promulgation of practice guidelines. Tissue plasminogen activator (t-PA), a clot-lysing drug for myocardial infarction, was released in late 1987, and, at C$2950 per treatment, constituted an unforeseen add-on cost for hospitals. The OMA subsequently convened an expert panel to develop guidelines for thrombolysis in myocardial infarction. Among the unanticipated results was the conclusion that insufficient evidence had accumulated to recommend routine use of t-PA instead of streptokinase, an older drug costing C$290. The OMA panel's guidelines were approved by the OMA executive, and led the government to reject special add-on funding for hospitals purchasing t-PA. The OMA's position and government decision provoked negative reactions from the OMA's own cardiology section. Indicative of clinicians' feelings, a follow-up survey of cardiologists and internists showed that only 28% of respondents were indifferent between t-PA and streptokinase, while 64% preferred t-PA. On the other hand, 74% supported clinical policy development by the OMA, while 94% opposed direct government involvement in guideline-setting. The case of the OMA thrombolysis guidelines illustrates a strategic conundrum facing Canadian organized medicine. Professional activism in guideline-setting may in theory protect the individual practitioner's autonomy by offering a voluntary alternative to utilization management by government, and is likely to strengthen the collective influence of organized medicine. However, among the risks are alienation of practitioners who see professional guidelines and government control as two sides of the same regulatory coin, and the transmogrification of voluntary guidelines into parameters for cost control and utilization management by government or hospitals. Future initiatives will depend on how these benefits and risks are weighed.

Cost Control↗