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PubMed2007

Dynamics of hospital-based plastic surgery.

BACKGROUND: Legislative regulations, decreasing reimbursements for office procedures, and malpractice premiums have transformed plastic surgery from an office-based specialty into a hospital-based one. Simultaneously, hospital economics has altered, wherein the "business model" has all but subsumed the old "medical care" model. Integration between plastic surgeons and the new hospital structure has been difficult for both. Limited understanding of the financial dynamics of hospital-based practices, unfamiliarity with the administrative processes, and resistance to accept and assimilate changes by both sides pose hurdles, in some situations even forcing plastic surgeons out of hospital settings. METHODS: Using well-defined financial terminology, changing national development in health care policy, and hospital-based administrative strategies as a backdrop, this study finds common ground for the plastic surgery specialty to coapt with the hospital. RESULTS: Key missing elements in the interaction between plastic surgeons and hospital administrations and ways of integrating these components are identified. To do so effectively, plastic surgeons must first understand the basic tenets of management that drive hospital administrators, participate at every level they can in guiding these processes, and assume leadership roles that will ultimately dictate the way they work and conduct their professional lives. CONCLUSIONS: It is critical that plastic surgeons engage in important processes that govern the economics of hospital-based health care delivery. This commitment will also ensure that all three groups (the patients, physicians, and hospital administrators) achieve a degree of satisfaction. The message to plastic surgeons is clear: be proactive and lead a campaign of change.

Financial Management, Hospital↗
PubMed2006

Variations in management of common inpatient pediatric illnesses: hospitalists and community pediatricians.

OBJECTIVE: The goal was to test the hypothesis that pediatric hospitalists use evidence-based therapies and tests more consistently in the care of inpatients and use therapies and tests of unproven benefit less often, compared with community pediatricians. METHODS: A national survey was administered to hospitalists and a random sample of community pediatricians. Hospitalists and community pediatricians reported their frequency of use of diagnostic tests and therapies, on 5-point Likert scales (ranging from never to almost always), for common inpatient pediatric illnesses. Responses were compared in univariate and multivariable logistic regression analyses controlling for gender, race, years out of residency, days spent attending per year, hospital practice type, and completion of fellowship/postgraduate training. RESULTS: Two hundred thirteen pediatric hospitalists and 352 community pediatricians responded. In multivariable regression analyses, hospitalists were significantly more likely to report often or almost always using the following evidence-based therapies for asthma: albuterol and ipratropium in the first 24 hours of hospitalization. After the first urinary tract infection, hospitalists were more likely to report obtaining the recommended renal ultrasound and voiding cystourethrogram. Hospitalists were significantly more likely than community pediatricians to report rarely or never using the following therapies of unproven benefit: levalbuterol, inhaled steroid therapy, and oral steroid therapy for bronchiolitis; stool culture and rotavirus testing for gastroenteritis; and ipratropium after 24 hours of hospitalization for asthma. CONCLUSION: Overall, in comparison with community pediatricians, hospitalists reported greater adherence to evidence-based therapies and tests in the care of hospitalized patients and less use of therapies and tests of unproven benefit.

Administration, Inhalation↗
PubMed2003

How mental health providers spend their time: a survey of 10 Veterans Health Administration mental health services.

BACKGROUND: Allocation of provider time across clinical, administrative, educational, and research activities may influence job satisfaction, productivity, and quality of care, yet we know little about what determines time allocation. AIMS: To investigate factors associated with time allocation, we surveyed all mental health providers in one Veterans Health Administration (VHA) network. We hypothesized that both facility characteristics (academic affiliation, type of organization of services, serving as a hub for treatment of severely mentally ill, facility size) and individual provider characteristics (discipline, length of time in job, having an academic appointment) would influence time allocation. METHODS: Eligible providers were psychiatrists, psychologists, social workers, physician assistants, registered or licensed practical nurses or other providers (psychology technicians, addiction therapists, nursing assistants, rehabilitation, recreational, occupational therapists) who were providing care in mental health services. A brief self-report survey was collected from all eligible providers at ten VHA facilities in late 1998 (N = 997). Data regarding facility characteristics were obtained by site visits and interviews with managers. Multilevel modeling was used to examine factors associated with three dependent variables: (i) total time allocation by activity (clinical, administrative, educational, research); (ii) clinical time allocation by treatment setting (inpatient vs. outpatient); and (iii) clinical time allocation by type of care (mental vs. physical). Licensed Practical Nurses (LPNs) were used as the reference group for all analyses because LPNs were expected to spend the majority of their time on clinical activities. RESULTS: Overall, providers spent most of their time on clinical activities (77%), followed by administrative (11%), and educational (10%). Surprisingly, research activities accounted for only 2% of their time. Multilevel analysis indicated none of the facility-level variables were significant in explaining facility variance in time allocation, but individual characteristics were associated with time allocation. The model for predicting time allocation by inpatient or outpatient settings explained 16-18% of the variance in the dependent variable. In all models, provider discipline and length of time in job played an important role. Having an academic appointment was important only in the model examining total time allocation by activity type. DISCUSSION: These simple models explained only a small amount of variance in the three dependent variables which were intended to capture issues related to time allocation; and the low number of facilities limited our power to examine effects of facility-level factors. Our models performed better in predicting allocation of clinical time to treatment setting and type of treatment than in predicting overall time allocation. Discipline and length of time in job were significant across all models. In contrast, having an academic appointment was associated with allocating significantly less time to clinical activities and more time to administrative activities but not to any significant difference in time spent in either research or education. IMPLICATIONS: While a gold standard of optimal time allocation does not exist, it is striking that research, a stated mission of the VHA, accounted for so little of providers' time. The lack of involvement of clinicians in research has implications for recruitment and retention of high-quality mental health providers in this network and for the education of future providers. Without involvement of clinicians, research conducted in the network by nonclinicians may be less relevant to "real-world" clinical issues. Reductions of funds available to mental health, coupled with increased clinical demands, may have prompted this pattern of time allocation, and these findings attest to the challenges faced by large institutions that are charged with balancing many often seemingly competing missions.

Health Services Research↗
PubMed1999

Genitourinary physicians and vulval clinics: a UK survey.

Our objectives are to examine the extent to which genitourinary physicians participate in vulval clinics in the UK; to determine the geographic distribution of such clinics and to study aspects of clinical practice and staffing of the vulval clinics identified in the survey. In February/March 1998 a questionnaire on vulval clinics was distributed via regional representatives of the British Co-operative Clinical Group to all the 174 consultants in charge of genitourinary medicine clinics in the UK. One hundred and sixty-four replies were received which identified a total of 61 vulval clinics in the UK. All former health regions had at least one vulval clinic or equivalent. Three former regions had 7 vulval clinics each. Forty-six vulval clinics had a dermatologist, 38 a genitourinary physician, and 30 had a gynaecologist. Only 7 vulval clinics claimed to have a counsellor or health adviser present. Ninety-four per cent took biopsies but only half this proportion met with a pathologist to discuss the histology. Eighty per cent had colposcopes and cameras available but rather fewer actually used them. Twenty-nine per cent had performed research in the past 5 years and 24% had either published or presented this. The majority of vulval clinics would accept direct referrals from all the agencies. This survey has demonstrated an increased number of genitourinary physicians participating in vulval clinics. Other studies have demonstrated the value of such clinics in improving diagnosis and management. It is to be hoped that further such clinics will be set up, particularly in parts of the country which are poorly served at present.

England↗
PubMed1988

[Psychotherapy institutions and their patients].

This article investigates a number of institutions and private practices involved in the Berlin psychotherapy study from the point of view of their patients and their offerings in the area of therapy. Certain similarities have been found to exist between the institutions in the sex and age structure of the patients as well as in terms of the high level of previous experience with psychotherapy and psychoanalysis and previous medical measures. None of the institutions or practices saw primarily socially privileged patients, as is sometimes maintained. To a considerable degree the people they see live in a destabilized situation or one that is not yet stabilized and enjoy little social certainty (ca. 50%). The rate of the indication for psychotherapy and its actual initiation varies considerably from one institution to another. It runs the spectrum from the municipal counseling services, whose little motivated patients are only open to psychotherapy at all at a rate of 50% (actual therapy 22%) to patients in private psychotherapeutic practices who have gone through a long motivational process and who begin therapy at a rate of 70%. Study of the relationship between the location of the institution and the area in which the patients live shows on the one hand a tendency toward regionalism insofar as institutions are preferred by the patients who live near by. On the other hand, these special institutions are also sought out by patients from more distant locations and from differently structured areas; these patients are represented to the same degree as patients from the immediate area. Although psychotherapeutic institutions are often situated in the "better" residential areas, their patients are by no means only from such privileged areas but from all regions, including those that are socially weak.

Adult↗
PubMed2005

Survey of clinical practice: pre- and postoperative physiotherapy for pelvic surgery.

BACKGROUND: The objective of this survey was to obtain information about current physiotherapy practice for patients undergoing pelvic surgery. The aims were to evaluate whether differences exist in service provision between women's health physiotherapists (WHPTs) and hospital physiotherapists (HPTs) and in the guidelines used by physiotherapists to direct their service delivery. METHODS. A questionnaire was posted to the members of the Victorian Continence and Women's Health Physiotherapy Group (n = 130) and physiotherapists working in metropolitan and rural hospitals (n = 90). The questionnaire comprised questions relating to the aspects of treatment, including how referrals are made, funding, interventions provided and how they are delivered, and use of outcome measures. Data were summarized using descriptive statistics and Chi-square analysis of differences between WHPTs and HPTs. RESULTS: The response rate was 75.9%. In 67% of cases, service delivery was initiated by surgeon request, and most commonly for gynecologic patients (85%). Individual consultations were used on 96% of occasions and 8% were group sessions. Content of physiotherapy treatment for in-patients varied, with WHPTs significantly more likely to prescribe pelvic floor muscle exercises (P = 0.003), bowel advice (P = 0.001), avoidance of risk activities (P = 0.002), and awareness of postoperative symptoms (P = 0.001). Conversely, HPTs were significantly more likely to perform respiratory checks (P = 0.002) and mobilization (P = 0.001). Eighty-seven percent of respondents regarded their service as suboptimal, citing the need for evidence to support the content and best timing of intervention. CONCLUSION: Differences exist in physiotherapy treatment for pelvic surgery patients. Further research is required to establish whether, and which, elements of physiotherapy intervention are effective.

Female↗
PubMed2005

Sensitivity of the National Eye Institute Refractive Error Quality of Life instrument to refractive surgery outcomes.

PURPOSE: To evaluate scores from the National Eye Institute Refractive Error Quality of Life instrument (NEI-RQL) relative to refractive surgery outcomes in myopic patients. SETTING: Large institutional ophthalmic practices. METHODS: Patients seeking refractive surgery (n = 59) self-administered the NEI-RQL before and 6 months after surgery; the comparison group of myopes and emmetropes (n = 72) not seeking refractive surgery also completed the NEI-RQL. Myopic patients seeking refractive surgery had bilateral, same-day laser in situ keratomileusis (LASIK) treatment. Regression analyses were conducted to compare survey scores in the LASIK treatment group before surgery with those in the myopic sample who were not seeking refractive surgery and to compare the survey scores in the post-LASIK treatment group (surgical emmetropes) to those in the naturally emmetropic group. Logistic regression was used to determine NEI-RQL subscales that were related to myopic patients seeking refractive surgery and myopic patients not seeking refractive surgery. RESULTS: Myopes seeking LASIK reported greater expectations for vision improvement (P < .0001), greater activity limitations (P < .0001), suboptimal correction (P = .04), worse appearance (P < .0001), and lower satisfaction (P < .0001) than myopes not seeking refractive surgery. Logistic regression showed that worse self-perceived appearance (odds ratio 20.71), more dissatisfaction with current correction (odds ratio 8.28), and higher expectations for "optimal" correction (odds ratio 6.41) were independently associated with myopes seeking LASIK, while better perceived "clarity of vision" (odds ratio = 0.20) was associated with myopes not seeking surgery. Overall, surgical emmetropes were similar to natural emmetropes in terms of refractive-error-specific quality of life (clarity of vision, near vision, far vision, diurnal fluctuations) and clinical measures of visual function, yet they reported significantly better appearance (P = .02) and greater satisfaction (P < .0001) than natural emmetropes. CONCLUSION: The NEI-RQL demonstrated vision-related quality-of-life differences when comparing patient samples associated with refractive surgery.

Adult↗
PubMed2003

What is the effect of reporting all emergency department radiographs?

OBJECTIVES: To evaluate the effect of formal radiological reporting of all emergency department (ED) radiographs on clinical practice and patient outcome, and to consider whether a selective reporting policy might prove safe and effective. METHODS: All radiographs taken in a single ED over a six month period were prospectively studied simultaneously in both the emergency and radiology departments to detect cases where a radiograph that was considered normal by ED staff was then reported as abnormal by the reporting radiologist. Whenever such a discrepancy occurred the patient's records were scrutinised to ascertain the source of the discrepancy, with a gold standard interpretation derived from senior clinical review and additional investigations where indicated. The clinical impact of the radiologist's formal report was then assessed. Accuracy of interpretation was considered in relation to the grade of ED staff and the radiographic examination obtained. RESULTS: During the study period, 19468 new patient attendances to the ED generated 11749 radiographic examinations. Discrepancies were detected in 175 patients (1.5% of all radiographic examinations). Of these, 136 (1.2%) were subsequently shown to have been incorrectly interpreted in the ED (ED false negatives), with 40 patients (0.3%) undergoing a change in management as a result. In the remaining 39 the ED interpretation was judged to be correct (radiology false positives), with 16 patients undergoing further investigations or visits to the ED to confirm this. CONCLUSIONS: The formal reporting of ED radiographs by the radiology department detects a number of clinically important abnormalities that have been overlooked. However, this formal reporting also generates a number of incorrect interpretations that may lead to further unnecessary investigations. Some groups of ED radiographs (such as those interpreted by an ED consultant and films of the fingers and toes) may not require formal radiological reporting. The adoption of a selective reporting policy may reduce the reporting workload of the radiology department without compromising patient care.

Consensus↗
PubMed2006

Aesthetic and functional efficacy of subcuticular running epidermal closures of the trunk and extremity: a rater-blinded randomized control trial.

OBJECTIVE: To ascertain whether subcuticular epidermal closures of elliptical excisions of the trunk and extremities result in better functional and cosmetic outcomes than simple running epidermal closures of the same sites. DESIGN: Randomized controlled trial, with allocation of epidermal closure of elliptical excisions to 4 arms, including 1 control arm (simple running polypropylene sutures removed after 14 days) and 3 experimental arms (subcuticular running polypropylene sutures removed after 14 days, subcuticular running polypropylene sutures left in place, and subcuticular running polyglactin 910 sutures left in place). All experimental interventions were preceded by deep dermal closure with simple interrupted polyglactin 910 sutures. Interventions were delivered by 3 surgeons, who underwent 2 training sessions to minimize intersurgeon technique variability. SETTING: Institutional referral practice providing ambulatory care in an urban environment. PATIENTS: A consecutive sample of 36 adult patients (ages 18-65 years), each referred for concurrent elliptical excision of at least 2 clinically atypical nevi of the trunk and/or extremity, were included in the study. MAIN OUTCOME MEASURES: Primary outcome measures obtained at 3 and 9 months included scar width in millimeters and blinded observer ordinal scale assessment of overall scar appearance. Secondary outcome measures included ratings on the standardized Vancouver Scar Scale and the Hollander Scar Scale; an additional nonstandard item was added to assess pruritus. RESULTS: No difference among groups was found in scar width at 3 or 9 months. Differences among groups were detected in overall scar appearance (3 months, P<.001; 9 months, P<.001), vascularity (3 months, P = .001; 9 months, P<.001), excessive distortion (3 months, P = .04; 9 months, P = .02), contour irregularity (3 months, P<.001), and edge inversion (3 months, P = .01). The best overall appearance was with a subcuticular running polyglactin 910 suture left in place, and the next best was with a subcuticular running polypropylene suture left in place; differences across groups persisted but decreased in intensity at 9 months. A secondary analysis that matched high-tension anatomic sites (back and lower leg), and high and moderate tension sites (also chest and shoulder) yielded the same main effects and mostly the same results in pairwise comparisons. CONCLUSION: While scar width does not appear to vary significantly based on choice of epidermal closure, bilayered closures of the trunk and extremity have better overall appearance and less associated erythema at 3 and 9 months after surgery with the use of a subcuticular running polyglactin 910 suture left in place.

Abdomen↗
PubMed1998

Clinical outcome of endoscopic surgery for frontal sinusitis.

OBJECTIVE: To determine the efficacy of endoscopic surgery for chronic frontal sinusitis. DESIGN: A prospective analysis of established measures of clinical outcome (Chronic Sinusitis Survey and Short Form 36) that was administered to patients before frontal sinus surgery and at intervals of 3 months, 6 months, and 1 year after surgery. INTERVENTIONS: For limited disease, the frontal recess was opened and the frontal ostium probed or enlarged. For more severe cases, a drill was used to resect the frontal sinus floor and interfrontal septum. SETTING: Private and institutional-based practices at an academic medical center. SUBJECTS: Eighty-seven patients who underwent endoscopic surgery for frontal sinusitis, including 24 patients with severe disease who underwent a frontal sinus drillout procedure. MAIN OUTCOME MEASURES: Scores on the Chronic Sinusitis Survey, Short Form 36, and surgical revision rate. RESULTS: Significant improvement in facial pain, nasal drainage, and congestion was observed 1 year after surgery (P<.01). Medication use was also significantly reduced during this period (P<.01). Quality-of-life measures showed greatest improvement in the domain of social functioning (P<.05). Three (12.5%) of 24 patients who underwent a frontal sinus drillout procedure did not respond to surgery secondary to restenosis of the frontal ostium. CONCLUSIONS: Although the long-term results of endoscopic surgery for frontal sinusitis are unknown, this approach appears to be effective for most patients and may provide a reasonable alternative to frontal sinus obliteration surgery in selected cases.

Adolescent↗
PubMed1978

Psychiatric manpower for state mental hospitals. A continuing dilemma.

A shortage of psychiatrists continues to exist in state mental hospitals (SMHs), and Public Law 94-484 is likely to aggravate this problem. A telephone survey was done of 50 state departments of mental health to collect data about (1) the number and kinds of SMHs in each state;(2) the percentage of psychiatrists in SMHs who are foreign medical graduates; and (3) strategies for attractiing psychiatrists to SMHs. States with SMH residency training programs employed significantly more psychiatrists and paid significantly lower salaries than did states without these programs. Nine states reported no or few problems obtaining psychiatric staff. These nine states employed more psychiatrists and had a smaller proportion of foreign medical graduates than the remaining 41; salaries were similar. Sets of strategies for obtaining psychiatrists were identified for all 50 states. The strategies of competitive salaries, university affillation, and incorporating the SMH into an interdependent network of quality mental health care delivery systems are examined in detail.

Foreign Medical Graduates↗
PubMed1999

Service quality in health care.

Although US health care is described as "the world's largest service industry," the quality of service--that is, the characteristics that shape the experience of care beyond technical competence--is rarely discussed in the medical literature. This article illustrates service quality principles by analyzing a routine encounter in health care from a service quality point of view. This illustration and a review of related literature from both inside and outside health care has led to the following 2 premises: First, if high-quality service had a greater presence in our practices and institutions, it would improve clinical outcomes and patient and physician satisfaction while reducing cost, and it would create competitive advantage for those who are expert in its application. Second, many other industries in the service sector have taken service quality to a high level, their techniques are readily transferable to health care, and physicians caring for patients can learn from them.

Delivery of Health Care↗
PubMed1976

French medical research: the risk of 'demedicalization'.

French medical research is at present financed almost entirely by INSERM (Institut National de la Santé et de la Recherceh Médicale). The INSERM budget (286 million francs in 1975) supports research in laboratoreis in university hospitals by doctors who have both clinical and teaching commitments and, especially, by more than a thousand 'statutory research workers' employed by INSERM. Research in INSERM laboratories now tends to be fundamental biological research rather than directed towards pathological problems. Among the reasons for this are (i) the mode of recruitment of staturtory research workers; (ii) the difficulties of clinical investigation, which are due mainly to the way the hospitals function and to lack of interest by the hospital administration in medical research; (iii) the small number of university doctors actively involved in research. Research on fundamental biological problems in INSERM laboratories is making excellent progress, due to the quality of the research workers, and it may pay in the long run. But medical research is now tending to become an 'ivory tower' for the victorious researchers, who sometimes scorn the clinicians. Medical research will, if no measures are taken, 'demedicalize.' Institutes of pure biological research could soon be isolated within the medical faculties and doctors may become even less scientific and investigative than they are today. This situation could be modified by: (i) re-evaluating the role of research in a university hospital career, making it impossible for a doctor to attain high levels of promotion unless he does some research (this could be done by asking doctors interested in such a career to work for several years in an INSERM laboratory after their training and before they take up clinical responsibilities); (ii) awarding clinicians, exceptionally, the status of research worker; (iii) increasing considerably the participation of the universities in financing medical research, a participation which at present is absurdly low and is every decreasing.

Academies and Institutes↗
PubMed2001

Safety and efficacy of suture-mediated closure after percutaneous coronary interventions.

Percutaneous coronary interventions (PCI) performed with concomitant use of heparin and platelet inhibitors are safe procedures with reported vascular complication rates of approximately 6.1%. EPILOG investigators demonstrated that utilizing a low-dose heparin regimen with abciximab, along with early sheath removal, vascular access-related bleeding was significantly lower than that reported in EPIC. Recently, a suture-mediated closure (SMC) device has been reported to be safe, appears effective, and may improve patient comfort by allowing early ambulation. We conducted a retrospective analysis (January 1999 to March 2000) of complication frequencies among PCI patients who underwent SMC and those who had manual compression (non-SMC). Furthermore, we compared the overall rates of complications to patients who underwent PCI prior to the introduction of SMC (1995-1998). When comparing the current cohort to the historical cohort, there was a significant decrease in the number of retroperitoneal bleeds (0.3% vs. 0.9%; P = 0.003), hematomas (5% vs. 9%; P < 0.001), pseudoaneurysms (1.2% vs. 2.7%; P < 0.001), and need for vascular surgery (0.9% vs. 2.8%; P < 0.001). There was no difference in the number of arterio-venous fistulas and a slight increase in transfusion needs (12% vs. 10%; P = 0.03). Within the current cohort, there was no difference in the vascular complications between SMC and non-SMC PCI patients, although there were lower rates of pseudoaneurysms (0.5% vs. 1.8%; P = 0.02) and transfusion requirements (72/880 vs. 132/874; P < 0.001). These results suggest that the complication rates for SMC are not different and may be lower when compared to non-SMC patients after PCI. At our institution, the practice of early sheath removal and less aggressive heparin dosing has led to a decrease in vascular complication rates and a 66% reduction in vascular surgeries on post-PCI patients. Because of the limitations of retrospective analyses, further studies will be necessary to confirm these findings.

Aged↗