Do administrative databases accurately measure waiting times for medical care? Evidence from general surgery

We abstracted the records of patients from general surgeons' offices in Winnipeg to compare waiting times from charts (i.e., the gold standard) with waiting times using administrative data. The administrative data method relies on physicians' billing data to identify a visit to the surgeon preoperatively to mark the start of the waiting time. There was no difference between waiting times using patient records versus administrative data. The study supported the use of administrative data to monitor waiting times.

[Today and tomorrow of forensic thanatology]

The essence of post-mortem examination and its special place among other disciplines of forensic medicine were presented. Attention was drawn to the role of better understanding of phenomena occurring during and directly after death in the development of forensic medicine. Progress in determination of the time of death and in estimation of the intravital character of injuries found on the corpse was discussed. The need for a wider application of results of bio- and thanatochemical analyses in determination of the cause of death and its mechanism was emphasized. Examples of progress in this domain were presented, based on a number of papers published in this field, especially in Poland. Finally, the author pointed to the necessity of upgrading training of medical doctors in the field of thanatology.

Is it time to reconsider subcutaneous administration of epoetin?

Anemia treatment in nondialysis chronic kidney disease (ND-CKD) and dialysis CKD patients (D-CKD) has been recently scrutinized in the literature and by the lay press. New evidence suggests that patients receiving epoetin and achieving higher hemoglobin have a higher risk of death and cardiovascular complications. Data from the Centers for Medicare & Medicaid Services demonstrate upward spiraling costs of injectables, especially epoetin, in the care of CKD patients. There is considerable literature favoring the use of subcutaneous administration of epoetin compared to intravenous route in hemodialysis patients. Evidence clearly shows that the subcutaneous route achieves the target hemoglobin level at a lower administered dose. Thus, the same clinical effect can be achieved at a lower cost. Despite the economic and evidentiary justifications for subcutaneous administration of epoetin, adoption of this strategy has been limited, especially in the United States. Reasons include: inflexibility by dialysis providers because of reduced profitability, claims that patients oppose the subcutaneous route because of pain at the site of injection, concerns regarding pure red cell aplasia associated with subcutaneous administration, and greater hemoglobin cycling with the subcutaneous route. In this article, the advantages and disadvantages of the subcutaneous route are reviewed.

The relative effectiveness of practice change interventions in overcoming common barriers to change: a survey of 14 hospitals with experience implementing evidence-based guidelines

AIMS AND OBJECTIVES

Changing practice to reflect current best evidence can be costly and time-consuming. The purpose of this survey was to determine the optimal combination of practice change interventions needed to overcome barriers to practice change commonly encountered in the intensive care unit (ICU).

DESIGN

A survey instrument delivered by mail with email follow-up reminders.

SETTING

Fourteen hospitals throughout Australia and New Zealand.

SUBJECTS

Individuals responsible for implementing an evidence-based guideline for nutritional support in the ICU.

SURVEY

Practice change interventions were ranked in order of effectiveness and barriers to change were ranked in order of how frequently they were encountered.

RESULTS

A response rate of 100% was achieved. Interventions traditionally regarded as strong (academic detailing, active reminders) were ranked higher than those traditionally regarded as moderate (audit and feedback), or weak (posters, mouse mats). The high ranks of the site initiation visit (educational outreach, modest) and in-servicing (didactic lectures, weak) were unexpected, as was the relatively low rank of educationally influential, peer-nominated opinion leaders. Four hospitals reported the same doctor-related barrier as 'most common' and the remaining 10 hospitals reported three different doctor-related barriers, two nursing-related barriers and three organizational barriers as most common.

CONCLUSIONS

When designing a multifaceted, multi-centre change strategy, the selection of individual practice change interventions should be based on: (1) an assessment of available resources; (2) recognition of the importance of different types of barriers to different sites; (3) the potential for combinations of interventions to have a synergistic effect on practice change, and (4) the potential for combinations of interventions to actually reduce workload.

A careful balance: multinational perspectives on culture, gender, and power in marriage and family therapy practice

In this study, we examined how marriage and family therapists from various countries and diverse cultural backgrounds address the intersection of gender, power, and culture in therapy. Twenty participants from 15 countries responded to an Internet survey that included several hypothetical, clinical vignettes not associated with any one particular culture or nationality. Participants selected a vignette based on its similarity to clinical situations they face in practice within their cultural contexts, and provided information about their conceptualizations of gender, culture, and power, along with treatment recommendations. We analyzed data using analytic induction and constant comparison methods. Results indicate the careful balance with which the participants work to engage clients in therapy, respect cultural values and practices, and promote equitable gender relationships.

Prenatal immunization education the pediatric prenatal visit and routine obstetric care

BACKGROUND

Vaccine safety concerns and lack of knowledge regarding vaccines contribute to delays in infant immunization. Prenatal vaccine education could improve risk communication and timely vaccination. This study sought to determine the proportion of obstetric practices and hospital-based prenatal education classes that provide pregnant women with infant immunization information, the willingness of obstetric practices to provide infant immunization information, and the proportion of first-time mothers who receive a pediatric prenatal visit.

METHODS

A telephone survey was conducted of 100 pediatric practices and 100 obstetric practices randomly selected from the American Medical Association Physician Masterfile between January and March 2005, with analysis performed April 2005.

RESULTS

Seventy-one of 100 (71%) selected obstetric practices and 85 of 100 (85%) selected pediatric practices participated. Sixteen obstetric practices (23%) reported providing pregnant women with information on routine childhood immunizations. Thirty-four of the 52 practices (65%) that did not provide such information reported willingness to do so. Ten of 51 hospitals (20%) did not provide information about routine childhood immunizations to prenatal class participants. Sixty-six of the 85 pediatric practices (78%) provided a pediatric prenatal visit. Among these, the median percentage of first-time mothers who received a visit was 30%.

CONCLUSIONS

Prenatal visits are a missed opportunity for providing education about infant immunizations. Incorporating immunization education into routine obstetric prenatal care may increase maternal knowledge of infant vaccines and reduce delayed immunization.

Dissociative symptom disorders in advanced nursing practice: background, treatment, and instrumentation to assess symptoms

Less well-known among the psychiatric disorders, dissociation is one of the most common underlying symptoms of individuals seeking mental health care (Maldonado, 2001). Closely associated with post-traumatic stress disorder, dissociation characteristics may include inconsistent consciousness, autobiographical forgetfulness, difficulties in self-regulation, regressions, alternate identities, disorganization in the development of a cohesive sense of self, depersonalization, and derealization (Trickett, Noll, Reiffman & Putnam, 2001). The major constructs and dimensions of the dissociative symptom disorders in adults are introduced. Several of the most prominent psychometric instruments that nurses and other mental health clinicians may use as adjuncts to diagnosis and treatment are described.

Online on-the-spot searching increases use of evidence during consultations in family practice

OBJECTIVE

The project aimed to search for online evidence in a structured way in consultation with the patient, to investigate whether the evidence discovered changed decisions.

METHODS

We developed the "Online on-the-spot" method (OOS) as a part of a quality improvement program. Within a general practice consultation three physicians and two trainees searched in a fixed pattern and sequence the national guidelines of general practitioners developed by the Dutch College of General Practitioners, Clinical Evidence, Trip-database and the British Medical Journal. All GPs who performed this quality improvement program were in favor of the project.

RESULTS

During 3 months five GPs registered 365 searches out of 2920 patient-doctor contacts. For each eight patient-doctor contacts there was one online search. Patients were actively involved in 53% of the searches (95%C.I.: 48-57%). On average, two databases were consulted. An answer to the question was found in 87% of cases and in almost half of cases it was relevant new information for the doctor. The GP changed his decision due to the problem in 26% (95%C.I.: 21-29) of cases. At the end of the OOS project, the number of searches within 5 min were significantly higher than at the start: 51% (95% C.I.: 44-59) to 33% (95% C.I.: 24-43), respectively.

CONCLUSIONS

The OOS project is a timely answer to the doctors' educational needs in attending to the patient.

PRACTICE IMPLICATIONS

OOS could connect the patient, the doctor and the evidence.

Evaluating nurse prescribing behaviour using constipation as a case study

Non-medical nurse prescribing in the UK continues to evolve with new legislative frameworks. Studies evaluating patterns of prescribing by nurses remain scarce. This secondary data analysis of national prescribing data investigated the prescribing behaviours of community-based nurses and general practitioners (GPs), using constipation as a case study. Currently, 37 683 registered nurses, midwives and health visitors are qualified to independently prescribe in the UK; however, only 16.6% of nurses prescribed items for constipation. Prescribing practices differed between nurses employed by primary care trusts (PCTs) and general practice, between nurses and GPs, and across regions. PCT-employed nurses undertook 83% of nurse prescribing although activity increased steadily among general practice-employed nurses. Pharmacological treatment choices differed between nurses and GPs. Over 60% of all nurses predominantly prescribed from one class of laxative compared with a wider range prescribed by GPs. The extent, impact and outcomes of medical prescribing need further study.

Undergraduate teaching of child and adolescent psychiatry in Australia: survey of current practice

OBJECTIVE

To identify the goals, content, and time allocated for undergraduate child psychiatry teaching programmes in Australian medical schools.

METHOD

A structured questionnaire designed specifically for the present study was used to identify the goals, content, and time allocated to child psychiatry teaching for undergraduate medical students. Staff responsible for child psychiatry teaching programmes at all 15 medical schools in Australia were contacted and those in 12 schools (80%) agreed to participate.

RESULTS

All 12 medical schools provided some teaching relevant to child psychiatry. Teaching was commonly provided as part of general psychiatry and/or paediatric teaching programmes. Between 4 and 12 h were allocated for child psychiatry teaching, with the exception of one school, which assigned 46 h. Ten schools (83%) offered clinical placements in child psychiatry to some or all students, with placements ranging in length from 0.5 days to 8 weeks. However, only four schools (33%) offered clinical placements to all students. Two schools (17%) offered no clinical placements or electives in child psychiatry. The skills required to assess children and families, and knowledge about normal child development were identified as key teaching goals. Barriers to teaching child psychiatry included the lack of academic child psychiatrists in Australia, and the limited time allocated for this teaching in medical school curricula.

CONCLUSIONS

The amount of time allocated for teaching child psychiatry in Australian medical schools is relatively small and not consistent with the size of the public health problem posed by child and adolescent mental disorders. Staff responsible for teaching child psychiatry need to coordinate their activities more effectively at a national level to identify teaching goals, design curricula, and advocate for high-quality child psychiatry teaching programmes in medical schools.

Pain management decision making among long-term care physicians and nurses

The purpose of this study is to explore attitudes and beliefs that affect decisions about prescribing and administering pain medications in older adults who live in long-term care (LTC), with a particular emphasis on those with cognitive impairment. At each of the four participating LTC facilities, data were gathered from three separate groups of health care professionals: physicians, registered nurses, and registered practical nurses. Based on grounded theory, a model was developed that highlighted critical decision points for nurses and physicians regarding pain management. The major themes that emerged from the data concerned pain assessment (lack of recognition of pain, uncertainty about the accuracy of pain assessment and diagnosis) and treatment (reluctance to use opioids, working to individualize pain treatments, issues relating to physician trust of the nurse on prescribing patterns). These findings may facilitate the development of innovative approaches to pain management in LTC settings.

An informatics approach to assess pediatric pharmacotherapy: design and implementation of a hospital drug utilization system

Drug utilization in the inpatient setting can provide a mechanism to assess drug prescribing trends, efficiency, and cost-effectiveness of hospital formularies and examine subpopulations for which prescribing habits may be different. Such data can be used to correlate trends with time-dependent or seasonal changes in clinical event rates or the introduction of new pharmaceuticals. It is now possible to provide a robust, dynamic analysis of drug utilization in a large pediatric inpatient setting through the creation of a Web-based hospital drug utilization system that retrieves source data from our accounting database. The production implementation provides a dynamic and historical account of drug utilization at the authors' institution. The existing application can easily be extended to accommodate a multi-institution environment. The creation of a national or even global drug utilization network would facilitate the examination of geographical and/or socioeconomic influences in drug utilization and prescribing practices in general.

Elimination of daily routine chest radiographs does not change on-demand radiography practice in post–cardiothoracic surgery patients

OBJECTIVE

We sought to determine the effect of elimination of daily routine chest radiographs on chest radiographic practice in cardiothoracic surgery patients in the intensive care unit and the post-intensive care unit ward.

METHODS

We used a prospective, comparative study design with an intervention in a 28-bed intensive care unit/post-intensive care unit ward (including a 4-bed medium-care unit) in a university hospital. Cardiothoracic surgery patients were admitted to the intensive care unit during a period of 6 months (3 months before intervention and 3 months after intervention). Daily routine chest radiographs in the intensive care unit were eliminated; all chest radiographs required a clinical indication. Routine chest radiographs were not performed in the post-intensive care unit ward, both before and after the intervention.

RESULTS

Before intervention, in the intensive care unit 353 daily routine chest radiographs and 261 on-demand chest radiographs were obtained in 175 patients; after intervention, 275 on-demand chest radiographs were obtained in 163 patients. Before intervention, in the post-intensive care unit ward 413 on-demand chest radiographs were obtained in 167 patients; after intervention, 445 on-demand chest radiographs were obtained in 161 patients. In the intensive care unit the number of chest radiographs per patient day decreased from 1.8 +/- 0.6 to 1.1 +/- 0.6. In the post-intensive care unit ward the number of chest radiographs per patient per day was 0.4 +/- 0.2, both before and after the intervention. Slightly more unexpected abnormalities were found in the on-demand chest radiographs after the intervention. No negative influence on chest radiography timing, length of stay in the intensive care unit and hospital, and readmission rate was seen.

CONCLUSIONS

Elimination of daily routine chest radiographs led to a decrease of the total number of chest radiographs obtained per patient per day in the intensive care unit and did not change chest radiography practice in the post-intensive care unit ward.

Should nurses prescribe blood components?

AIM

To explore the feasibility of nurses prescribing blood components.

METHOD

Using a convenience snowball sample, a UK-wide questionnaire survey was undertaken to identify transfusion practices and canvass the opinions of nurses and doctors.

RESULTS

A total of 179 (59%) of 302 respondents were supportive of nurses prescribing blood components, saying it would have a positive effect on the quality of patient care, result in fewer treatment delays and help doctors and nurses to use their time more effectively. The remaining 123 (41%) respondents had reservations about time and resource constraints and worries about undermining medical care and responsibility.

CONCLUSION

Development of non-medical prescribing to allow nurses to prescribe blood components has the potential to deliver a more patient-centred quality service.

Occupational contact dermatitis in Australia: diagnostic and management practices, and severity of worker impairment

The aims of this study were to compare treatment and referral practices between general practitioners (GPs) and dermatologists and to evaluate predictors for occupational contact dermatitis (OCD) disease severity measured in terms of worker impairment. Data were collected from 181 patients recruited for a larger study of OCD. Information about treatment recommendations and usual referral practices are reported for 123 patients. Data from patients, diagnosed with work-related skin disease, were modelled for severity of worker impairment. GPs were more likely to treat a patient independently, referring if the patient did not improve, whereas dermatologists were more likely to refer for patch testing on initial presentation. Dermatologists were more likely to recommend gloves and GPs were more likely to recommend soap avoidance/substitution. 2 GPs and no dermatologists reported recommending the best practice combination of moisturizers, topical corticosteroids and soap substitutes. When adjusted for all variables including age, sex, duration and diagnostic subgroup, workers with atopy as a cofactor had the most severe impairment. This study suggests that in Australia, patients with suspected OCD are initially managed within general practice, few clinicians recommend best practice treatments for OCD, and that atopy is associated with severity. These findings have implications for health resource allocation, clinician education, and the pre-employment counselling of atopic patients.

The role of microbiology and pharmacy departments in the stewardship of antibiotic prescribing in European hospitals

This observational, cross-sectional study describes the role played by clinical microbiology and pharmacy departments in the stewardship of antibiotic prescribing in European hospitals. A total of 170 acute care hospitals from 32 European countries returned a questionnaire on antibiotic policies and practices implemented in 2001. Data on antibiotic use, expressed as Defined Daily Doses per 100 occupied bed-days (DDD/100 BD) were provided by 139 hospitals from 30 countries. A total of 124 hospitals provided both datasets. 121 (71%) of Clinical Microbiology departments and 66 (41%) of Pharmacy departments provided out of hours clinical advice. 70 (41%) of microbiology/infectious disease specialists and 28 (16%) of pharmacists visited wards on a daily basis. The majority of laboratories provided monitoring of blood cultures more than once per day and summary data of antibiotic susceptibility testing (AST) for empiric prescribing (86% and 73% respectively). Most of the key laboratory and pharmacy-led initiatives examined did not vary significantly by geographical location. Hospitals from the North and West of Europe were more likely to examine blood cultures more than once daily compared with other regions (p < 0.01). Hospitals in the North were least likely routinely to report susceptibility results for restricted antibiotics compared to those in the South-East and Central/Eastern Europe (p < 0.01). Hospital wards in the North were more likely to hold antibiotic stocks (100%) compared with hospitals in the South-East which were least likely (39%) (p < 0.001). Conversely, hospital pharmacies in the North were least likely to dispense antibiotics on an individual patient basis (16%) compared with hospital pharmacies from Southern Europe (60%) (p = 0.01). Hospitals that routinely reported susceptibility results for restricted antibiotics had significantly lower median total antibiotic use in 2001 (p < 0.01). Hospitals that provided prescribing advice outside normal working hours had significantly higher antibiotic use compared with institutions that did not provide this service (p = 0.01). A wide range of antibiotic stewardship measures was practised in the participating hospitals in 2001, although there remains great scope for expansion of those overseen by pharmacy departments. Most hospitals had active antibiotic stewardship programmes led by specialists in infection, although there is no evidence that these were associated with reduced antibiotic consumption. There was also no evidence that pharmacy services reduced the amount of antibiotics prescribed.