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PubMed1997

[Effectiveness and economics of private practice established surgeons, exemplified by ambulatory laparoscopic cholecystectomy in 1994 and 1996].

Ambulatory laparoscopic cholecystectomy is a safe procedure providing high patient satisfaction if performed by an experienced surgeon. These are the results of a prospective documentation of 150 outpatients to undergo laparoscopic cholecystectomy between 1994 and 1996. Patients returned to work early (mean 13.2 days off). No patient had to be admitted to hospital following ambulatory operation. All patients declared that they would have the operation performed in the same way a second time if necessary at all. Looking at the money earned for the ambulatory operation compared to the costs, there is a deficit of nearly DM 800 with each performance. Despite the good results and the great satisfaction on the part of the patients, outpatient laparoscopic cholecystectomy will not be widely performed until and unless the surgeons costs are at least covered.

Absenteeism↗
PubMed1959

Marriage problems; dealing with them in private practice.

Marriages and divorces in Los Angeles County almost equal each other. Marriage per se is not the cause of neurosis. When two neurotic persons marry, the resulting neurotic interaction too often ends in conflict, broken homes and a new generation of neurotic children. Psychotherapy must be related to the diagnosis of family psychopathology, should include all the involved members and should be directed toward the realistic goal of integrating them into family living. Of 100 cases taken from the author's experience, 64 involved married couples and the majority of these had serious interspouse conflicts. In 37 cases both spouses were treated and substantial psychotherapy was given to one or both of the partners. It included one or more modalities varying from electroshock therapy, tranquilizers, and such psychotherapy as supportive, dynamic interpretive, individual, spouses together, group and hypnotherapy. Thirteen achieved clinical recovery, nine improved, twelve were still in therapy. In three cases therapy failed.

Adult↗
PubMed1982

Lupus nephritis. Experience with 230 patients in a private practice from 1950 to 1980.

Nephritis developed in 230 of 609 private patients with systemic lupus erythematosus (SLE) (38 percent) followed up from 1950 to 1980. Eighty-seven percent of patients with nephritis were female; 71 percent were Caucasian. They were observed a mean of 10 years. Five- and 10-year survival rates were 80 percent and 65 percent, with improvement to 86 percent and 76 percent in the last decade. Normalization of urinary sediment and protein levels, blood pressure and serum albumin levels correlated with improved survival and tended to occur during the first year. Life-threatening complications of SLE were more common after the onset of nephritis but decreased as renal function worsened. Infection was the most frequent cause of death in the last decade. Forty-four patients received nitrogen mustard; 55 percent of the courses were followed by significant improvement in renal function and reduced steroid dosage. Control of the disease was associated with improved long-term survival of patients with SLE.

Adolescent↗
PubMed1990

Pregnancy rates with fresh versus computer-controlled cryopreserved semen for artificial insemination by donor in a private practice setting.

From late 1970 through December 1987, 580 women began 733 treatment programs (a total of 3405 insemination cycles) with fresh semen for artificial insemination by donor. The unadjusted pregnancy rate was 48.5% and the cumulative pregnancy rate after seven cycles by life-table analysis was 59.6% with a monthly fecundability of 11.9%. From 1988 to the present, 113 women have begun 115 treatment programs (a total of 371 insemination cycles) with cryopreserved semen for artificial insemination by donor. The unadjusted pregnancy rate to date is 18.3% and the cumulative pregnancy rate after seven cycles by life-table analysis is 48.6% with a monthly fecundability of 5.9%. This report shows that using cryopreserved semen for artificial insemination by donor will take somewhat longer to produce a pregnancy but the ultimate pregnancy rate will be similar to that with fresh semen for artificial insemination by donor.

Adult↗
PubMed1975

Preventive dentistry in private practice: a survey in Kentucky.

General practitioners in Kentucky were surveyed to establish a profile of preventive practice in the state and to identify factors influencing the profile. Both questionnaire and interview methods were used. A Kentuckian has a 55% chance of seeing a dentist who advises all his patients about prevention, and an 87% chance of seeing one who adivses some of his patients. Persons between the ages of 6 and 24 are most likely to receive preventive services. The dentist is selective about who receives a preventive-oriented examination, and he is more likely to perform the services than auxillaries. The profile shows the need for a greatly increased emphasis on preventive dentistry in undergraduate and continuing education courses and for the increased use of auxiliary personnel in the delivery of preventive services.

Adolescent↗
PubMedDate not supplied

Experience with the use of apligraf to heal complicated surgical and nonsurgical wounds in a private practice setting.

Apligraf is supplied as a ready-to-use living fibroblast and keratinocyte bilayer in culture. This therapy has been shown to facilitate healing of venous ulcers and diabetic foot ulcers. Several case reports suggest that Apligraf may also be effective in healing acute excisional wounds and complicated surgical defects. Apligraf can, in appropriate settings, be used as an alternative to autografts, avoiding the morbidity of donor site wounds. The present case review summarizes outcomes in 16 patients with 18 complicated surgical and nonsurgical wounds treated with Apligraf, which was meshed or fenestrated as needed to obtain better wound coverage and to allow drainage. Of 16 patients, 15 (94%) experienced complete healing (16 of 18 wounds; 89%). Both surgical and nonsurgical wounds responded well, with healing times ranging from 21 to 550 days. Patients generally stated that they were satisfied with their degree of healing and with the opportunity to avoid the surgical procedures associated with autograft donor sites.

Adult↗
PubMed1992

Carotid arterial surgery using local anesthesia: a private practice retrospective study.

Carotid endarterectomy has recently become one of the more controversial operations. The tremendous increase in the number of endarterectomies performed, coupled with the apparent increase in morbidity and mortality associated with this operation in some studies, have brought into question the indications and results of the procedure. The potential for complications from the procedure itself, as well as increased morbidity and mortality from surgery on the elderly, make carotid endarterectomy a dangerous operation that must be done carefully and thoughtfully. The authors have performed carotid endarterectomies exclusively under local anesthesia to more closely evaluate the neurologic status of the patient. They believe that the operation performed in this manner obviates the use of a shunt and its inherent complications in greater than 80 per cent of the patients. This, coupled with the fact that many of the patients also have severe cardiac disease and the use of local anesthesia causes less hemodynamic changes and stress, should make carotid endarterectomy under local anesthesia the preferred approach.

Age Factors↗
PubMed2005

[Sponsoring of physicians in private practice].

The financing of advanced medical training for physicians by the pharmaceutical industry has been the subject of legal discussions for more than two decades. Recent legal changes have renewed the importance of industry sponsoring. At the 106th national convention of the German physicians, the model ordinance for the German medical profession ("Musterberufsordnung für die deutschen Arztinnen und Arzte-MBO-A") has been reformed, and for the first time individual physicians are now permitted, under certain circumstances, to receive financial support from sponsors to participate in medical-training events. A recent legal reform to modernize the healthcare system ("GKV-Modernisierungsgesetz"--GMG) obliges physicians to observe the law that regulates advertising of medicinal products ("Heilmittelwerbegesetz"--HWG); consequently, the physicians can commit a misdemeanor when accepting prohibited financial support. This essay discusses the implications of this legal reform for the most important types of commercially-sponsored medical training. The GMG reform has introduced an obligation for physicians to absolve continuous medical training, however the resulting legal situation has not changed the requirement that this training remain free of commercial interests.

Advertising↗
PubMed1994

Obstetricians' resistance to independent, private practice by nurse-midwives in Washington, D.C. hospitals.

This paper examines obstetricians' explanations for the longstanding and current conflict between obstetricians and nurse-midwives in the District of Columbia over the struggle for independent practice for nurse-midwives. Based on extended interviews with obstetricians, this study shows they are reluctant to provide nurse-midwives with medical backup, a requirement of D.C. law for nurse-midwives to deliver babies in District hospitals. Obstetricians' concerns involve the boundaries of professional responsibility, and economic constraints. Obstetricians believe their more extensive training better qualifies them to handle difficult pregnancies, and they are concerned that nurse-midwives may not call for their help when it is needed. They argue that expanding the use of nurse-midwives will lead to a competition for healthy clients, a competition for paying clients, increased exposure to malpractice liability for obstetricians providing backup, and difficulty obtaining reimbursement from nurse-midwives for their services.

Clinical Competence↗
PubMedDate not supplied

A database in private practice: the Brooklyn Outcomes of Arthritis Rheumatology Database (BOARD).

Rheumatologists generally use few quantitative measures in making clinical decisions. In the US, fewer than 10% use questionnaires in routine clinical care, and fewer than 15% perform a formal joint count at each visit. Patient questionnaires are the quantitative tools rheumatologists have to monitor their patients' health status and response to therapy. The health assessment questionnaire (HAQ) and its derivatives have been shown to be the best predictors of functional and work disability, costs, joint replacement surgery and mortality; they are as good as and usually better predictors than joint counts, radiographs and laboratory tests. The Brooklyn Outcomes of Arthritis Registry Database was initiated with the aim of collecting quantitative data using a multi-dimensional health assessment questionnire (MDHAQ) from all rheumatology patients seen as part of routine care, each and every time the patient was seen. Data that are feasible to collect in routine clinical care provide the only way to assess quantitatively how our patients are doing. If data are not collected and recorded, an opportunity is lost forever. If there is a reason for the visit, there is a reason to complete a questionnaire.

Arthritis↗
PubMed1994

Service-mix provided to patients in Australian private practice.

Service-mix can reflect changes in demographic factors, oral health, patient demand and treatment philosophies. The aim of this study was to compare service-mix by patient age in 1988 with baseline data from 1983. A weighted, stratified random sample of dentists in Australia was surveyed by mailed questionnaire in 1983 and again in 1988. Service-mix was dominated by restorative, diagnostic and preventive areas. Comparing 1988 with 1983, there were significant increases for diagnostic, preventive, advanced restorative, orthodontic and general areas. Patterns across patient age groups and between years indicated younger patients were being provided with increased preventive services (patients aged 5-11, 25-44 years) and decreased restorative services (patients aged 5-11, 12-17 years), while older patients were being provided with reduced prosthodontic services (patients aged 25-44, 45-64 years), but increased restorative services (patients aged 45-64, 65+ years) and advanced restorative services (patients aged 25-44, 45-64 years). These patterns of service-mix have implications for dental education, research and service delivery.

Adolescent↗
PubMedDate not supplied

[Bacteriologic study of acute otitis media in hospitals and private practice].

The authors report the results of the study of 435 bacteriological samples taken in children presenting with acute otitis media, in the out-patient department of ENT at the hospital Bretonneau (Paris) and in Valognes (Manche) from October 1981 to September 1987. Three bacterial organisms prevailed: Haemophilus (37 and 22% respectively), S. pneumoniae (25 and 7%) and Staphylococcus (16 and 17%). Pseudomonas was fairly frequent in cases with otorrhea, even when recent. Comparison with other studies shows the clear progression of the incidence of Haemophilus in acute otitis media. The percentage of the strains secreting a beta-lactamase was 17% whether the children live in the country or in town. The frequency of S. pneumoniae was independent of age but was clearly lower in cases with prolonged or relapsing otitis. According to these results, the authors discuss the therapeutic strategy for acute otitis media. Amoxicillin still remains the antibiotic of choice. In case of persisting or relapsing otitis, the bacteriological examination will allow choosing the best adapted antibiotic: first generation cephalosporin, clavulanic acid and amoxicillin or trimethoprime and sulfamethoxazole.

Acute Disease↗
PubMed1992

Should all children receive two measles vaccinations? A study of measles susceptibility in a suburban New Jersey private practice.

Because of the rising incidence of rubeola, we tested all our patients who were vaccinated prior to 15 months of age and those vaccinated after 15 months, if requested, for susceptibility to measles (IgG, ELISA). Those found to be susceptible were revaccinated. Of 1,228 tested, 264 (21.5%) were susceptible. In the group vaccinated before 1980, 237 of 901 (26.3%) were susceptible, whereas only 27 of 327 (8.3%) vaccinated after 1980 were not immune. Susceptibility was sharply divided by month of age at vaccination at the 14-month mark. Less than 5% of those vaccinated after age 15 months in the 1980s (one of 22, or 4.5%) were susceptible. Waning immunity (secondary vaccine failure) was not found to be a factor in our patients. Despite outbreaks of measles in surrounding communities and in our area, none of our patients developed measles. Identification of high-risk groups and selective measles revaccination should be considered as an alternative to universal revaccination in populations such as ours, since it is more cost-effective and may prove equally successful.

Analysis of Variance↗
PubMed2001

Clinical application of the SADL scale in private practice II: predictive validity of fitting variables. Satisfaction with Amplification in Daily Life.

Predictive validity of 44 independent variables and their interactions with Satisfaction with Amplification in Daily Life (SADL) scores was assessed. SADL scores were influenced by patient age, years of hearing aid experience, hours of use per day, perceived hearing difficulty, pure-tone average, hearing aid style, processor type, and manufacturer's invoice cost. The relative importance of these variables to SADL measures was complex and very small, but the variables and their squares and interactions improved r2 predictions of SADL Global and subscale scores in a separate stepwise multiple linear regression procedure by 12 to 33 percent compared to SADL norms alone. More research with additional variables is needed to develop a clinically useful model for predicting wearer satisfaction. Clinically, SADL scores yield subscale-specific patterns of satisfaction and dissatisfaction that help in intervention planning and serve as graphic "snapshots" of satisfaction status. A series of patient profiles are presented illustrating the potential usefulness of the SADL in predicting hearing aid satisfaction. With its good construct and psychometric properties, the SADL could serve as a gold standard for satisfaction outcomes and a basis for development of a predictive model of hearing aid fitting success.

Adult↗
PubMed1999

The long-term outcome of dysthymia in private practice: clinical features, temperament, and the art of management.

BACKGROUND: With the clinical availability of fluoxetine in the United States, we were interested in documenting improvements in the clinical care of dysthymic patients beyond what was reported from our clinic 2 decades earlier during the "tricyclic (TCA) era." METHOD: In open treatment of 42 consecutive DSM-III-R primary dysthymic patients who were personally followed up in our mood clinic since 1988, response was defined as sustained remission, i.e., no longer meeting criteria for dysthymia and achieving DSM-III-R Axis V Global Assessment of Functioning (GAF) score > 70 throughout much of the mean follow-up of 5 years. RESULTS: Compared to patients with nondysthymic episodic major depressive disorder (N = 42), dysthymic patients had a significantly earlier mean age at onset (12.6 vs. 34 years), were more likely to have never been married, had a greater frequency of superimposed major depressive episodes (except for the 14% [N = 6] with "pure" dysthymia), and had more psychiatric and fewer medical comorbidities; furthermore, patients with dysthymia had significantly greater familial loading of both unipolar and bipolar disorders. Continued treatment with TCA-type antidepressants or fluoxetine (including various augmenting strategies) led to an overall robust and sustained response rate of 76% (N = 32) among dysthymic patients; in tandem, major depressive episodes and suicidality were prevented in all responders. Females treated with fluoxetine had the highest response rate (85% [N = 17]); some were able to walk out of dependent abusive relationships for the first time in their lives. However, dramatic responses with "hyperthymic" switches in temperament occurred in only 12% of dysthymic patients; nearly all were males with bipolar family history. The more prototypic positive change among dysthymic responders consisted of coping with daily hassles without being overwhelmed. Qualitatively, the highest level of adaptive functioning was observed among fluoxetine-treated dysthymics (50% of responders [N = 12] achieved DSM-III-R GAF score of 81-90). Of TCA-treated patients, 39% had intolerable side effects, necessitating switch-over to fluoxetine. Agitation occurred in 11% of fluoxetine-treated patients (N = 4) and was associated with nonresponse and/or dropout; otherwise, this selective serotonin reuptake inhibitor was well tolerated, thereby contributing to long-term compliance. More provocatively, patients with dysthymia who had required extensive psychotherapeutic attention prior to state-of-the-art pharmacotherapy no longer required such therapy. CONCLUSION: These data extend and enrich what has been learned from controlled trials among dysthymic patients. With sustained pharmacotherapy and specialized clinical care in a private mood clinic, 3 of 4 patients immersed in gloom for much of their lives achieved for the first time good to superior levels of functioning that were maintained for an average of 5 years. Although the art of clinical management of dysthymia should be fully grounded in understanding the interpersonal context of depression, we submit that SSRIs such as fluoxetine appear broadly efficacious in areas previously deemed to be the domain of formal psychotherapy.

Adult↗
PubMed1997

Office spirometry: equipment selection and training of staff in the private practice setting.

Spirometry is a basic pulmonary function test that is widely used for the detection of airflow limitation. Its use will continue to grow in the medical office setting because it is useful for both diagnostic and monitoring purposes. Additionally, the assessment of airflow reversibility is a quick, safe, and useful adjunct to baseline spirometry. Many manufacturers offer various models and types of spirometers. Before purchasing, determine the needs and characteristics of the office and its staff, and then choose an appropriate device. There is no "holy grail" for selecting what instrument is best for a specific office. Rather, it requires time and effort to make a good choice. Carefully assess the instrument before purchase and, ideally, compare several instruments. Once an instrument is purchased and it arrives, carefully validate it before reporting results. Proper training of the technicians who perform the testing is perhaps the most important factor in obtaining good spirometric testing. After adequate training, it is also important to have continued competency assessments, periodic inservices, and careful review of test results. The ATS and American Association for Respiratory Care (AARC) published extensive guidelines on the performance of spirometry. These recommendations should be followed to ensure quality and reduce interlaboratory variability. Patients should be properly prepared, the instrumentation properly calibrated, and the test conducted so that there is a good start, adequate exhalation time, satisfactory end-of-test, and good reproducibility between trials.

Age Factors↗
PubMed2005

Can the MiniSCID improve the detection of bipolarity in private practice?

BACKGROUND: Several recent studies have re-examined the prevalence of Bipolar Disorder, raising the suspicion that it is being underdiagnosed, particularly early in the course of the disease. The MiniSCID is a screening instrument for Axis-I diagnoses. METHOD: A chart review was performed on all 1161 active patients seen in an outpatient setting. Data collected included demographic information, initial clinical diagnosis, current clinical diagnosis, MiniSCID diagnoses, and SCL-90 results. RESULTS: Of the 796 patients who had taken the MiniSCID at their initial visit, 256 have a current clinical diagnosis of Bipolar Disorder, and 540 have a nonbipolar diagnosis. They were seen over an average period of 5.3 years. The MiniSCID had a sensitivity of 0.58 and a specificity of 0.63 in predicting a current diagnosis of bipolar disorder. There are 201 patients who endorsed current or past mania/hypomania on the MiniSCID, yet have a current clinical diagnosis of a nonbipolar illness. These patients had a SCL-90 profile that was much closer to those of bipolar patients than those of unipolar patients. LIMITATIONS: The major limitation is the reliability and validity of the MiniSCID. CONCLUSIONS: There is a large group of patients who are potentially bipolar, but are not yet clinically diagnosed as such. Several factors relating to this finding are discussed. The use of MiniSCID and SCL-90 as an in-office-screening tool can improve recognition of Bipolar illness.

Adult↗
PubMed1992

Lack of agreement of tympanic membrane temperature assessments with conventional methods in a private practice setting.

An infrared tympanic membrane thermometer (FIRST temp) said to approximate core temperature accurately is being marketed as a noninvasive, quick, and easy-to-use clinical instrument. The determination of tympanic membrane temperatures by this device was compared with the determination of oral, rectal, or axillary temperatures by a conventional glass thermometer. Subjects were patients of a pediatric group practice in Houston, Texas. FIRST temp and conventional temperature determinations on individual patients were completed within 5 minutes of each other. The presence or absence of otitis media was noted by the examining physician. Agreement between the two methods of temperature determination was assessed by calculating limits of agreement within which 95% (+/- 2 standard deviations) of individual differences would fall. The location of conventional thermometer (oral, rectal, axillary), time interval between the two separate measures, and the presence or absence of otitis media were entered into a multiple regression analysis to determine whether these factors influenced the observed differences between the two methods. A total of 144 patients were enrolled in the study; oral comparisons were obtained in 92 (57%) patients, rectal in 35 (24%), and axillary in 29 (19%). The upper and lower limits of agreement between temperature methods were 1.12 degrees C and 0.89 degrees C and the mean difference was -0.12 degrees C. Regression analysis revealed that only the site of conventional thermometer location (oral, rectal, axillary) was a significant predictor of FIRST temp/conventional differences. Each site had a range of agreement greater than 1.65% degrees C; axillary temperatures had the greatest range (-0.94 degree C to +1.30 degrees C.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗