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PubMed2001

National estimates of physician assistant productivity.

Analysis of productivity data from a nationally representative sample of physician assistants (PAs) showed that PAs performed 61.4 outpatient visits per week compared with 74.2 visits performed by physicians, for an overall physician full-time equivalent (FTE) estimate of 0.83. However, productivity of PAs varies strongly across practice specialty and location, with generalist PAs performing more visits than their specialist counterparts. Rural PA productivity is higher than urban productivity because of the concentration of generalist PAs in rural settings. A generalist PA physician FTE estimate of 0.75 appears to be more accurate than the 0.5 currently under consideration in proposed modifications to Health Personnel Shortage Area designation regulations.

Ambulatory Care↗
PubMedDate not supplied

Control of the antigen-antibody ratio in antibody detection/compatibility tests.

An evaluation was made of the variation and importance of dropper volume delivery on pretransfusion testing in ten hospital transfusion services which annually perform a combined total of 225,000 compatibility tests on the serum of approximately 70,000 patients. The pretransfusion testing by these institutions typifies practices throughout the United States in that serum and red blood cells are used with little awareness of actual volumes used and the resultant proportion of one reactant to the other. Tests of the hospitals' dropper pipettes showed a range of serum delivery per test of 0.0465 to 0.1155 ml. Commercial reagent red blood cell vial droppers delivered (according to cell concentration) from 0.00166 to 0.00294 ml packed red blood cells (pcv). From these findings, it could be shown that the serum to cell ratio in the tests done in two transfusion services was as low as 19 to 1 and that the highest ratio of 70 to 1 was used in only one institution. In none was the serum-cell ratio the optimum of 80 to 1.

Antibodies↗
PubMedDate not supplied

The hospitalist.

Efforts to improve the efficiency and quality of hospital inpatient care have led to the movement to replace the primary care physician with the hospitalist as the inpatient physician of record. A hospitalist serves as the physician of record after accepting referrals of hospitalized patients from primary care physicians. The hospitalist then keeps the primary care physician informed of major healthcare decisions during the patient's entire hospital stay. One of the forces promoting the hospitalist movement is the assumption that inpatient care provided by a small number of physicians is less costly, of higher quality, and less variable than the care provided by primary care physicians who see patients only briefly once a day. Hospitalists are accessible throughout their shifts and can better respond to changing patient needs. With this model of care, hospitalists have taken a more proactive role in redesigning support-care systems based on the needs of the patient. Many perform quality improvement and utilization review, and engage in the development of clinical practice guidelines. Concern over the hospitalist model has focused on the break in continuity of care. Patients and their families may feel that they are losing a physician whom they know and for whom they have some level of comfort and confidence. As the hospitalist movement picks up momentum, so too does its expectation to improve and provide for quality end of life care.

Case Management↗
PubMedDate not supplied

Practices and hospitals, their physicians, and their noncompetes: breaking up should be hard to do.

The availability of specialty healthcare has become an issue of increasing importance. Practices and hospitals must be encouraged to assume the risk and responsibilities of expanding their fields of care. For their part, courts must give heavier weight to that aspect of the public interest in determining how their decision impacts access to specialty healthcare. In short, courts deciding the enforceability of noncompetition agreements must be willing to do something more than count doctors.

Contracts↗
PubMedDate not supplied

Pediatric hospitalists in Canada and the United States: a survey of pediatric academic department chairs.

OBJECTIVES: To document the prevalence and practice patterns of pediatric hospitalists in academic centers in Canada and the United States; to characterize academic pediatric department chairs' definition of the term hospitalist; and to characterize pediatric department chairs' views of the training requirements for pediatric hospitalists. METHODS: A 14-item questionnaire was sent to all 145 pediatric department chairs from Canada and the United States during the fall of 1998. We defined hospitalists as physicians spending at least 25% of their time in inpatient care. RESULTS: Of the 145 eligible pediatric chairs, 128 (89%) responded (United States, 111/126; Canada, 14/16; Puerto Rico, 3/3). Ninety-nine (77%) of 128 pediatric chairs either have (64/128) or are planning to have (35/128) hospitalists in their institutions. Within academic programs with hospitalists, 82% of hospitalists currently work on general pediatric wards. Two thirds of hospitalists teach, 50% provide outpatient care, 50% have administrative duties, and 44% conduct research. One hundred eight (84%) of 128 believe that hospitalists should spend at least 50% of their time in inpatient care. Less than one third (30%) of pediatric chairs believe that hospitalists require training not currently provided in residency. CONCLUSIONS: A large proportion of academic pediatric centers either employed or planned to employ hospitalists in 1998. Pediatric academic department chairs do not see a need for training beyond residency for hospitalists. Further studies should address how pediatric hospitalists affect quality of care, cost, and patient satisfaction.

Academic Medical Centers↗
PubMed1994

Structuring medical practice acquisitions.

A successful medical practice acquisition requires both the buyer and the seller to understand the complex legal and business issues that arise throughout the negotiation of the transaction. This article surveys the key issues involved in setting the purchase price, determining how that price will be paid, deciding whether to acquire assets or stock, establishing a physician employment agreement, and addressing the concerns of nonphysician staff.

Commerce↗
PubMedDate not supplied

Maxillofacial trauma: current practice in management at Pakistan Institute of Medical Sciences.

BACKGROUND: This study was carried out to determine the aetiology, pattern and management of maxillofacial injuries at PIMS, Islamabad. METHODS: This descriptive study was conducted at Plastic Surgery Department, PIMS Islamabad from 1st February 1998 to 30th April 2002. All the adult patients presenting with maxillofacial injures were included where as patients less than 12 years of age and only facial lacerations were excluded. Similarly isolated nasal bone fractures were also excluded because these patients were routinely managed by ENT department. Age, sex, presentation, aetiology, associated injuries and treatment modalities undertaken in these patients were recorded. RESULTS: In 164 patients 254 fractures were noted. Most were male (86%), ranging in age from 13-71 years with a male to female ratio of 6:1 respectively. The most frequent (48%) cause noticed was road traffic accidents followed by assault. Mandible was the commonest to be involved in such injuries followed by maxilla. Most of the patients (32%) had associated facial injuries. Various treatment modalities were practiced. CONCLUSION: Maxillofacial fractures should be managed by open reduction and internal fixation as early as possible.

Academic Medical Centers↗
PubMed1987

Doctors and unions: is collective bargaining the cure for physicians' labor pains?

Increasing governmental regulation, the proliferation of alternative health-care options, and a glut of physicians in some areas have substantially affected the way physicians practice medicine today. Health-care consumers are not the only people affected. Where physicians were once their own bosses, many now find themselves as employers of health-care providers. In this new role, physicians are now considering union representation as a vehicle to assert their interests and concerns. This article examines why some doctors favor unionization, why some oppose it, and the legal implications of unionized physicians.

Employment↗
PubMedDate not supplied

Clinical practice guidelines in complementary and alternative medicine. An analysis of opportunities and obstacles. Practice and Policy Guidelines Panel, National Institutes of Health Office of Alternative Medicine.

An estimated 1 of 3 Americans uses some form of complementary and alternative medicine (CAM), such as acupuncture, homeopathy, or herbal medicine. In 1995, the National Institutes of Health Office of Alternative Medicine convened an expert panel to examine the role of clinical practice guidelines in CAM. The panel concluded that CAM practices currently are unsuitable for the development of evidence-based practice guidelines, in part because of the lack of relevant outcomes data from well-designed clinical trials. Moreover, the notions of standardization and appropriateness, inherent in guideline development, face challenging methodologic problems when applied to CAM, which considers many different treatment practices appropriate and encourages highly individualized care. Due to different belief systems and divergent theories about the nature of health and illness, CAM disciplines have fundamental differences in how they define target conditions, causes of disease, interventions, and outcome measures of effectiveness. These differences are even more striking when compared with those used by Western medicine. The panel made a series of recommendations on strategies to strengthen the evidence base for future guideline development in CAM and to meet better the current information needs of clinicians, patients, and guideline developers who seek information about CAM treatments.

Complementary Therapies↗
PubMed2000

The effect of HMO penetration on physician retirement.

OBJECTIVE: To examine the effect of HMO penetration on physician retirement. STUDY DESIGN: We linked together historical data from the Physician Masterfile of the American Medical Association for successive years to track changes in physicians' activity status between 1980 and 1997. We used a multivariate discrete-time survival model to examine how the probability of physician retirement was affected by the level of HMO penetration in the physician's market area, controlling for other physician and market characteristics. The study population included all active allopathic patient-care physicians in the United States who reached age 55 between the years of 1980 and 1996. The main outcome measure was physician retirements as reported on the Physician Masterfile. PRINCIPAL FINDINGS: HMO penetration had a statistically significant positive effect on the retirement probabilities of generalists and medical/surgical specialists, but it s effect on hospital-based specialists and psychiatrists was not significant . For generalists regression-adjusted retirement probabilities were roughly 13 percent greater in high-penetration markets (HMO penetration of 45 percent ) than in low-penetration markets (HMO penetration of 5 percent ). For medical/surgical specialist s regression-adjusted retirement probabilities were roughly 17 percent greater in high-penetration markets than in low-penetration markets. CONCLUSIONS: Our findings suggest that many older physicians have found it preferable to retire rather than adapt their practices to an environment with a high degree of managed care penetration . Because the number of physicians entering the older age categories will increase rapidly over the next 20 years, the growth of managed care and other influences on physician retirement will play an increasingly important role in determining the size of the physician workforce.

Aged↗
PubMedDate not supplied

Barriers to providing osteoporosis care in skilled nursing facilities: perceptions of medical directors and directors of nursing.

OBJECTIVES: The objectives of this study were to identify the barriers to osteoporosis clinical practice guideline use perceived by Medical Directors (MED DIR) and Directors of Nursing (DON) in skilled nursing facilities; and to describe differences in the perceptions of MED DIRs and DONs. DESIGN: The authors conducted a cross-sectional national survey. PARTICIPANTS: This study consisted of a random national sample of MED DIRs (n=1300) and DONs (n=1300) belonging to the American Medical Directors Association or the National Association of Directors of Nursing Administration in Long-term Care. MEASUREMENTS: A 24-item survey using a five-point Likert scale was developed. The survey measured agreement to questions in four domains (provider factors, guideline characteristics, patient factors, environmental factors) and 10 content areas (problem acknowledgment, patient/family concern, patient/family compliance, testing availability, safety, reimbursement, regulatory oversight, staff knowledge/time/ability, belief in guidelines, and malpractice liability). Response distributions to each item were plotted and differences between MED DIRs and DONs were tested. RESULTS: Survey response rates were 40% for MED DIRs and 48% for DONs. Respondents strongly agreed that fractures are a problem in their facilities and that osteoporosis guidelines are useful and cost-beneficial (mean responses > or = 4.0). A large proportion of respondents (at least 40% of the sample) identified multiple patient comorbidities, reimbursement issues, length of stay, and regulatory oversight as barriers to providing osteoporosis care. Respondents did not believe that patient and family acceptance, testing availability, staff time, staff self-efficacy, or concerns about bisphosphonate safety were barriers to osteoporosis care. DONs were more likely than MED DIRs to believe that patients and families are concerned about fractures, whereas MED DIRs were more likely to endorse length of stay, staffing issues, and regulatory oversight as influencing treatment decisions. Years of practice and facility size, but not formal geriatrics training, significantly influenced responses. CONCLUSION: Perceived barriers to implementing osteoporosis guidelines differ between facilities and between MED DIRs and DONs. Identification of these barriers could facilitate quality improvement initiatives and improve the quality of osteoporosis care.

Attitude of Health Personnel↗
PubMed1997

Effects of second office and hospital consulting practices of physicians on rural communities.

This research examined the prevalence of second offices and hospital consulting practices of physicians in Missouri, the characteristics of physicians participating in such practices, the change in availability of services through these practices, the characteristics of counties and hospitals involved, and the practice organization of participating physicians. The assessment of the factors was conducted within the conceptual framework of community and physician characteristics, practice form and organization, and health system resources. In 1993, 64 of the 93 nonmetropolitan counties in Missouri gained, on average, 1.3 full-time equivalent physicians through second office and hospital consulting practices. Eighteen nonmetropolitan counties lost, on average, 0.4 full-time equivalent physicians through these practices; 11 nonmetropolitan counties were not affected. The majority of physicians engaged in these two types of practices are nonprimary care specialists. Consequently, in addition to the net contribution to total physician service availability, many nonmetropolitan counties gained access locally to a wider variety of specialty services. This change in availability of physician services, not generally incorporated in decisions, needs to be considered when policy efforts are undertaken to change the spatial and specialty distribution of physicians.

Career Choice↗
PubMedDate not supplied

Improving blood transfusion practice: role of a computerized hospital information system.

The recent focus on medical risk and financial cost has prompted a need for better guidelines for prescribing the transfusion of blood components. In 1987, to respond to the issues of quality transfusion practice and accurate evaluation, LDS Hospital (Salt Lake City, UT) began using a computerized, knowledge-based blood-ordering system. Each transfusion request was reviewed and flagged by the computer when it did not meet the criteria established by the medical staff. The study reviewed the use of red cells, platelets, and fresh-frozen plasma in 13,082 transfusion orders for 5847 consecutive patients from July 1, 1988, through June 30, 1989. The evaluation assessed, first, the adherence of physicians to computerized criteria and, second, their adherence to the quality of transfusion practice. A high percentage of the blood units ordered met the established criteria: 91.2 percent for the red cell transfusions, 72.9 percent for platelets, and 81.7 percent for fresh-frozen plasma. From the July 1, 1987, implementation date through June 1989, the mean hematocrit of persons being transfused dropped from 28.6 to 27.7 percent (0.29 = 0.28) (p less than 0.005) and the number of orders requiring review by the quality assurance department dropped from 100 to 14 percent; moreover, there was a true-exception rate of only 0.37 percent. The use of the computer system effected the implementation of the following measures: 1) identification of the indications and establishment of clear clinical and biologic parameters for every transfusion, and 2) measurement and improvement of institutional transfusion practice. These results demonstrated the efficacy of a computerized hospital information system in implementing continuous quality improvement for transfusion practice.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Transfusion↗
PubMed1992

Variations in the use of cesarean delivery for dystocia: lessons about the source of care.

Aggregate data show variations in the use of cesarean delivery according to the source of care, which suggests that rising cesarean rates are at least in part attributable to nonmedical factors. In the research presented here, the likelihood of cesarean delivery is examined for low-risk, primiparous women with physicians who practice in a single hospital but are from three practice organizations--a health maintenance organization (HMO), private practice, and a hospital clinic--while controlling for a wide spectrum of clinical factors. Maternal age was found to be a dominant factor in determining the decision for a cesarean delivery, independent of clinical risk and physicians' practice organization. Only among women in their optimal childbearing years (25 to 29 years) was having an HMO physician associated with a lower likelihood of cesarean delivery. The authors conclude that lowering the primary cesarean rate in the 1990's may require more reeducation and clinical policy formulation, with particular attention being paid to maternal age, and less reorganization of services than the aggregate data suggests.

Adult↗
PubMedDate not supplied

How to design a hospitalist service. An academic health system case study.

Medical centers throughout the country are employing hospitalists--dedicated inpatient specialists--to care for patients during hospitalization in place of their primary care provider. There has been expansive growth of hospitalist programs as the number of practicing hospitalists has doubled in two years from approximately 1,500 to over 3,000. In July 1997, the department of medicine at University Hospitals of Cleveland, the primary teaching affiliate of Case Western Reserve University, created a hospitalist service. This paper will discuss the design of a hospitalist service at a major academic medical center, the factors that were considered during the design stage and financial feasibility.

Academic Medical Centers↗
PubMed1999

Hospitalists: do they represent a best practice for patients? Part I.

Hospitalists: Do they improve care? Hospitalists are physicians dedicated to the care of hospitalized patients. The use of hospitalists is growing rapidly nationwide, primarily in markets marked by competitive managed care environments. When hospitalists are used, length of stay and costs are cut about 20%. The "handoff" of the patient from primary physician to hospitalist upon admission is seen by many as a weak, and possibly fatal, characteristic of the hospitalist model. The key to making the hospitalist model work in today's health care system is to make the "handoff at the hospital" voluntary, thereby garnering vital primary physician support.

Benchmarking↗
PubMed2002

Collaborative practice in advanced practice nursing in acute care.

APN in the United States encompasses a variety of collaborative models of care. Collaborative relationships with other disciplines such as medicine, pharmacy, social service, and physical, respiratory, and occupational therapy are an important component of the APN role. The collaborative relationship of the APN and physician is a unique one for providing optimal patient and family care. As changes in healthcare in acute care settings continue to occur, additional collaborative models for APN and physician care will only continue to help in meeting the healthcare needs of patients.

Cooperative Behavior↗
PubMed2004

ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education--2003.

PURPOSE: Results of the 2003 ASHP national survey of pharmacy practice in hospital settings that pertain to monitoring and patient education are presented. METHODS: A stratified random sample of pharmacy directors at 1173 general and children's medical-surgical hospitals in the United States was surveyed by mail. SMG Marketing Group, Inc., supplied data on hospital characteristics; the survey sample was drawn from SMG's hospital database. RESULTS: The response rate was 47.1%. Virtually all hospitals (95.3%) had pharmacists regularly monitoring medication therapy in some capacity. Patient monitoring has improved since 2000; fewer respondents reported monitoring less than 25% of patients in the hospital, and most hospitals reported an increase in the amount of time pharmacists devoted to monitoring activities. Pharmacists were provided computer access to laboratory information in 78% of hospitals to facilitate this function. Detection and reporting of adverse drug events (ADEs) have substantially increased since 1999, with an increase of 42% in events reported internally. Strategies to improve ADE reporting were in place in 84% of hospitals, indicating that pharmacists are adopting the widely recommended philosophy of learning from errors. Errors were less widely reported externally, limiting the value of aggregated data for improving the medication-use process. Most hospitals (85.5%) had an interprofessional infrastructure in place to discuss and learn from voluntary reports of ADEs. Medication counseling continued to be relatively infrequent, with nearly three fourths of hospitals reporting fewer than 26% of inpatients received medication education. Pharmacist staffing in hospitals has risen significantly, from an average of 8.6 full-time equivalents (FTEs) in 2002 to 9.4 FTEs per hospital. Vacancy rates for pharmacists decreased from 7.3% in 2002 to 43%. It is now estimated that there are 1846 vacancies in hospital pharmacies. CONCLUSION: Notable improvements in hospital pharmacy practice have been made. The percentage of patients whose medication therapy is monitored by pharmacists has increased, and most hospitals reported that the amount of time pharmacists spent monitoring patients' medication therapy had increased. Internal and external reporting of ADEs has increased, and pharmacist vacancies have decreased from 2002. Staffing has also improved, suggesting an abatement of the critical shortage of pharmacists in the hospital setting.

Adverse Drug Reaction Reporting Systems↗