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PubMed2001

Report of two preventive medicine job market surveys.

INTRODUCTION: The American Association of Public Health Physicians (AAPHP) conducted two surveys to explore the value of general preventive medicine/public health (GPM) training and board certification to physicians seeking GPM jobs. METHODS: The first survey reviewed advertisements in recent issues of four medical journals. The second surveyed physician registrants at the Prevention 99 meeting. RESULTS: The first survey screened about 18, 500 job advertisements. Of these, 1427 (7.7%) met the study's GPM screening criteria. Only 145 (10.6%) preferred an MPH, management, or related degree. Forty-one (2.9%) preferred a doctorate (MD/DO/PhD) and an MPH, management, or related degree. Only one (0. 07%) required or preferred GPM board certification. Results were consistent across market sectors (federal, state/local, academic, health care delivery) and across job roles (management, direct service, research, technical). The second survey gathered credential, job search, and employment data from 140 physician registrants at Prevention 99 (annual joint meeting of the American College of Preventive Medicine and the Association of Teachers of Preventive Medicine in March 1999). Seventy-eight (55.7%) reported that GPM training was of major importance in securing their current employment. Only 18.5% of physicians holding GPM jobs secured their current employment by responding to an advertisement. CONCLUSION: GPM board certification is of little or no value when competing for the vast majority of GPM-related jobs. RECOMMENDATION: The AAPHP recommends prompt coordinated action by national organizations representing GPM physicians to increase the number of job offerings preferring or requiring physicians with GPM board certification. A six-point action plan is proposed.

Adult↗
PubMedDate not supplied

Cost and demand analysis of excimer laser use: first World Wide Web Internet survey of the interest in refractive surgery.

PURPOSE: To determine the actual size of the refractive surgery market in the United States and to identify factors involved in the decision to have refractive surgery. SETTING: World Wide Web. METHODS: A survey was placed on the World Wide Web. Questions covered price sensitivity, preferred type of refractive procedure, and factors involved in the decision to have a refractive procedure. RESULTS: Average age of respondents was 34 years; refractions ranged from -0.50 diopter (D) to -12.00 D. The recommendation of ophthalmologist, friends, and relatives; the refractive surgeon's credentials; and office staff were critical factors in the decision-making. Sixty-six percent said they would have a refractive procedure if it were free. Only two said they would have photorefractive keratectomy (PRK) if it cost over $1500 per eye; none would have radial keratotomy (RK) if it were over $1500 per eye. Forty-eight percent rated their opinion of PRK as high to very high; 45% rated RK as high to very high. CONCLUSIONS: We conclude that the actual number of refractive procedures performed with the laser will be the same as before-between 100,000 and 250,000 annually. The survey suggests that PRK will share this potential market with RK, and the total number of potential patients converting to PRK may be considerably less than predicted unless the price falls to $500 per eye.

Adult↗
PubMed2003

A statistical analysis of board certification in clinical neuropsychology.

In this paper, we use tools from decision theory to evaluate the effectiveness of the current psychology board certification process used by the American Board of Clinical Neuropsychology (ABCN). These analyses indicate that ABCN's current process is likely to be failing to certify too many competently trained candidates, and identifying relatively few truly competent neuropsychologists. In fact, we estimate that ABCN is only certifying between 16 and 52% of competent clinical neuropsychologists. This is in contrast to the processes of the American Board of Medical Specialties (ABMS), after which ABCN has indicated that it models its examination. ABMS estimates that 89% of all practicing physicians are board-certified by one of their member boards. Based on our analyses, specific recommendations for change are offered for credentialing the profession of neuropsychology.

Certification↗
PubMed2002

Sedation and analgesia in pediatric patients for procedures outside the operating room.

Sedation and analgesia in pediatric patients for procedures outside the operating room are becoming more frequent as health care is being driven to be more cost effective and "efficient." Although anesthesiologists may not be directly involved in sedation or analgesia outside of the operating room, there is a high likelihood that they will be asked by their institutions to be integrally involved in creating and supervising sedation policy given that the American Society of Anesthesiologists and the Joint Commission on Accreditation of Healthcare Organizations consider sedation and analgesia as part of a continuum ranging from minimal sedation to moderate sedation and analgesia, deep sedation and analgesia, and, finally, general anesthesia. Further, anesthesiologists will be asked to define, teach, and credential nonanesthesiology practitioners who perform deep sedation because these practitioners are now required to be qualified to "rescue from general anesthesia."

Ambulatory Surgical Procedures↗
PubMed2000

Perioperative management issues in pediatric patients.

Recent developments in perioperative practice, emphasizing issues that are of greatest concern in pediatric patients, are reviewed in this article. Many areas bear further evaluation in the evolving field of perioperative medicine: Effective techniques of psychologic preparation for children and their parents in an era in which the family rarely encounters the hospital environment before the day of surgery Application of newer intraoperative anesthetics, such as new narcotics and muscle relaxants, to shorten PACU and pediatric ICU stay while maintaining safety and comfort Critical evaluation of current methods of pain management to optimize comfort, while minimizing cost of such management in an increasingly cost-conscious health care environment The recent advent of a process for credentialing pediatric anesthesia fellowship programs, which requires a research component, bodes well for the prospect of finding answers to some of these questions.

Anesthesia↗
PubMed1999

Clinical economics of head and neck malignancies.

With the continued increase in medical expenditures and the growing awareness that resources are not limitless, there is increasing pressure to curb health care costs and to establish priorities. As potential solutions are proposed and implemented, there is understandable concern that policy choices may adversely affect both the access to and the quality of care. Economic analyses are one tool used to optimize resource allocation decisions. The primary goal of these analyses is to maximize value and efficiency, not necessarily to decrease spending. The current focus on cost cutting is often associated with a more truncated, nonsocietal perspective (e.g., that of the payer or provider). To be most useful, these analyses must be methodologically rigorous. Standard guidelines, such as those established by Eisenberg, are helpful. As shown in the reports applicable to head and neck malignancies that have been discussed here, many articles published in the clinical literature must be interpreted cautiously, because fundamental methodological concerns (e.g., using costs rather than charges, discounting to a common base year) were frequently not addressed. Economic investigations are one aspect of the broader fields of outcomes and health services research. It is easy to underestimate how greatly economic studies depend on the availability of high quality noneconomic data. In that context, current initiatives in evidence-based medicine (EBM), using the best available evidence (considering for example, the type of trial, the quality of the research, and the credentials of the researcher) to help clinicians practice in situations where doubt may exist in the diagnosis, treatment, or prognosis of patients, will likely grow in importance. Evidence-based clinical practice guidelines and systematic literature reviews are manifestations of this trend. Historically, disease control measures and survival have been the primary and points in clinical cancer studies. Economic analyses and studies evaluating other end points (e.g., function, quality of life) will likely play a larger role in the future in evaluating the diagnosis, treatment, and follow-up of head, neck and other malignancies.

Cost of Illness↗
PubMed1997

Forensic child and adolescent psychiatry: a review of the past 10 years.

OBJECTIVE: To review important developments in child and adolescent forensic psychiatry from 1987 through 1996. METHOD: Major changes in the law and developments in research and practice were surveyed in the areas of the legal regulation of psychiatry, family law (divorce and child abuse), consultation to juvenile and criminal courts, civil litigation, and the development of the subspecialty. RESULTS: There has been a large increase in research based on quantifiable descriptive data of forensic populations, although studies using comparison or control groups remain relatively rare. While managed care has heavily influenced treatment practice, legal liability remains largely with the clinician. Issues regarding techniques of evaluation for sexual abuse have been scrutinized by the courts and by researchers. Legislative responses to rising rates of juvenile violence have been in the direction of treating violent adolescent offenders as criminally responsible adults. There has been a major move toward setting standards for forensic evaluations, training, and credentials. CONCLUSIONS: Child and adolescent forensic psychiatry remains an area encompassing diverse clinical issues. It remains unclear the extent to which it will develop into a formal subspecialty.

Adolescent↗
PubMed2003

Inter-society standards for the performance of brachytherapy: a joint report from ABS, ACMP and ACRO.

PURPOSE: The proliferation of various brachytherapy modalities for different anatomical sites necessitates the creation of standards for brachytherapy. METHODS: A panel consisting of members of The American Brachytherapy Society (ABS), The American College of Medical Physics (ACMP) and The American College of Radiation Oncology (ACRO) developed standards for the clinical practice and quality assurance (QA) of brachytherapy. These were based upon their clinical experience and a review of the literature. RESULTS: Recommended practice standards are presented for clinical processes, treatment planning, equipment, facilities, QA, dose evaluation, dose specification, dose reporting, the training, and credentialing of personnel, and radiation control/safety/protection. Safe and efficacious performance of brachytherapy requires a highly structured QA program and carefully designed treatment delivery processes, as well as a coordinated effort amongst the team members. CONCLUSION: Standards for clinical brachytherapy are proposed. Practitioners are encouraged to use these standards to design and implement a consistent and efficacious brachytherapy program.

Brachytherapy↗
PubMed2003

Clinical experience of marketed Levetiracetam in an epilepsy clinic-a one year follow up study.

Levetiracetam is a new anti-convulsant with impressive pivotal trial credentials. We examined its effectiveness in refractory clinic patients with epilepsy with a year's follow up. Six months after initiation 32% of the patients were seizure free, and 26% at one year. By the end of the 12 months follow up 77% of patients were still taking the drug, having gained benefit from it: 23% had dropped out due to intolerable side effects, seizure increase or lack of efficacy. There is evidence that the drug is broad spectrum and as effective in primary generalised epilepsy as in partial onset epilepsy. Our audit of its use and effectiveness has led us to position it as our first choice add-on drug if the initial monotherapy drug fails.

Anticonvulsants↗
PubMedDate not supplied

Economic outcomes analysis from an ambulatory surgical center.

In the competitive healthcare marketplace, foot surgeons are being placed under pressure to demonstrate the economic value of surgical care. The management methodology of "fiscal outcomes review" is one tool being used to evaluate such care. Initially developed for internal corporate management as an executive decision support system, the process is being used an an external cost control technique to "economically credential" providers of surgical care. Consequently, the economic outcomes analysis of a single surgical procedure represents a first attempt to gather, allocate, analyze, and interpret meaningful charge information relative to the podiatric Ambulatory Surgery Center setting. When compared with the traditional outpatient hospital setting, charge reductions are documented without compromising quality. The long-held belief that Ambulatory Surgery Center surgery is more efficient than traditional outpatient surgery, can then be corroborated.

Ambulatory Surgical Procedures↗
PubMed2001

Federal efforts to improve quality of care: the Quality Interagency Coordination Task Force (QuIC).

FORMATION OF THE QUIC: The Quality Interagency Coordination Task Force (QuIC) was established in 1998 to enable the participating federal agencies to coordinate their activities to study, measure, and improve the quality of care delivered by federal health programs; provide people with information to help them in making more informed choices about their care; and develop the research base and infrastructure needed to improve the health care system, including knowledgeable and empowered workers, well-designed systems of care, and useful information systems. STUDY, MEASURE, AND IMPROVE CARE: The QuIC's initial efforts to improve the care delivered in federal health care programs have focused on diabetes, depression, and the effect of working conditions on quality of care. More recently, patient safety efforts are under way to establish a coordinating center that will enable those who are testing methods of reducing errors to share information across their projects and with experts in error reduction. DEVELOP A RESEARCH BASE AND INFRASTRUCTURE: The QuIC has coordinated efforts in credentialing, information on measures of quality, a taxonomy of quality improvement methods, and errors data collection. PROVIDE INFORMATION TO AMERICANS ABOUT HEALTH CARE QUALITY: The QuIC agencies are developing products that will enhance their ability to communicate with the American people about their health care choices: improved gateways for consumer information available from federal agencies, a glossary of commonly used terms, and guidance for producing report cards on quality of care. MOVING THE QUALITY IMPROVEMENT AGENDA FORWARD: Federal efforts to improve quality of care are moving forward in a more integrated fashion on a wide number of fronts.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2001

The forgotten component of the quality triad: can we still learn something from "structure"?

BACKGROUND: Quality assessment was founded on structural measures, such as accreditation status of facilities, credentialing of providers, and type of provider. Recent efforts in measures development have focused on processes and outcomes because research has suggested that structural measures are not strong markers of the quality of care at the health plan or provider levels. Nevertheless, the literature on the quality of health care contains a number of examples illustrating the potential application of structural measures to the assessment of quality. The continued development of measures of structure-which would at least measure aspects of the physical environment, working conditions, organizational culture, and provider satisfaction--may be helpful because generalizing from studies of process and outcome requires specification of the conditions under which these linkages are found. A ROAD MAP FOR MEASURES DEVELOPMENT: The Leapfrog Group of large purchasers has promoted the application of three patient safety "leaps" that are, in essence, structural measures: the use of computerized physician order entry, the selective referral of patients to high-volume providers for certain procedures, and the availability of board-certified critical care specialists in intensive care units. Structural measures, like process and outcomes measures, face the same challenges of standardization, reliability, validity, and portability. Field testing of potential measures will be required to examine the feasibility and added value of these measures in real-world settings. CONCLUSION: Research to date suggests that a new cadre of structural measures of health care quality, which have largely been overlooked in the recent measures development boom, have the potential to fill in important gaps in our ability to assess quality.

Efficiency, Organizational↗
PubMed1993

Empowering health care improvement: an operational model.

BACKGROUND: The shift from compliance to continuous improvement requires a bridge--empowerment--that enables the creation of an environment in which employees can contribute the full range of their expertise in service to the organization. Leaders are responsible for creating this empowering environment. MODEL: An operational model that describes the nine aspects of empowerment (for example, mission and values, access to information, avenues of influence) can serve as a template for leaders to use to promote an atmosphere of empowerment in their organizations. METHOD: The authors adapted this model as a survey instrument to uncover some hospital success stories that demonstrate several aspects of empowerment in action. The survey was administered at two hospitals. CASE STUDY 1: At Beth Israel Hospital (Boston, Mass), Nutrition Services rated the "mission and vision" aspect of empowerment in their department at an average of 3.5 out of a possible 4.0. The department attributes this high rating to their focus on specific goals that reinforce the larger mission and vision of the hospital as a whole. These goals form the basis for annual employee evaluations. For example, a 1992 patient-focused goal was to provide nutrition counseling and education. The department approached this goal by developing a daily format ("Eat Smart") for the daily hospital cafeteria menu that provided nutritional information. The rationale was to educate employees, who could then bring back information to their patients. Alignment of the department's efforts with the larger mission of the hospital enabled Nutrition Services to extend its influence beyond departmental and professional boundaries. Implementation of other plans at the hospital demonstrate a sustained process of vision development on the part of the executive leadership. CASE STUDY 2: At Robert Wood Johnson University Hospital (New Brunswick, NJ), Support Services gave the "environment of trust and respect" aspect an average rating of 3.7. The key to this success story lies in the upgraded role of the housekeepers as "hosts." The "Pro-Act" restructuring model for patient care delivery creates and upgrades positions to relieve nurses of their task loads. The three nursing services that participated in the survey gave their highest rating to the "access to the education and training" aspect of empowerment. The high quality of professional excellence is supported by tuition reimbursement, incentives for credentials, the extern program and scholarships provided to attract outstanding nursing students to their staff and encouragement of nursing staff at all levels for publication, presentations, and poster sessions. CONCLUSION: These case studies demonstrate how leaders created an environment in which collective learning has become a way of doing business. Given the multifaceted nature of the empowerment model, some may wonder where to begin to focus leadership efforts. It is important to emphasize that the constellation of empowerment aspects constitutes an integral system; the full potential for empowerment arises from synergy among all nine aspects.

Attitude of Health Personnel↗
PubMed1999

Using a quality scorecard to measure and improve medical groups' performance.

BACKGROUND: Blue Cross of California (BCC) uses an annual Quality Scorecard to measure performance of participating medical groups (PMGs) and independent practice associations (IPAs). The scorecard provides information to the PMGs/IPAs on their performance in several domains relative to the average network score. BCC pays annual bonuses to PMGs/IPAs with superior quality performance. A structured intervention was designed to improve the performance of PMGs/IPAs that performed poorly on the scorecard. METHODS: A cohort study was conducted in a large health maintenance organization in California in 1997. All PMGs/IPAs received a detailed summary of the components of the annual quality scorecard. Scorecard components include an annual audit of quality, utilization management, credentialing, and members' rights and responsibilities, grievance rates, member transfer for quality reasons, a satisfaction survey, and a preventive health review. Twenty-two of 124 PMGs/IPAs with more than 1,000 BCC members during 1996 that had scored lower than 1 standard deviation below the mean were targeted. These 22 outlier PMGs/IPAs received additional information indicating that their performance was below average. A BCC quality team subsequently visited the outlier PMGs/IPAs to provide supplementary information on the deficient areas and provide assistance in making improvements. RESULTS: The outlier groups showed significant improvements in the annual audit of quality score, member satisfaction with access, member satisfaction with last visit, overall member satisfaction with PMGs/IPAs, mammography screening, and the total score. CONCLUSIONS: A structured quality improvement intervention in poorly performing PMGs/IPAs was followed by improvements in specific performance measures.

Benchmarking↗
PubMed2001

National practice patterns of sentinel lymph node dissection for breast carcinoma.

BACKGROUND: The sentinel node is the first regional lymph node to receive tumor cells that metastasize through the lymphatic channel from a primary tumor. The tumor status of the sentinel node should reflect the tumor status of the entire regional node basin. Sentinel lymph node dissection (SLND) has recently been investigated for use in patients with early breast carcinoma to avoid the sequelae of complete axillary lymph node dissection (ALND). Published studies of SLND in breast cancer patients identify marked variations in technique, and there are few guidelines for credentialing surgeons to perform SLND. STUDY DESIGN: The purpose of this study was to assess the current practice of SLND for breast cancer in the United States. A 27-item questionnaire was mailed to 1,000 randomly selected Fellows of the American College of Surgeons. Responses were anonymous. Statistical analysis was performed using SAS software (SAS Institute, Cary, NC). RESULTS: Response rate was 41% (n = 410), and 77% of those who responded performed SLND for breast cancer. The majority (60%) of surgeons responding routinely ordered preoperative lymphoscintigraphy. Of those who did lymphoscintigraphy, 28% removed internal mammary lymph nodes when lymphoscintigraphy showed drainage to these nodes. Ninety percent of surgeons used both blue dye and radiocolloid. Eighty percent of centers responding performed routine immunohistochemistry on sentinel lymph nodes, and 15% performed reverse transcription polymerase chain reaction. Ninety-six percent of surgeons performed SLND for primary tumors 5 cm or smaller, and 95% performed SLND for an excisional cavity 6 cm and smaller. Twenty-eight percent performed SLND for high-grade ductal carcinoma in situ, and 28% of respondents performed 10 or fewer SLND procedures with subsequent ALND before performing SLND alone. Surgeons learned SLND through courses (35%), oncology fellowships (26%), observation of other surgeons (31%), or were self-taught (26%). CONCLUSIONS: The majority of surgeons in the United States use similar technique for SLND breast cancer. But, there was marked variation in the number of SLND cases validated by an ALND before performing SLND only.

Academic Medical Centers↗
PubMed1999

Perceived value of the American Board of Surgery certificate: a survey of 2,000 Fellows of the American College of Surgeons.

BACKGROUND: This study was undertaken to identify perceptions of surgeons of the value of the American Board of Surgery (ABS) certificate. STUDY DESIGN: Two-thousand Fellows of the American College of Surgeons received a 30-item survey designed to identify their demographics and their assessments of the functional and financial value of the certificate. Functional value was assessed using a 5-point scale in the areas of professional recognition, personal satisfaction, court proceedings, job security, mobility, and advancement, whether the certificate was necessary to obtain an academic or a clinical position, and whether it served as an indicator of depth or breadth of surgical knowledge or of clinical competence. Perceived professional lifetime financial value of the certificate was also assessed. RESULTS: Return response rate was 37.2%. The ABS certificate was perceived to be most valuable in obtaining an academic or a clinical position and playing a significant role in court proceedings. It was perceived as least valuable in indicating breadth of knowledge and clinical competence. Sixty-seven percent responded that certified surgeons should earn more, and 49% estimated the certificate's lifetime financial value as more than $500,000. Sixty-two percent of surgeons approved of continuing the recertification process every 10 years. CONCLUSIONS: The ABS certificate is perceived as an objective credentialing instrument that affords diplomates power, status, an opportunity to obtain an academic or clinical position, job mobility, protection in court proceedings, and greater income. Although it is perceived as an instrument that could aid a career, it is not viewed as an indicator of a person's clinical competence.

Attitude of Health Personnel↗
PubMed1995

100 laparoscopic hysterectomies in private practice and visiting professorship programs.

STUDY OBJECTIVE: To evaluate 100 laparoscopic hysterectomies and their variations in private practice and visiting professorship programs. DESIGN: A prospective observational study. SETTING: Gynecology departments of 17 teaching, community, and proprietary hospitals in the northeastern United States. PATIENTS: One hundred women who successfully underwent laparoscopic hysterectomy, 91 of whom were followed for 6 months. INTERVENTIONS: From July 1990 to August 1994, 108 women (mean age 41.6 yrs, range 38-68 yrs) for whom a vaginal hysterectomy was relatively contraindicated underwent a hysterectomy attempted by the laparoscopic route. The most common indications for hysterectomy were pelvic pain, chronic menorrhagia, and uterine leiomyomas. The women were classified according to hysterectomy, with groups comparable in age, weight, uterine size and weight, concomitant surgery performed, uterine and coexisting pathology, and history of pelvic surgery. Of the 108 women, 35 had laparoscopic hysterectomies (LH), 56 had laparoscopic-assisted vaginal hysterectomies (LAVH), and 9 had subtotal laparoscopic hysterectomies (SLH). Eight procedures were converted to laparotomy, two attempted LHs and six attempted LAVHs. In 22 cases, bipolar coagulation of vascular pedicles was done exclusively, in 58 the Endo GIA 30 stapler was used exclusively, and in 20 a combination of both modalities was used. Bilateral ureteral catheters were inserted 49 times. MEASUREMENTS AND MAIN RESULTS: There were eight complications (8.0%): two blood transfusions, two cases of transient, asymptomatic pyrexia, two abdominal wall hematomas, one Richter hernia, and one urinary tract infection. The hernia repair was the only delayed laparotomy. The mean (+/-SEM) surgical time was 123 +/- 8 minutes (range 45-235 min), and the mean hospital stay was 1.48 days +/- 0.4 (range 1-5 days). Ninety-five of the 100 women who successfully underwent a laparoscopic procedure returned to work within 2 weeks (range 4-14 days, range 15-53 days for the remaining 5). CONCLUSION: Hysterectomy performed or aided by the laparoscope, whether LH, LAVH, or SLH, is effective and safe as long as at least one member of the surgical team is an experienced and appropriately trained laparoscopic surgeon. Further studies are necessary to determine if the credentialing process for advanced laparoscopic surgery would be facilitated by a visiting professorship program.

Adult↗
PubMed1994

Introduction of laparoscopically assisted vaginal hysterectomy in a private teaching community hospital.

STUDY OBJECTIVE: To compare laparoscopically assisted vaginal hysterectomy (LAVH) with traditional total abdominal hysterectomy (TAH) when the laparoscopic approach is introduced into a private hospital. DESIGN: During 1 year, 49 LAVHs were performed and compared with 51 consecutive TAHs using retrospective chart review and statistical analysis. SETTING: A private, university-affiliated, teaching hospital. PATIENTS: All patients undergoing LAVH, and the first 51 TAHs performed during the study year. MEASUREMENTS AND MAIN RESULTS: No major complications occurred in either group. Significant differences were observed in uterine weight (161 +/- 92 g vs 331 +/- 354 g), operating time (164 +/- 48 min vs 108 +/- 28 min), and hospital stay (2.93 +/- 1.21 days vs 4.00 +/- 1.54 days) for LAVH and TAH, respectively. Hospital charges for LAVH average $4074 more than for TAH, primarily due to the use of disposable laparoscopic equipment. CONCLUSIONS: Laparoscopically assisted vaginal hysterectomy may be performed safely in a private community hospital with appropriate surgeon credentialing and training. Modifying techniques to minimize the use of disposable equipment would make the procedure more cost effective.

Adult↗