Skepticism: a lost clinical art. (17/341)

Under the contemporary avalanche of new biomedical discoveries, most physicians find themselves in a losing battle to keep up to date. An underappreciated but important consequence of this struggle has been an abdication of the traditional responsibility of clinicians to critically review novel findings. We appear as a group to prefer our data predigested. Understandably, but unfortunately, we have become too accepting of formal guidelines and trusting of expert advice. Imprecision in our thinking and misapplication of cutting edge technologies have resulted, often to the detriment of the individual patient and the society at large. This essay illustrates some specific examples that demonstrate how superficial knowledge and blind faith can promote suboptimal care and inappropriate use of resources. Reflexive approaches to problems erode the individuality of diagnostic and treatment plans. Accordingly, I challenge my colleagues to be more skeptical about the validity and utility of how they are directed to practice medicine.  (+info)

Integration of health care process analysis in the design of a clinical information system: applying to the blood transfusion process. (18/341)

Hospital information systems have to support quality improvement objectives. The requirements of the system have to meet users' needs in relation to both the quality (efficacy, conformity, safety) and the monitoring of all health care activities (traceability). Information analysts need complementary methods to conceptualize clinical information systems that provide actors with immediate individual benefits and guide collective behavioral changes. A methodology is proposed to elicit users' needs using a process-oriented analysis, and it is applied to the field of blood transfusion. We defined a process data model, the main components of which are: activities, resources, constrains, guidelines and indicators. Although some aspects of activity, such as "where", "what else", and "why" are poorly represented by the data model alone, this method of requirement elicitation fits the dynamic of data input for the process to be traced. A hierarchical representation of hospital activities has to be found for this approach to be generalised within the organisation, for the processes to be interrelated, and for their characteristics to be assessed.  (+info)

Predictors of outcome in a primary care depression trial. (19/341)

OBJECTIVE: Previous treatment trials have found that approximately one third of depressed patients have persistent symptoms. We examined whether depression severity, comorbid psychiatric illness, and personality factors might play a role in this lack of response. DESIGN: Randomized trial of a stepped collaborative care intervention versus usual care. SETTING: HMO in Seattle, Wash. PATIENTS: Patients with major depression were stratified into severe (N = 149) and mild to moderate depression (N = 79) groups prior to randomization. INTERVENTIONS: A multifaceted intervention targeting patient, physician, and process of care, using collaborative management by a psychiatrist and primary care physician. MEASUREMENTS AND MAIN RESULTS: Patients with more severe depression had a higher risk for panic disorder (odds ratio [OR], 5.8), loneliness (OR, 2.6), and childhood emotional abuse (OR, 2.1). Among those with less severe depression, intervention patients showed significantly improved depression outcomes over time compared with those in usual care (z = -3.06, P<.002); however, this difference was not present in the more severely depressed groups (z = 0.61, NS). Although the group with severe depression showed differences between the intervention and control groups from baseline to 3 months that were similar to the group with less severe depression (during the acute phase of the intervention), these differences disappeared by 6 months. CONCLUSIONS: Initial depression severity, comorbid panic disorder, and other psychosocial vulnerabilities were associated with a decreased response to the collaborative care intervention. Although the intervention was appropriate for patients with moderate depression, individuals with higher levels of depression may require a longer continuation phase of therapy in order to achieve optimal depression outcomes.  (+info)

A comparison of Medicare fee-for-service and a group-model HMO in the inpatient management and long-term survival of elderly individuals with syncope. (20/341)

OBJECTIVE: To compare the management and survival of elderly patients hospitalized with syncope in 2 healthcare delivery systems. STUDY DESIGN: Retrospective cohort. PATIENTS AND METHODS: Using hospitalization records from Medicare and a group-model health maintenance organization (HMO) in Oregon, we identified individuals with an admission or discharge diagnosis of syncope between 1992 and 1994. Among patients 65 years or older (median age = 79 years), we randomly selected a sample of the standard Medicare patients (primarily fee-for-service; n = 473) and all of the group-model HMO patients (n = 583). Use of inpatient testing and consultation was ascertained by chart review; all-cause mortality was obtained from the National Death Index. RESULTS: Median diagnostic testing and consultation costs were the same (P = .35) in the standard Medicare population ($643) and the HMO population ($619), although the use of specific tests differed. More cardiovascular syncope was identified in the Medicare population (23% vs 18%; P = .02). Inpatient, 30-day, 1-year, and 4-year mortality rates were higher in the Medicare population (1.7%, 3.8%, 16.7%, and 50.6% respectively) than in the HMO population (0.7%, 1.5%, 13.2%, and 41.8%). After adjusting for age, gender, comorbidity, diagnostic testing, and administrative factors, the relative risk (RR) of dying was lower for group-model HMO patients (RR = 0.74; 95% confidence interval = 0.60, 0.91) than for standard Medicare patients (RR = 1.0). CONCLUSIONS: The inpatient management of these elderly patients with syncope was similar in the group-model HMO and standard Medicare settings, but survival was better for the individuals in the HMO. The reason for the differential survival is not obvious and warrants additional study.  (+info)

Educational instruction on a hospital information system for medical students during their surgical rotations. (21/341)

OBJECTIVE: To evaluate the benefit, for medical students on their surgical rotations, of real-time educational instruction during order entry on a hospital information system. DESIGN: Prospective controlled trial. INTERVENTION: Access to educational information during computerized order entry. SUBJECTS: Medical students in their final year at the University of Calgary. MAIN OUTCOMES: Attainment of the surgery rotation educational objectives, as measured by performance on a multiple-choice examination. METHODS: Before they began their surgical rotations, students at two hospitals took a multiple-choice examination to measure their knowledge of surgery. One hospital had an information system with computerized order entry; students at this hospital had access, while composing orders, to educational material on the system. The other hospital did not have an information system; students there wrote orders on a paper chart. At the end of the rotation, all students took another multiple-choice examination. RESULTS: Of 50 eligible students, 45 agreed to participate in the project, 21 in the treatment group and 24 in the control group. Pre-rotation scores were similar for the two groups (43 percent in the treatment group and 40 percent in the control group; SD, 10 percent). Post-rotation scores were identical for the two groups (65 percent in the treatment group and 65 percent in the control group; SD, 12 percent). A t-test analysis revealed no significant difference in performance on the examinations between the two groups. CONCLUSION: This study did not demonstrate a learning advantage for medical students who have access to educational material on a hospital information system.  (+info)

Regional access to acute ischemic stroke intervention. (22/341)

BACKGROUND AND PURPOSE: Benefit-risk ratios from recombinant tissue plasminogen activator (rtPA) therapy for acute ischemic stroke demonstrate lack of efficacy if intravenous administration is commenced beyond 3 hours of symptom onset. We undertook to enhance therapeutic effectiveness by ensuring equitable access to rtPA for patients affected by acute ischemic stroke within a 20 000 km(2) population referral base served by a tertiary facility. METHODS: Representatives of all provider groups involved in emergency medical services developed a Regional Acute Stroke Protocol (RASP), a coordinated regional system response by dispatch personnel, paramedics, physicians, community service providers, emergency and inpatient staff in community hospitals, and the tertiary facility acute stroke team. RESULTS: As of July 26, 1999, all ambulance services in Southeastern Ontario began bypassing the closest hospital to deliver patients meeting the criteria for the RASP to the Kingston General Hospital. At 12 months, approximately 403 ischemic strokes have occurred in the region, the RASP has been activated 191 times, and 42 patients have received rtPA. CONCLUSIONS: We conclude that (1) acute stroke patients in Southeastern Ontario have improved access to interventions for stroke care; (2) geography of the region is not a barrier to access to interventions for patients with acute stroke; and (3) acute ischemic stroke patients treated with rtPA account for 5% of all acute strokes and 10% of all ischemic strokes in this region.  (+info)

An orthodontic patient administration system (OPAS) for complete departmental management. (23/341)

There is a requirement for effective management and audit in today's hospital environment. This paper discusses some of the principal requirements of a computer program for comprehensive orthodontic department management and describes in detail one system.  (+info)

The future of capitation: the physician role in managing change in practice. (24/341)

Capitation-based reimbursement significantly influences the practice of medicine. As physicians, we need to assure that payment models do not jeopardize the care we provide when we accept higher levels of personal financial risk. In this paper, we review the literature relevant to capitation, consider the interaction of financial incentives with physician and medical risk, and conclude that primary care physicians need to work to assure that capitated systems incorporate checks and balances which protect both patients and providers. We offer the following proposals for individuals and groups considering capitated contracts: (1) reimbursement for primary care physicians should recognize both individual patient encounters and the administrative work of patient care management; (2) reimbursement for subspecialists should recognize both access to subspecialty knowledge and expertise as well as patient care encounters, but in some situations, subspecialists may provide the majority of care to individual patients and will be reimbursed as primary care providers; (3) groups of physicians should accept financial risk for patient care only if they have the tools and resources to manage the care; (4) physicians sharing risk for patient care should meet regularly to discuss care and resource management; and (5) physicians must disclose the financial relationships they have with health plans and medical care organizations, and engage patients and communities in discussions about resource allocation. As a payment model, capitation offers opportunities for primary care physicians to influence the future of health care by improving the management of resources at a local level.  (+info)