Infection control and changing health-care delivery systems.
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In the past, health care was delivered mainly in acute-care facilities. Today, health care is delivered in hospital, outpatient, transitional care, long-term care, rehabilitative care, home, and private office settings. Measures to reduce health-care costs include decreasing the number of hospitals and the length of patient stays, increasing outpatient and home care, and increasing long-term care for the elderly. The home-care industry and managed care have become major providers of health care. The role of specialists in health-care epidemiology has changed accordingly. (+info)
Quality, quantity and distribution of medical education and care: regulation by the private sector or mandate by government?
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The public, the federal government and most state governments have become increasingly concerned with the lack of access to primary care as well as the specialty and geographic maldistribution problems. Currently, there is a race in progress between the private sector and the federal government to devise solutions to these problems. In the federal sector, varying pieces of legislation are under active consideration to mandate the correction of specialty and geographic maldistribution; proposals include: 1) setting up federal machinery to regulate the numbers and types of residencies; 2) make obligatory the creation of Departments of Family Practice in each medical school; 3) withdraw current education support from medical schools causing tuition levels to increase substantially--federal student loans would then provide the necessary leverage to obligate the borrower to two years of service in an under-served area in exchange for loan forgiveness. In the private sector, for the first time in the history of the United States, the five major organizations involved in medical care have organized to form the Coordinating Council on Medical Education (CCME) and the Liaison Committee on Graduate Medical Education (LCGME). One of the initial major endeavors of the CCME has been to address itself to the problem of specialty maldistribution. The LCGME has been tooling up to become the accrediting group for residency training thus providing an overview of the quality and quantity of specialty training. It will be the intent of this presentation to bring the membership of the Southern Surgical Association an up-to-date report on these parallel efforts. The author's personal hope is that the private sector can move sufficiently rapidly to set up its own regulatory mechanisms and avert another federally controlled bureaucracy that will forever change the character of the medical profession in the United States. (+info)
Impact of 18F-FDG PET on managing patients with colorectal cancer: the referring physician's perspective.
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Whole-body PET imaging with 18F-FDG has been used successfully to stage colorectal cancer. However, the impact of FDG PET on patient management from the referring physician's point of view has not been determined. METHODS: A questionnaire was sent to referring physicians to determine whether and how PET altered the management of colorectal cancer patients. Management changes, when present, were classified as intermodality (e.g., medical to surgical, surgical to radiation, medical to no treatment) or intramodality (e.g., altered medical, surgical, or radiotherapy approach). RESULTS: Of 60 responses from referring physicians, changes in clinical stage were reported for 25 patients (42%). Among these, the disease was upstaged in 20 patients (80%) and downstaged in 5 patients (20%). The PET findings contributed to intermodality management changes in 22 of the 60 patients (37%), intramodality changes in 11 patients (18%), a combination of management changes in 4 patients (7%), and no change in 19 patients (32%). Two of the 60 patients (3%) had other changes, and no response to this question was received for the remaining 2 patients (3%). As a result of PET findings, physicians avoided major surgery in 41% of patients for whom surgery was the intended treatment. CONCLUSION: This survey-based study of referring physicians shows that FDG PET had a major impact on the management of colorectal cancer patients and contributed to changes in clinical stage and major management decisions in >40% of patients. (+info)
Primary care physicians' attitudes to battered women and feelings of self-competence regarding their care.
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BACKGROUND: Previous descriptive studies have demonstrated the problematic nature of physicians' attitudes toward battered women. However, little empirical research has been done in the field, especially among the various medical specialties. OBJECTIVES: To compare the approach and feelings of competence regarding the care of battered women between primary care and non-primary care physicians. The non-primary care physicians who are likely to encounter battered women in the ambulatory setting are gynecologists and orthopedists. METHODS: A self-report questionnaire formulated for this study was mailed to a random sample of 400 physicians working in ambulatory clinics of the two main health maintenance organizations in Israel (300 primary care physicians, 50 gynecologists and 50 orthopedists). RESULTS: In both physician groups, treating battered women tended to evoke more negative emotional states than treating patients with infectious disease. The most prevalent mood state related to the management of battered women was anger at her situation. Primary care physicians experienced more states of tension and confusion than non-primary care physicians and had lower perceived self-efficacy and self-competence in dealing with battered women. CONCLUSIONS: Though both physician groups exhibited negative feelings when confronting battered women, the stronger emotion of the primary care physicians may indicate greater sensitivity and personal awareness. We believe that more in-service training should be introduced to help physicians at the undergraduate and postgraduate levels to cope both emotionally and professionally with these patients. (+info)
Racial differences in the use of cardiac catheterization after acute myocardial infarction.
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BACKGROUND: Several studies have reported that black patients are less likely than white patients to undergo cardiac catheterization after acute myocardial infarction. The role of the race of the physician in this pattern is unknown. METHODS: We analyzed data from the Cooperative Cardiovascular Project, a study of Medicare beneficiaries hospitalized for acute myocardial infarction in 1994 and 1995, to evaluate whether differences between black patients and white patients in the use of cardiac catheterization within 60 days after acute myocardial infarction varied according to the race of their attending physician. RESULTS: Our study cohort consisted of 35,676 white and 4039 black patients with acute myocardial infarction who were treated by 17,550 white and 588 black physicians. Black patients had lower rates of cardiac catheterization than white patients, regardless of whether their attending physician was white (rate of catheterization, 38.4 percent vs. 45.7 percent; P< 0.001) or black (38.2 percent vs. 49.6 percent, P<0.001). We did not find a significant interaction between the race of the patients and the race of the physicians in the use of cardiac catheterization. The adjusted mortality rate among black patients was lower than or similar to that among white patients for up to three years after the infarction. CONCLUSIONS: Racial differences in the use of cardiac catheterization are similar among patients treated by white physicians and those treated by black physicians, suggesting that this pattern of care is independent of the race of the physician. (+info)
A national survey of the chemotherapy regimens used to treat small cell lung cancer (SCLC) in the United Kingdom.
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Many chemotherapy regimens are used for treating SCLC in the United Kingdom, but it is not known, in any detail, which regimens are used, by which specialists, for which types of patient. We conducted a survey among all medical and clinical oncologists, respiratory physicians and general physicians with respiratory interest in the United Kingdom to find out. The questionnaire asked for the number of SCLC patients treated annually; how many were given chemotherapy; the drugs, doses and schedules chosen according to prognostic group (as defined by the clinician); and the reasons for choice of regimen. 1214 questionnaires were sent out, and responses were received from 1070 (88%) clinicians; 266 (25%) of these treated SCLC with chemotherapy. Of 4674 patients given chemotherapy annually, 36% were given it by clinical oncologists, 30% by medical oncologists, 27% by respiratory physicians, and 7% by general physicians. In all, 34 regimens were reported with 151 different combinations of dose and schedule. In 2311 good prognosis patients, 23 regimens were used, the commonest being ACE (doxorubicin, cyclophosphamide, etoposide), ICbE (ifosfamide, carboplatin, etoposide), CAV (cyclophosphamide, doxorubicin, vincristine), CbE (carboplatin, etoposide), and PE (cisplatin, etoposide). In 1517 poor prognosis patients, 21 regimens were used, the commonest being CAV, EV (etoposide, vincristine), CbE, CAV alternating with PE, and oral etoposide. 452 patients were treated regardless of prognosis and for 219 no prognostic criteria were specified. The remaining 175 were given second-line chemotherapy or were given regimens chosen to avoid toxicity or because of intercurrent disease or other reasons. The main reasons affecting choice of regimen were routine local practice, patients' convenience, quality of life considerations, trial results and cost. The results show wide variation in routine practice and will be useful in reporting and planning clinical trials and in deciding on local treatment policies. (+info)
An audit of audits: are we completing the cycle?
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Clinical audit plays an important part in the drive to improve quality of patient care and thus forms a cornerstone of clinical governance. We evaluated the standard of clinical audits conducted by all departments in a teaching hospital between 1996 and 1997. Of a total of 213 audits carried out, 102 (48%) were 'partial' and only 29 (14%) were 'full'. Recommendations for improvement emerged from 134 (63%) of the audits performed. In only 51 audits (24%) was the cycle completed by re-auditing, during the subsequent 3 years. Most departments undertake clinical audits but failure to close the loop undermines their effectiveness and wastes resources. (+info)
Influence of physician specialty on adoption and relinquishment of calcium channel blockers and other treatments for myocardial infarction.
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OBJECTIVE: Recent reports have linked calcium channel blockers (CCBs) with an increased risk of acute myocardial infarction (AMI). We sought to determine to what extent physicians relinquished CCBs following these adverse reports and if there were differences in the use of CCBs and other AMI therapies across 3 levels of specialist involvement: generalist attendings, collaborative care (generalist with cardiologist consultation), and cardiologist attendings. DESIGN: We measured use of CCBs during hospitalization for AMI before (1992--1993) and after (1995--1996) the adverse CCB reports, controlling for hospital-, physician-, and patient-level variables. We also examined use of effective medications (aspirin, beta-blockers, thrombolytic therapy) and ineffective AMI treatments (lidocaine). SETTING: Thirty-seven community-based hospitals in Minnesota. PATIENTS: Population-based sample of 5,347 patients admitted with AMI. MEASUREMENTS: The primary outcome was prescription of a CCB at the time of discharge from hospital. Secondary outcomes included use of other effective and ineffective AMI therapies during hospitalization and at discharge. MAIN RESULTS: Compared with cardiologists, generalist attendings were less likely to use aspirin (37% vs 68%; adjusted odds ratio [OR], 0.58; 95% confidence interval [95% CI], 0.42 to 0.80) and thrombolytics (29% vs 64%; adjusted OR, 0.18; 95% CI, 0.13 to 0.25), but not beta-blockers (20% vs 46%; adjusted OR, 0.93; 95% CI, 0.66 to 1.31). From 1992--1993 to 1995--1996, the use of CCBs in patients with AMI decreased from 24% to 10%, the net result of physicians starting CCBs less often and discontinuing them more often. In multivariate models, the odds of CCB relinquishment after the adverse reports (adjusted OR, 0.33; 95% CI, 0.27 to 0.39) were independent of, and not modified by, the involvement of a cardiologist. CONCLUSIONS: Compared with cardiologists, generalist physicians were less likely to adopt some effective AMI therapies, particularly those associated with risk such as thrombolytic therapy. However, generalists were as likely as cardiologists to relinquish CCBs after the adverse reports. This pattern of practice may be the generalist physicians' response to an expanding, but increasingly risky and uncertain, pharmacopoeia. (+info)