Do physicians do as they say? The case of mammography

Postgraduate clinical physiotherapy education in acute hospitals: a cohort study

Background: Junior physiotherapists require satisfactory clinical skills to work effectively within the acute hospital setting for service quality and consistency. Objective: To investigate the effects of stream-specific clinical training on junior physiotherapist self-efficacy, self-rated confidence, and self-rated ability to work independently during weekend shifts. Design: Prospective cohort study. Participants: Eighteen junior physiotherapists. Methods: Physiotherapists undertook 8 h of stream-specific education in: pediatrics, women's health, neuro-medical, musculoskeletal, cardiorespiratory, and critical care over 8 weeks. Learning objectives were evaluated using a self-efficacy (0-100) scale and self-rated confidence was measured with a 4-point Likert scale (not confident to independent). Self-rated ability to independently work weekend shifts was measured dichotomously (yes/no). Results: Participants completed an average of three stream-specific programs in the study period. Post-training, mean improvement in self-efficacy across objectives ranged from 2.9 (95% CI -8.7 to 14.5) to 43.3 (95% CI 4.8-81.8) points, p < 0.05 for 80% of objectives. Self-rated confidence scores improved for 45.6% of stream-specific learning objectives; 52.8% were unchanged and 1.7% reported a decrease in confidence. Self-rated ability to work stream-specific weekend shifts increased from 56-70%, but no stream achieved a significant increase in staff able to independently work weekend shifts (p range 0.10 to 1.0). Conclusions: A stream-specific education program increased junior physiotherapists' self-efficacy and self-rated confidence but not perceived ability to work independently on weekends. Results were non-randomized and actual practice change was not assessed. Future studies could investigate different educational structures in a blinded, randomized manner on clinical practice change.

Mobilization of ventilated patients in the intensive care unit: An elicitation study using the theory of planned behavior

PURPOSE

Early mobilization in intensive care unit (ICU) is safe, feasible, and beneficial. However, mobilization frequently does not occur in practice. The study objective was to elicit attitudinal, normative, and control beliefs (barriers and enablers) toward the mobilization of ventilated patients, to inform development of targeted implementation interventions.

MATERIALS AND METHODS

A 9-item elicitation questionnaire was administered electronically to a convenience sample of multidisciplinary staff in a tertiary ICU. A snowball recruitment approach was used to target a sample size of 20 to 25. Two investigators performed word count and thematic analyses independently. Themes were cross-checked by a third investigator.

RESULTS

Twenty-two questionnaires were completed. Respondents wrote the most text about disadvantages. Positive attitudinal beliefs included better respiratory function, reduced functional decline, and reduced muscle wasting/weakness. The main negative attitudinal beliefs were that mobilization is perceived as time consuming and poses a risk of line dislodgement/disconnection. Positive control beliefs (enablers) included increased staff availability, positive staff attitudes, engagement, and teamwork. Negative control beliefs (barriers) included unstable patient physiology and negative workplace culture.

CONCLUSIONS

Intensive care unit staff expressed positive and negative attitudinal, normative, and control beliefs across the spectrum, and disadvantages were most frequently reported. Identified beliefs can be used to inform development of future interventions.

Variation in cardiologists' propensity to test and treat: is it associated with regional variation in utilization?

BACKGROUND

Regional variation in healthcare utilization, including cardiac testing and procedures, is well documented. Some factors underlying such variation are understood, including resource supply. However, less is known about how physician behaviors and attitudes may influence variation in utilization across regions.

METHODS AND RESULTS

We performed a survey of a national sample of cardiologists using patients vignettes to ascertain physicians' self-reported propensity to test and treat patients with cardiovascular problems, computing a Cardiac Intensity Score for each physician based on his/her responses intended to measure the physician's propensity to recommend high-tech and/or invasive tests and treatments. In addition, we asked under what circumstances they would order a cardiac catheterization "for other than purely clinical reasons." For some survey items, there was substantial variation in physician responses. We found that the Cardiac Intensity Score was associated with 2 measures of population based healthcare utilization measured within geographic regions, with a stronger association with general healthcare spending than with delivery of cardiac services. Although nearly all physicians denied ordering a potentially unnecessary cardiac catheterization for financial reasons, some physicians acknowledged ordering the test for other reasons, including meeting patient and referring physician expectations, meeting peer expectations, and malpractice concerns. More than 27% of respondents reported ordering a cardiac catheterization if a colleague would in the same situation frequently or sometimes, and nearly 24% reported doing so out of fear of malpractice. These 2 factors were significantly associated with the propensity to test and treat, but only fear of malpractice was associated with regional utilization.

CONCLUSIONS

Variability in cardiologists' propensity to test and treat partly underlies regional variation in utilization of general health and cardiology services. The factor most closely associated with this propensity was fear of malpractice suits. This factor may be an appropriate target of intervention.

Reality check: perceived versus actual performance of community mammographers

OBJECTIVE

Federal regulations mandate that radiologists receive regular albeit limited feedback regarding their interpretive accuracy in mammography. We sought to determine whether radiologists who regularly receive more extensive feedback can report their actual performance in screening mammography accurately.

SUBJECTS AND METHODS

Radiologists (n = 105) who routinely interpret screening mammograms in three states (Washington, Colorado, and New Hampshire) completed a mailed survey in 2001. Radiologists were asked to estimate how frequently they recommended additional diagnostic testing after screening mammography and the positive predictive value of their recommendations for biopsy (PPV2). We then used outcomes from 336,128 screening mammography examinations interpreted by the radiologists from 1998 to 2001 to ascertain their true rates of recommendations for diagnostic testing and PPV2.

RESULTS

Radiologists' self-reported rate of recommending immediate additional imaging (11.1%) exceeded their actual rate (9.1%) (mean difference, 1.9%; 95% confidence interval [CI], 0.9-3.0%). The mean self-reported rate of recommending short-interval follow-up was 6.2%; the true rate was 1.8% (mean difference, 4.3%; 95% CI, 3.6-5.1%). Similarly, the mean self-reported and true rates of recommending immediate biopsy or surgical evaluation were 3.2% and 0.6%, respectively (mean difference, 2.6%; 95% CI, 1.8-3.4%). Conversely, radiologists' mean self-reported PPV2 (18.3%) was significantly less than their mean true PPV2 (27.6%) (mean difference, -9.3%; 95% CI, -12.4% to -6.2%).

CONCLUSION

Despite regular performance feedback, community radiologists may overestimate their true rates of recommending further evaluation after screening mammography and underestimate their true positive predictive value.

The difference between study recommendations, stated policy, and actual practice in a clinical trial

BACKGROUND

We determined whether physicians involved in a clinical trial adhere to the study recommendations or the stated policy of their treatment centre with respect to the administration of boost radiation after breast conserving surgery.

PATIENTS AND METHODS

Boost radiation treatment policy was determined by survey at 25 oncology centres involved in a randomised trial of breast or breast plus nodal radiation in Canada. Actual practice was compared with stated policy and study recommendations.

RESULTS

Among 248 subjects, 201 (81%) were treated according to stated policy [kappa=0.40, 95% confidence intervals (CI) 0.27-0.52; P<0.0001], indicating only a fair to moderate agreement between stated and actual practice, while 232 (94%) were treated according to study recommendations (kappa=0.59, 95% CI 0.40-0.77; P<0.0001), indicating moderate to near substantial agreement between study recommendations and actual practice (P=0.88 for z-test of difference). In a multivariate analysis, subjects who had invasive disease at a resection margin were more likely to get a boost than those with margins clear of invasive tumour by 2 mm [odds ratio (OR) 49, 95% CI 7.6-322; P<0.0001].

CONCLUSIONS

Physicians appear compliant with study recommendations for a non-randomised manoeuvre in a clinical trial, possibly at the expense of compliance with stated local policy. Clinical trial protocols should incorporate standard practice.

A comparison of the National Ambulatory Medical Care Survey (NAMCS) measurement approach with direct observation of outpatient visits

BACKGROUND

The National Ambulatory Medical Care Survey (NAMCS) informs a wide range of important policy and clinical decisions by providing nationally representative data about outpatient practice. However, the validity of the NAMCS methods has not been compared with a reference standard.

METHODS

Office visits of 549 patients visiting 30 family physicians in Northeastern Ohio were observed by trained research nurses. Visit content measured by direct observation was compared with data reported by physicians using the 1993 NAMCS form.

RESULTS

Outpatient visit physician reports of procedures and examinations using the NAMCS method showed generally good concordance with direct observation measures, with kappas ranging from 0.39 for ordering a chest x-ray to 0.86 for performance of Pap smears. Concordance was generally lower for health behavior counseling, with kappas ranging from 0.21 for alcohol counseling to 0.60 for smoking cessation advice. The NAMCS form had high specificity (range, 0.90-0.99) but variable (range, 0.12-.84) sensitivity compared with direct observation, with the lowest sensitivities for health behavior counseling. The NAMCS physician report method overestimated visit duration in comparison with direct observation (16.5 vs. 12.8 minutes).

CONCLUSIONS

Compared with direct observation of outpatient visits, the NAMCS physician report method is more accurate for procedures and examinations than for health behavior counseling. Underreporting of behavioral counseling and overreporting of visit duration should lead to caution in interpreting findings based on these variables.

The influence of previous breast cancer upon mammography utilization

Women with a previous history of breast cancer are at increased risk for developing cancer in the opposite breast. However, the literature is inconsistent regarding whether a previous history of breast cancer is associated positively with mammography utilization. Some studies indicate that women with a previous history of breast cancer are less likely to utilize mammography, although behavioral models of health care theorize that women with a history of breast cancer may be more vigilant regarding the disease. We analyzed responses from 830 women > or =50 years who participated in the 1998 National Health Interview Survey. A significantly greater proportion of women with breast cancer reported had a mammogram in the previous year (73.13%) as compared with women who did not have breast cancer (56.69%). Although a previous history of breast cancer was found to be associated positively with mammography use, women with public sources of health insurance are less likely to report mammography use. Results indicate that women with a previous history of breast cancer appear aware of the necessity for continued screening. However, enabling factors such as type of health insurance continue to exert an influence upon the utilization of mammography.

Characteristics of primary care physicians and their practices associated with mammography rates for older women

BACKGROUND

Mammography screening rates are below national recommendations for older women. Understanding the relation between the characteristics of primary care physicians (PCPs) and mammography rates for older women can help to target screening improvement efforts.

METHODS

Subjects were 2527 PCPs practicing in Michigan between 1997 and 1998. A cross-sectional design used Medicare data to identify women age 68 years or older in 1998 whom PCPs treated in 1997-1998 and to determine whether these women had a mammogram between 1996 and 1998. Eligible women were Medicare beneficiaries age 65 years or older by 1996, residing in Michigan from 1996 to 1998, without specified comorbidities likely to affect decisions regarding mammography. Correlations and multiple regressions examined the relation between this score and characteristics of both PCPs and their practice populations of older women.

RESULTS

Mammography rates across physicians' practices ranged from 3-100% (mean = 59%, standard deviation = 17%). Five predictors accounted for 55% of the variance in mammography rates across practices. Higher mammography rates were found to be independently related to physicians who have: a lower mean age for female Medicare patients, a higher mean number of physicians billing for patients' care, a lower mean number of inpatient admissions, obstetrics/gynecology practices, and a higher mean education level in patient's zip code (beta weights >/= 0.25, P < 0.0001).

CONCLUSIONS

PCPs vary substantially with regard to mammography rates for older women. Mammography rates vary more with the population of patients in physicians' practices than with commonly measured personal characteristics of physicians. Mammography rates should be adjusted for patient population to target individual PCPs with low mammography rates for interventions.

Accuracy of responses from postal surveys about continuing medical education and information behavior: experiences from a survey among German diabetologists

BACKGROUND

Postal surveys are a popular instrument for studies about continuing medical education habits. But little is known about the accuracy of responses in such surveys. The objective of this study was to quantify the magnitude of inaccurate responses in a postal survey among physicians.

METHODS

A sub-analysis of a questionnaire about continuing medical education habits and information management was performed. The five variables used for the quantitative analysis are based on a question about the knowledge of a fictitious technical term and on inconsistencies in contingency tables of answers to logically connected questions.

RESULTS

Response rate was 52%. Non-response bias is possible but seems not very likely since an association between demographic variables and inconsistent responses could not be found. About 10% of responses were inaccurate according to the definition.

CONCLUSION

It was shown that a sub-analysis of a questionnaire makes a quantification of inaccurate responses in postal surveys possible. This sub-analysis revealed that a notable portion of responses in a postal survey about continuing medical education habits and information management was inaccurate.

Bowel surveillance patterns after a diagnosis of colorectal cancer in Medicare beneficiaries

BACKGROUND

Postoperative colon surveillance has been recommended for patients with a diagnosis of local/regional colorectal cancer. The extent to which these recommendations are followed in practice is poorly characterized. Patterns of surveillance after surgery for colorectal cancer were determined by using a large population-based database.

METHODS

This is a retrospective cohort study with cancer registry data linked to Medicare claims. Identified were 52,283 patients treated for local/regional colorectal cancer between 1986 and 1996, and surveillance patterns through 1998 were determined. Surveillance patterns were analyzed by using survival analysis and by computing the proportion of surviving patients who underwent procedures during 4 time periods after treatment: 2 to 14 months, 15 to 50 months, 51 to 86 months and more than 87 months.

RESULTS

Median times to first through fifth surveillance events were 20, 14, 15, 15, and 15 months, respectively. For 17% of the cohort there was no surveillance event. Younger patients were more likely to undergo surveillance. Surveillance patterns were not affected by stage. The proportions of the cohort that underwent no surveillance during the 4 respective time periods were 54%, 52%, 60%, and 69%. The percentages of patients who underwent surveillance annually or more frequently in the latter 3 time periods, respectively, were 19%, 10%, and 5%, or 11% overall, treating the data for the 3 events as a whole. Over the period from 1986 to 1998, the proportion of patients who had no surveillance procedures gradually decreased, whereas the proportion of those who underwent procedures annually or more frequently remained relatively constant.

CONCLUSIONS

During the period from 1986 to 1998 there was low utilization of postdiagnosis colon surveillance in a substantial proportion of elderly patients with a diagnosis of local/regional colorectal cancer. Over time there was a trend toward increasing receipt of any surveillance procedures. The percentages of patients undergoing surveillance annually or more frequently did not change between earlier and later periods.

The association of race/ethnicity, socioeconomic status, and physician recommendation for mammography: who gets the message about breast cancer screening?

OBJECTIVES

This study investigated the association between physician recommendation for mammography and race/ethnicity, socioeconomic status, and other characteristics in a rural population.

METHODS

In 1993 through 1994, we surveyed 1933 Black women and White women 52 years and older in 10 rural counties.

RESULTS

Fifty-three percent of the women reported a physician recommendation in the past year. White women reported recommendations significantly more often than did Black women (55% vs 45%; odds ratio = 1.49). Controlling for educational attainment and income eliminated the apparent racial/ethnic difference. After control for 5 personal, 4 health, and 3 access characteristics, recommendation for mammography was found to be more frequent among women who had access to the health care system (i.e., had a regular physician and health insurance). Recommendation was less frequent among women who were vulnerable (i.e., were older, had lower educational attainment, had lower annual family income).

CONCLUSIONS

Socioeconomic status, age, and other characteristics--but not race/ethnicity--were related to reports of a physician recommendation, a precursor strongly associated with mammography use. Efforts to increase physician recommendation should include complementary efforts to help women address socioeconomic and other barriers to mammography use.

Problems in recruiting community-based physicians for health services research

OBJECTIVE

To qualitatively determine factors that are associated with higher participation rates in community-based health services research requiring significant physician participation burden.

MEASUREMENTS

A review of the literature was undertaken using MEDLINE and the Social Science Research Index to identify health services research studies that recruited large community-based samples of individual physicians and in which the participation burden exceeded that of merely completing a survey. Two reviewers abstracted data on the recruitment methods, and first authors were contacted to supplement published information.

MAIN RESULTS

Sixteen studies were identified with participation rates from 2.5% to 91%. Almost all studies used physician recruiters to personally contact potential participants. Recruiters often knew some of the physicians to be recruited, and personal contact with these "known" physicians resulted in greater participation rates. Incentives were generally absent or modest, and at modest levels, did not appear to affect participation rates. Investigators were almost always affiliated with academic institutions, but were divided as to whether this helped or hindered recruitment. HMO-based and minority physicians were more difficult to recruit. Potential participants most often cited time pressures on staff and themselves as the study burden that caused them to decline.

CONCLUSIONS

Physician personal contact and friendship networks are powerful tools for recruitment. Participation rates might improve by including HMO and minority physicians in the recruitment process. Investigators should transfer as much of the study burden from participating physicians to project staff as possible.

The role of the physician as an information source on mammography

PURPOSE

The value of mammography for asymptomatic women younger than 50 years of age has been under debate, and it had been suggested that each woman should decide for herself whether to start having mammograms in her 40s. This decision-making process requires women to have knowledge of screening guidelines. This study reported key determining informational factors that led women age 40 and older to obtain a mammogram.

DESCRIPTION OF STUDY

To examine the relationship between sources of information and utilization of mammography, the authors conducted a communitywide telephone survey, in English and Spanish, of a stratified random sample of 999 white, black, and Hispanic women in Dade County, Florida. The survey was designed to measure knowledge, attitudes, practices, and beliefs about breast cancer, its prevention, and its early detection. Data for 784 women 40 years and older are analyzed and reported here.

RESULTS

The most commonly cited source of information was the media (90.2%). In a logistic regression, having had a checkup in the past year was the strongest predictor of having had a recent mammogram as opposed to a distant one (OR 4.17; 95% CI 2.92-5.95). Women who named their physician as an important source of information about health and prevention were also more likely to have had a recent examination (OR 1.85; 95% CI 1.27-2.69).

CLINICAL IMPLICATIONS

This analysis of the relationship between the source of information and utilization of mammography suggests that physicians, as sources of information, serve to motivate women to obtain a mammogram. This is true even after taking into account the patient's age and utilization of the healthcare system for preventive care in general. For this reason, it is imperative that clinicians be aware of national guidelines for breast cancer screening; of the risks and benefits of screening measures; and of the implications of a positive and negative test result. In addition, clinicians must realize the importance of follow-up to remind the patient to obtain a mammogram or other screening test and should develop strategies to provide this service.