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At least 163 records · Page 9Linked to original sources
PubMed2002

Profiling care provided by different groups of physicians: effects of patient case-mix (bias) and physician-level clustering on quality assessment results.

BACKGROUND: Patient characteristics (case-mix bias) and physician-level variation (clustering) are often overlooked in profiling the quality of care provided by different groups of physicians, such as specialties. OBJECTIVE: To examine the effect of case-mix bias and physician-level clustering on differences in quality of diabetes care between specialty groups participating in the American Diabetes Association's Provider Recognition Program. DESIGN: Retrospective record review of both process and outcome measures over 1 year and a cross-sectional patient survey. The sample included 29 solo and group practice sites in diverse regions of the United States. Of the 29 sites, 15 were endocrinology sites and 14 were primary care sites. PATIENTS: 1750 adults with diabetes. MEASUREMENTS: Process measures included frequency of hemoglobin A(1c), lipid, and urine protein testing; blood pressure measurement; and foot and eye examinations. Outcome measures included A(1c)level, blood pressure, lipid levels, and patient satisfaction. Patient case-mix variables included age, sex, health status, level of education, ethnic minority status, and duration of diabetes. RESULTS: Unadjusted differences between endocrinologists and generalists were statistically significant for most process and outcome measures. Inclusion of patient case-mix variables reduced the statistical significance of specialty differences for some quality measures. After accounting for the substantial physician-level clustering, observed differences between specialties were no longer statistically significant for any of the quality measures except patient satisfaction. CONCLUSIONS: The findings underscore the importance of designing physician profiling studies with sufficient power to account for physician-level variation (clustering) as well as patient case-mix. Studies that are not designed with both sufficient numbers of physicians and patients per physician may distort differences in quality of care between physician groups.

Adolescent↗
PubMed1999

Determinants of Canadian physicians' opinions about legalized physician-assisted suicide: a national survey.

OBJECTIVES: To ascertain the opinions of practising Canadian physicians about their willingness to participate in legalized physician-assisted suicide; and to seek possible associations between willingness to practise legalized assisted suicide, and personal and medical professional determinants. DESIGN: Cross-sectional, mailed survey of a random sample of Canadian physicians, stratified non-proportionally with respect to five geographic regions, and proportionally for type of practice (general practitioner or specialist). RESULTS: Useable responses came from 2,010 (59 per cent) physicians (regional range 53 to 64 per cent), of whom 1,855 were in clinical practice. Respondents' gender and type of practice did not deviate from national reference data; 57 per cent were unwilling to practice legalized assisted suicide, but 40 per cent would wish it for themselves. Significantly different associations were found between opinions about willingness to practise legalized assisted suicide and the personal determinants of age, geographic regions, country of graduation, and religious activity, but not for gender, and type or experience in practice and terminal care. CONCLUSIONS: The opinions of Canadian physicians about the practice of legalized physician-assisted suicide are more strongly influenced by personal determinants than by medical professional determinants. This reveals potential conflicts between physicians' professional and personal preferences. In this context, a plurality of Canadian physicians supports legislated change, but most would not practise legalized physician-assisted suicide at this time in Canada.

Attitude of Health Personnel↗
PubMed1994

How many physicians is enough?: the debate over the supply of United States' physicians in context.

Physician manpower policy is a vital part of current efforts at United States health-care reform. The fundamentals of the ongoing debate over the adequacy of the national physician supply are: (1) what constitutes an adequate supply of physicians? (2) how does one determine if supply will be adequate in the future? (3) what are the consequences of having too many or too few physicians? and (4) what approaches could be taken to influence the size, specialty composition, or geographic distribution of the physician work force? Virtually all forecasts agree that the United States faces a future aggregate oversupply of physicians, with significant specialty imbalances. With these surpluses come economic costs that the nation appears unwilling to assume. Options for bringing physician supply into balance with requirements include reducing the numbers of new physicians entering active practice, increasing retirements, limiting availability of positions in oversubscribed specialties, and encouraging physicians to work in underserved areas.

Education, Medical↗
PubMed1997

Retraining physicians for primary care. A study of physician perspectives and program development.

OBJECTIVE: To determine the number and kinds of programs that medical schools and managed care organizations offer or plan to offer to retrain physician specialists to practice primary care medicine and to discover physicians' attitudes toward such retraining. DESIGN: A survey was mailed in 1994 to all 126 medical schools and the 19 largest US managed care organizations to collect detailed information about existing and potential retraining programs. Physicians' attitudes toward retraining were elicited from participants in 3 geographically diverse focus groups. Selected specialists were polled through the national survey of the American Medical Association's Socioeconomic Monitoring System to ascertain the demand for retraining. RESULTS: The majority of institutions contacted perceived a need for retraining, but few programs had been established. Programs being "considered" varied widely in duration, class size, target audience, accreditation, and projected training settings. Although unenthusiastic about retraining, physicians preferred programs that would expand their patient base, maintain the practice population, be inexpensive and close to home, and provide hands-on training in the eventual practice environment. Physicians also preferred a goal-oriented, part-time retraining program in a large group practice or managed care setting that would allow them to practice their specialty while retraining. Few planned or existing programs incorporate many of these features. The most likely candidates for retraining are subspecialty physicians who currently provide some primary care and are employed by a medical plan. CONCLUSIONS: Despite efforts by those who perceive that a need for more generalist physicians is stimulating interest in retraining specialists and subspecialists to provide primary medical care, physician interest and program availability remain low, and programs under development are not being designed to attract those who may seek retraining. This situation is probably fortuitous, because changed perceptions about the adequacy of the generalist physician workforce since the beginning of this study have diminished the call for retraining.

Adult↗
PubMed1998

Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experience.

BACKGROUND: The advent of managed care has resulted in considerable debate regarding the relative effects of specialist and primary care on patient outcomes and costs. Studies on these subjects have been limited to a disease-focused orientation rather than a patient-focused orientation inherent in primary care management. We examined whether persons using a primary care physician have lower expenditures and mortality than those using a specialist as their personal physician. METHODS: Using data on a nationally representative sample of 13,270 adult respondents tot he 1987 National Medical Expenditure Survey reporting as their personal physician either a primary care physician (general practitioner, family physician, internist, or obstetrician-gynecologist) or a specialist, we examined total annual health care expenditures and 5-year mortality experience. RESULTS: Respondents with a primary care physician, rather than a specialist, as a personal physician were more likely to be women, white, live in rural areas, report fewer medical diagnoses and higher health perceptions and have lower annual healthcare expenditures (mean: $2029 vs $3100) and lower mortality (hazard ratio = 0.76, 95% confidence interval [CI], 0.64-0.90). After adjustment for demographics, health insurance status, reported diagnoses, health perceptions, and smoking status, respondents reporting using a primary care physician compared with those using a specialist had 33% lower annual adjusted health care expenditures and lower adjusted mortality (hazard ratio = 0.81; 95% CI, 0.66-0.98). CONCLUSIONS: These findings provide evidence for the cost-effective role of primary care physicians in the health care system. More research is needed on how to optimally integrate primary and specialty care.

Economics, Medical↗
PubMed2001

Physicians' responses to patients' requests for physician-assisted suicide.

BACKGROUND: Studies show that patient requests for physician-assisted suicide (PAS) are a relatively common clinical occurrence. The purpose of this study was to describe how experienced physicians assess and respond to requests for assisted suicide. METHODS: Focused ethnography in the offices of 11 acquired immunodeficiency syndrome physicians, 8 oncologists, and 1 hospice physician who had received requests for assisted suicide in their practice. Ten had facilitated PAS. RESULTS: Informants had a similar approach to evaluating patients who requested assisted suicide, often asking, "Why do you want to die now?" Reasons for requests fell into 3 broad categories: physical symptoms, psychological issues, and existential suffering. Physicians thought they competently addressed patients' physical symptoms, and this obviated most requests. They treated depression empirically and believed they did not assist depressed patients with assisted suicide. Physicians had difficulty addressing patients' existential suffering, which led to most facilitated requests. Informants rarely talked to colleagues about requests for assisted suicide, suggesting a "professional code of silence." CONCLUSIONS: Regardless of divergent attitudes about PAS, physicians respond similarly to requests for assisted suicide from their patients, creating a common ground for professional dialogue. Our sample addressed physical suffering aggressively, treated depression empirically, but struggled with requests arising from existential suffering. A professional code of silence regarding PAS creates professional isolation. Clinicians do not share knowledge or receive social support from peers about their decisions regarding assisted suicide. Educational strategies drawing on approaches used by experienced clinicians may create an atmosphere that enables physicians with divergent beliefs to discuss this difficult subject.

Adult↗
PubMed2006

Effects of compensation methods and physician group structure on physicians' perceived incentives to alter services to patients.

OBJECTIVE: To examine how health plan payment, group ownership, compensation methods, and other practice management tools affect physician perceptions of whether their overall financial incentives tilt toward increasing or decreasing services to patients. DATA SOURCE: Nationally representative data on physicians are from the 2000-2001 Community Tracking Study Physician Survey (N=12,406). STUDY DESIGN: Ordered and multinomial logistic regression were used to explore how physician, group, and market characteristics are associated with physician reports of whether overall financial incentives are to increase services, decrease services, or neither. PRINCIPAL FINDINGS: Seven percent of physicians report financial incentives are to reduce services to patients, whereas 23 percent report incentives to increase services. Reported incentives to reduce services were associated with reports of lower ability to provide quality care. Group revenue in the form of capitation was associated with incentives to reduce services whereas practice ownership and variable compensation and bonuses for employee physicians were mostly associated with incentives to increase services to patients. Full ownership of groups, productivity incentives, and perceived competitive markets for patients were associated with incentives to both increase and reduce services. CONCLUSIONS: Practice ownership and the ways physicians are compensated affect their perceived incentives to increase or decrease services to patients. In the latter case, this adversely affects perceived quality of care and satisfaction, although incentives to increase services may also have adverse implications for quality, cost, and insurance coverage.

Attitude of Health Personnel↗
PubMed2001

Physicians' and patients' perspectives on office-based dispensing: the central role of the physician-patient relationship.

OBJECTIVE: To describe physicians' and patients' reasons for participating in office-based sales of dermatologic products. DESIGN: Survey data on the attitudes, opinions, and beliefs of dermatologists and their patients were analyzed. SETTING: A market research study of office-based selling. PARTICIPANTS: Thirty dermatologists involved in direct selling from the office, 20 dermatologists not involved in direct selling, 22 patients who purchase products from their dermatologists' offices, and 25 office managers. MAIN OUTCOME MEASURE: The hypotheses of this study were formulated after the market research study had been done. The main outcome measure was the physicians' and patients' reported reasons for patients purchasing skin care products from dermatologists rather than from retail stores. RESULTS: "Trust" was the most frequent reason cited by physicians for patient purchases, while "physician knowledge" was the most frequent reason cited by the purchasing patients. The most common location to display the products was the waiting room (20 [67%] of the physicians). The most common types of products sold included glycolic acid products (15 [50%]), moisturizers (13 [43%]), sunscreens (12 [40%]), and alpha-hydroxy acid products other than glycolic acid (9 [30%]). CONCLUSION: The interaction between physicians who sell products in their offices and their patients is highlighted by 2 key elements of the physician-patient relationship: trust and physician knowledge.

Adult↗