[How information on a patient's social status is gathered. An anthropological analysis of the discourses employed in private medical practice]. / Les pratiques de repérage de la situation sociale des patients. Analyse anthropologique de discours de praticiens libéraux.

BACKGROUND: A number of studies have highlighted differences and even discrimination in health care offer according to social category, and shown that they contribute to the production of inequality. On the other hand, when the health care system treats every patient equally, and does not take personal difficulties into consideration, some authors have suggested inequality "by omission". That is why public health actors at different levels have recommended systematic collection of information on patients' social status. The objective of this article is to analyze data gathering on patients' socio-economic condition and its repercussions. METHODS: The survey is based on more than 50 semi-structured face-to-face interviews with doctors and dentists in private practice. Their answers were subjected to socio-anthropological analysis. RESULTS: While some practitioners collect information on patients' social status proactively by systematic interrogation, others proceed indirectly and in accordance with subjective criteria. Quite often, patient status remains ignored, usually due to lack of interest, and less frequently because practitioners wish to guard against any risk of stigmatizing underprivileged patients. Different rationales may explain these attitudes: need to prioritize relevant information, wish to observe equity and equality, determination to refrain from social labeling, desire to protect patient self-esteem and to reinforce the practitioner-patient relationship. When identification does occur, it is essentially justified by a desire to adapt the care pathway to potential socio-economic obstacles. CONCLUSION: When a patient's social situation is sought out by private doctors and dentists, they are mainly concerned with customizing care pathways by taking financial impediments into close consideration. In most cases, their justifications for asking questions are subjective; by doing so, they inadvertently introduce arbitrariness in an area where the French state endeavors to produce social justice via provisions such as "CMU" ("universal", across the board health coverage). Systematic questioning on a patient's social status can represent a form of supplementary if unconscious symbolic violence toward frequently disqualified persons; what is more, it runs the risk of inducing stereotypes and manifesting prejudice. Only when contextualized does such questioning seem appropriate. On the other hand, when a practitioner misses out on social issues liable to impede care and treatment, he will probably have no "second chance" to address these concerns. Some practitioners have emphasized a need for suitable timing and contextualizing of questions on a patient's social status, and for putting them forward in a climate of trust.

The role of accountable care organization affiliation and ownership in promoting physician practice participation in quality improvement collaboratives.

BACKGROUND: Quality improvement collaboratives (QICs) have emerged as an important strategy to improve processes and outcomes of clinical care through interorganizational learning. Little is known about the organizational factors that support or deter physician practice participation in QICs. PURPOSE: The aim of this study was to examine organizational influences on physician practices' propensity to participate in QICs. We hypothesized that practice affiliation with an accountable care organization (ACO) and practice ownership by a system or community health center (CHC) would increase the propensity of physician practices to participate in a QIC. METHODOLOGY: Data from the third wave of the National Study of Physician Organizations, a nationally representative sample of medical practices (n = 1,359), were analyzed. Weighted multivariate regression analyses were estimated to examine the association of ACO affiliation, ownership, and QIC participation, controlling for practice size, health information technology capacity, public reporting participation, and practice revenue from Medicaid and uninsured patients. The Sobel-Goodman Test was used to explore the extent to which practice use of quality improvement (QI) methods such as Lean, Six Sigma, and use of plan-do-study-act cycles mediates the relationship between ACO affiliation and QIC participation. FINDINGS: Only 13.6% of practices surveyed in 2012-2013 participated in a QIC. In adjusted analyses, ACO affiliation (odds ratio [OR] = 1.51, p < .01), CHC ownership (OR = 6.57, p < .001), larger practice size (OR = 14.72, p < .001), and health information technology functionality (OR = 1.15, p < .001) were positively associated with QIC participation. Practice use of QI methods partially mediated (13.1%-46.7%) the association of ACO affiliation with QIC participation. PRACTICE IMPLICATIONS: ACO-affiliated practices are more likely than non-ACO practices to participate in QICs. Practice size rather than system ownership appears to influence QIC participation. QI methods often promoted and used by health care systems such as CHCs and ACOs may promote QIC participation.

Comparison of Colonoscopy Quality Measures Across Various Practice Settings and the Impact of Performance Scorecards.

BACKGROUND: Quality performance measures for screening colonoscopy vary among endoscopists. The impact of practice setting is unknown. AIMS: We aimed to (1) compare screening colonoscopy performance measures among three different US practice settings; (2) evaluate factors associated with adenoma detection; and (3) assess a scorecard intervention on performance metrics. METHODS: This multi-center prospective study compared patient, endoscopist, and colonoscopy characteristics performed at a tertiary care hospital (TCH), community-based hospital (CBH), and private practice group (PPG). Withdrawal times (WT), cecal intubation, and adenoma detection rates (ADR) were compared by site at baseline and 12 weeks following scorecard distribution. Generalized linear mixed models identified factors associated with adenoma detection. RESULTS: Twenty-eight endoscopists performed colonoscopies on 1987 asymptomatic, average-risk individuals ≥50 years. Endoscopist and patient characteristics were similar across sites. The PPG screened more men (TCH: 42.8%, CBH: 45.0%, PPG: 54.2%; p < 0.0001). Preparation quality varied with good/excellent results in 70.6, 88.3, and 92% of TCH, CBH, and PPG cases, respectively (p < 0.0001). Male ADRs, cecal intubation, and WT exceeded recommended benchmarks despite variable results at each site; female ADRs were <15% at the PPG which screened the fewest females. Performance remained unchanged following scorecard distribution. Adenoma detection was associated with increasing patient age, male gender, WT, adequate preparation, but not practice setting. CONCLUSIONS: Each practice performed high-quality screening colonoscopy. Scorecards did not improve performance metrics. Preparation quality varies among practice settings and can be modified to improve adenoma detection.

Trends in quality of screening colonoscopy in Austria.

Background and study aim: Screening colonoscopy only effectively prevents colorectal cancer if performed with high quality. The aim of this study was to analyze the detection rates of premalignant colorectal lesions in screening colonoscopies performed within a nationwide quality control program for screening colonoscopy in Austria. Methods: Data from electronic records of the screening program from its implementation in 2007 until December 2014 were analyzed in order to calculate detection rates for adenomas, advanced adenomas, polyps, and proximal lesions, and rates of cecal intubation, sedation, complications, and adequate bowel preparation. Results were evaluated to identify trends and changes in quality parameters over the 8-year study period. Results: During the study period, 301 endoscopists provided data from 159 246 screening colonoscopies. Mean age of screened individuals was 61.1 years, and 49.1 % were women. Significant increases over time were found for age- and sex-adjusted adenoma detection rates (ADRs), which increased from a mean of 22.2 % (SD 10.7 %) in 2007/2008 to 24.2 % (SD 11.6 %) in 2013/2014. On average, each endoscopist increased their individual ADR by + 1.5 percentage points per 2-year period (95 % confidence interval [CI] 0.9 - 2.2 percentage points; P < 0.01). Similarly, detection rates for proximal lesions rose from 15.8 % (SD 9.8 %) to 21.7 % (SD 13.3 %  + 2.5 percentage points per 2-year period, 95 %CI 1.9 - 3.1 percentage points; P < 0.01). ADR in men increased from 27.6 % in 2007/2008 (SD 11.1 %) to 29.2 % in 2013/2014 (SD 12.7 %; P < 0.01); ADR in women increased from 14.2 % (SD 7.1 %) in 2007/2008 to 19.0 % (SD 10.5 %) in 2013/2014 (P < 0.01). Advanced adenoma detection rates decreased during the study period, from 11.4 % (SD 9.0 %) in 2007/2008 to 7.6 % (SD 5.4 %) in 2013/2014 (P = 0.06) in men, and from 5.5 % (SD 5.3 %) in 2007/2008 to 4.0 % (SD 4.1 %) in 2013/2014 in women (P = 0.21). Conclusions: This study showed an improvement in the quality of screening colonoscopies performed within a quality assurance program in Austria between 2007 and 2014. Although, overall ADR increased significantly during the study period, there was a decrease in the rate of advanced adenoma detection.

University clinic and private practice treatment outcomes in Class I extraction and nonextraction patients: A comparative study with the American Board of Orthodontics Objective Grading System.

INTRODUCTION: The aim of this study was to compare treatment outcomes in university vs private practice settings with Class I patients using the American Board of Orthodontics Objective Grading System. METHODS: A parent sample of 580 Class I patients treated with and without extractions of 4 first premolars was subjected to discriminant analysis to identify a borderline spectrum of 66 patients regarding the extraction modality. Of these patients, 34 were treated in private orthodontic practices, and 32 were treated in a university graduate orthodontic clinic. The treatment outcomes were evaluated using the 8 variables of the American Board of Orthodontics Objective Grading System. RESULTS: The total scores ranged from 10 to 47 (mean, 25.44; SD, 9.8) for the university group and from 14 to 45 (mean, 25.94; SD, 7.7) for the private practice group. The university group achieved better scores for the variables of buccolingual inclination (mean difference, 2.28; 95% confidence interval [CI], 0.59, 3.98; P = 0.01) and marginal ridges (mean difference, 1.32; 95% CI, 0.28, 2.36; P = 0.01), and the private practice group achieved a better score for the variable of root angulation (mean difference, -0.65; 95% CI, -1.26, -0.03; P = 0.04). However, no statistically intergroup differences were found between the total American Board of Orthodontics Objective Grading System scores (mean difference, -0.5; 95% CI, -3.82, 4.82; P = 0.82). CONCLUSIONS: Patients can receive similar quality of orthodontic treatment in a private practice and a university clinic. The orthodontists in the private practices were more successful in angulating the roots properly, whereas the orthodontic residents accomplished better torque control of the posterior segments and better marginal ridges.

Treatment and outcomes of metastatic colorectal cancer in Australia: defining differences between public and private practice.

BACKGROUND: Prior studies have suggested improved outcomes for cancer patients managed in private centres, despite universal healthcare within Australia. AIMS: To compare patient, disease, treatment and survival data for metastatic colorectal cancer (mCRC) managed in private versus public centres. METHODS: Analysis of prospectively collected registry data for consecutive patients with mCRC managed at 16 participating centres from July 2009. RESULTS: Data for 1065 patients were examined. Age, gender and Charlson comorbidity score were similar for public and private patients. Private patients were more commonly Eastern Cooperative Oncology Group performance score 0-1 (85% vs 78%, P = 0.008), in the highest Index of Relative Socioeconomic Advantage and Disadvantage quintile (57% vs 18%, P < 0.001) or had a single metastatic site (62% vs 54%, P = 0.009). Patients treated in private were more likely to receive chemotherapy (84% vs 70%, P < 0.001), bevacizumab (59% vs 50%, P = 0.008), be treated with curative intent (37% vs 26%, P < 0.001) and undergo metastasectomy (30% vs 22%, P = 0.001). These management differences remained statistically significant after adjusting for baseline characteristics. Management in the private setting was associated with superior overall survival (median 27.9 vs 20 months, hazard ratio 0.7, 95% confidence interval: 0.57 to 0.86, P = 0.001), significant in multivariate analysis adjusting for all baseline covariates. CONCLUSIONS: Significant differences in baseline characteristics were noted for private versus public patients. However, these do not explain the higher rates of treatment delivery in the private setting, which likely contributed towards the observed survival difference. Further studies are required to determine if the increased likelihood of intervention in the private setting is driven by patient, clinician and/or institutional factors.

Are Australasian Genetic Counselors Interested in Private Practice at the Primary Care Level of Health Service?

This study explored the perceived interest in development of private genetic counseling services in collaboration with primary care physicians in the Australasian setting by online survey of members of the Australasian Society of Genetic Counselors. Four hypothetical private practice models of professional collaboration between genetic counselors and primary care physicians or clinical geneticists were proposed to gauge interest and enthusiasm of ASGC members for this type of professional development. Perceived barriers and facilitators were also evaluated. 78 completed responses were included for analysis. The majority of participants (84.6 %) showed a positive degree of interest and enthusiasm towards potential for clinical work in private practice. All proposed practice models yielded a positive degree of interest from participants. Model 4 (the only model of collaboration with a clinical geneticist rather than primary care physician) was the clearly preferred option (mean = 4.26/5), followed by Model 2 (collaboration with a single primary care practice) (mean = 4.09/5), Model 3 (collaboration with multiple primary care clinics, multidisciplinary clinic or specialty clinic) (mean = 3.77/5) and finally, Model 1 (mean = 3.61/5), which was the most independent model of practice. When participants ranked the options in the order of preference, Model 4 remained the most popular first preference (44.6 %), followed by model 2 (21.6 %), model 3 (18.9 %) and model 1 was again least popular (10.8 %). There was no significant statistical correlation between demographic characteristics (age bracket, years of work experience, current level of work autonomy) and participants' preference for private practice models. Support from clinical genetics colleagues and the professional society was highly rated as a facilitator and, conversely, lack of such support as a significant barrier.

Improving performance in medical practices through the extended use of electronic medical record systems: a survey of Canadian family physicians.

BACKGROUND: Numerous calls have been made for greater assimilation of information technology in healthcare organizations in general, and in primary care settings in particular. Considering the levels of IT investment and adoption in primary care medical practices, a deeper understanding is needed of the factors leading to greater performance outcomes from EMR systems in primary care. To address this issue, we developed and tested a research model centered on the concept of Extended EMR Use. METHODS: An online survey was conducted of 331 family physicians in Canadian private medical practices to empirically test seven research hypotheses using a component-based structural equation modeling approach. RESULTS: Five hypotheses were partially or fully supported by our data. Family physicians in our sample used 67% of the clinical and 41% of the communicational functionalities available in their EMR systems, compared to 90% of the administrative features. As expected, extended use was associated with significant improvements in perceived performance benefits. Interestingly, the benefits derived from system use were mainly tied to the clinical support provided by an EMR system. The extent to which physicians were using their EMR systems was influenced by two system design characteristics: functional coverage and ease of use. The more functionalities that are available in an EMR system and the easier they are to use, the greater the potential for exploration, assimilation and appropriation by family physicians. CONCLUSIONS: Our study has contributed to the extant literature by proposing a new concept: Extended EMR Use. In terms of its practical implications, our study reveals that family physicians must use as many of the capabilities supported by their EMR system as possible, especially those which support clinical tasks, if they are to maximize its performance benefits. To ensure extended use of their software, vendors must develop EMR systems that satisfy two important design characteristics: functional coverage and system ease of use.

Some intrapersonal qualities of SA homeopaths who have established successful private practices.

PURPOSE: The purpose of the study was to explore the experiences of homeopaths who have established successful private practices in South Africa (SA) with the aim of identifying some of their intrapersonal qualities which may have contributed to their establishing a successful practice. METHOD: This was a qualitative phenomenological research design using in-depth interviews with homeopaths running successful private practices across 5 provinces in SA, which were digitally recorded. Of these, 18 were transcribed and analysed using a descriptive coding approach and strategies for phenomenological analysis. Themes and supporting categories are identified and described. FINDINGS: Homeopaths experiences suggest that they are authentic, self-aware, self-reflective and proactive. They experienced a need for self-care and support and further found that their integrity, positive attitude, self-discipline and passion, contributed to their success in practice. CONCLUSION: The intrapersonal qualities can be roughly divided between those that generate inner-support and those which aid homeopaths attain their goal of establishing a practice and are therefore crucial aspects of success generation.

Practice-oriented research: what it takes to do collaborative research in private practice.

The goal of this paper is to describe the authors' experience conducting research in and for private practice. Based on two distinct research programs (one guided by a scientist practitioner leading various groups of clinicians and another from a network of practitioners and researchers), a number of practice-oriented studies are presented. Lessons learned from these collaborative projects are discussed in terms of challenges and strategies to deal with them, as well as benefits that can be earned from conducting empirical studies within clinical routine. General recommendations are then offered to foster the engagement of clinicians in their own working environment and to facilitate partnerships between researchers and practitioners in developing and implementing valid, feasible, and informative clinical studies.

[Adapting a private health care facility to the new Peruvian Public Health Sistem. Quality rating in a Middle Income Economy country]. / L'adeguamento di una struttura sanitaria privata alla nuova sanità pubblica Peruviana. Valutazione di qualità in un paese a Middle Income Economy.

The aim of the study is the Assessment of Quality Sevices provided by a no-profit Medical Center in Peruvian Sierra, through an evidence-based decision-making process to identify infrastructure and capacity building interventions, to achieve accreditation and economic sustainability and increase competitiveness in the renewed Peruvian National Health System. The quali-quantitative collection of data shows how is fundamental an Healthcare Management focused on the responsiveness of services to the real needs and the local culture to reach the goals.

Relationships between medicine and industry: approaches to the problem of conflicts of interest.

Relationships between physicians and industry are prevalent in medical education, clinical practice, and research, as well as at the level of medical institutions. These relationships can be valuable for the advancement of medicine but have also received increased scrutiny in recent years because they create conflicts of interest that pose a risk of biasing the judgments of physicians. Responses to these conflicts of interest by medical institutions, journals, and governments have utilized four main tools: education, disclosure, management, and prohibition. Each of the four has its advantages and drawbacks. Medicine faces the challenge of tailoring the use of these tools to minimize the risk of bias while allowing useful medical-industry collaborations to proceed. Viewing the dilemmas created by physicians' relationships with industry as a version of the principal-agent problem, which is much discussed by economists, may help in developing creative approaches to these issues.

Digital intraoral radiographic quality assurance and control in private practice.

At present, the American Dental Association and the American Academy of Oral Maxillofacial Radiology have guidelines for the dental environment that include quality assurance and control of film-based radiography. Approximately 19%-30% of US dental offices currently use some form of digital intraoral radiography, and growth is expected to continue. It is anticipated that new tools and guidelines will be needed to aid in the development of quality assurance (QA) and control of digital intraoral radiographic images. Working with a representative sample of private practice dental offices, this study examined and evaluated the entire digital intraoral radiographic system used in each operatory. The X-ray machine was tested for equipment performance and accuracy, and the computer monitor calibration was evaluated and adjusted as needed. The results confirm the continued need for updated QA procedures in the dental office that include digital X-ray imaging. By implementing these changes and practices, dentists should be able to improve the diagnostic quality of radiographs while reducing the radiation exposure of the patient.

Data quality of the Australia and New Zealand Dialysis and Transplant Registry: a pilot audit.

AIM: Most clinical registries in Australia, including the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), do not audit submitted data. Inaccurate data can bias registry analysis. This study aimed to audit data submitted to ANZDATA from a single region. METHODS: A retrospective audit of individual haemodialysis patient data recorded by ANZDATA at 31 December 2009 was completed by nephrologists in a blinded fashion. Original data were recorded by nursing staff. Patients received treatment at a public hospital, two affiliated satellite haemodialysis units, and three private haemodialysis units. RESULTS: Fifty-one audits were completed of a total 175 patients (29.1%) undertaking haemodialysis in 2009. Primary renal disease was correct in 86.3% (95%CI: 74.3-93.2), although errors in type of glomerulonephritis were common. Date of first dialysis (± 1-month error margin) was correct for 93.6%. Creatinine at first dialysis (± 10% error margin) was correct in 74.4%. Baseline comorbidity accuracy included: peripheral vascular disease (sensitivity 36.4% (95%CI: 24.6-50.1), specificity 82.8% (95%CI: 70.2-90.7)), ischaemic heart disease (sensitivity 69.2% (95%CI: 55.6-80.2), specificity 88.0% (95%CI: 76.3-94.3)), chronic lung disease (sensitivity 25.0% (95%CI: 15.2-38.3), specificity 93.6% (95%CI: 83.4-97.7)), diabetes (sensitivity 86.4% (95%CI: 74.4-93.2), specificity 96.6% (95%CI: 87.5-99.1)), cerebrovascular disease (sensitivity 75.0% (95%CI: 61.7-84.8), specificity 95.3% (95%CI: 85.8-98.6)), and ever smoked (sensitivity 83.3% (95%CI: 70.3-91.4), specificity 71.4% (95%CI: 57.3-82.3)). Non-melanoma skin cancer was under-reported and inaccurate. CONCLUSION: Data accuracy was favourable compared with other renal registry validation studies. Data accuracy may be improved by education and training of collectors. A larger audit is necessary to validate ANZDATA.

Practice size, financial sharing and quality of care.

BACKGROUND: Although we are observing a general move towards larger primary care practices, surprisingly little is known about the influence of key components of practice organization on primary care. We aimed to determine the relationships between practice size, and revenue sharing agreements, and quality of care. METHODS: As part of a large cross sectional study, group practices were randomly selected from different primary care service delivery models in Ontario. Patient surveys and chart reviews were used to assess quality of care. Multilevel regressions controlled for patient, provider and practice characteristics. RESULTS: Positive statistically significant associations were found between the logarithm of group size and access, comprehensiveness, and disease prevention. Negative significant associations were found between logarithm group size and continuity. No differences were found for chronic disease management and health promotion. Practices that shared revenues were found to deliver superior health promotion compared to those who did not. Interacting group size with the presence of a revenue-sharing arrangement had a negative impact on health promotion. CONCLUSIONS: Despite the limitations of our study, our findings have provided preliminary evidence of the tradeoffs inherent with increasing practice size. Larger group size is associated with better access and comprehensiveness but worse continuity of care. Revenue sharing in group practices was associated with higher health promotion compared to sharing only common costs. Further work is required to better inform policy makers and practitioners as to whether the pattern revealed in larger practices mitigates any of the previously reported benefits of continuity of primary care. We found few benefits of revenue sharing--even then the effect of revenue sharing on health promotion seemed diminished in larger practices.

Development of and field test results for the CAHPS PCMH Survey.

OBJECTIVE: To develop and evaluate survey questions that assess processes of care relevant to Patient-Centered Medical Homes (PCMHs). RESEARCH DESIGN: We convened expert panels, reviewed evidence on effective care practices and existing surveys, elicited broad public input, and conducted cognitive interviews and a field test to develop items relevant to PCMHs that could be added to the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Clinician & Group (CG-CAHPS) 1.0 Survey. Surveys were tested using a 2-contact mail protocol in 10 adults and 33 pediatric practices (both private and community health centers) in Massachusetts. A total of 4875 completed surveys were received (overall response rate of 25%). ANALYSES: We calculated the rate of valid responses for each item. We conducted exploratory factor analyses and estimated item-to-total correlations, individual and site-level reliability, and correlations among proposed multi-item composites. RESULTS: Ten items in 4 new domains (Comprehensiveness, Information, Self-Management Support, and Shared Decision-Making) and 4 items in 2 existing domains (Access and Coordination of Care) were selected to be supplemental items to be used in conjunction with the adult CG-CAHPS 1.0 Survey. For the child version, 4 items in each of 2 new domains (Information and Self-Management Support) and 5 items in existing domains (Access, Comprehensiveness-Prevention, Coordination of Care) were selected. CONCLUSIONS: This study provides support for the reliability and validity of new items to supplement the CG-CAHPS 1.0 Survey to assess aspects of primary care that are important attributes of PCMHs.

Antenatal sexually transmitted infection screening in private and indigent clinics in a community hospital system.

OBJECTIVE: To determine whether clinics that serve indigent patients demonstrate equal compliance with sexually transmitted infection testing guidelines when compared with private clinics. STUDY DESIGN: One hundred eighty-three women were divided into cohorts based on whether they received prenatal care at a private or indigent clinic. Timing of required antenatal sexually transmitted infection screening was collected for 8 tests and compliance scores were calculated. Primary outcome was average compliance score compared between clinic types. Secondary outcomes included disease-specific compliance and percent of perfect compliance at different office types. RESULTS: Compliance was found to be different between clinic types (P = .023). Indigent clinics had the same median with slightly higher inner-quartile range than private clinics (7 [7-8], 7 [7-7]). Indigent clinics had higher mean compliance scores (7.1 vs 6.9) and a greater percentage of patients demonstrating perfect compliance (42% vs 14%, P < .001). CONCLUSION: Clinics serving indigent patient populations had a higher compliance with required testing compared to private clinics. HIV testing in the third trimester remains the greatest need for improvement for all practice types.

Transitioning patients taking clozapine from the public to private/GP shared-care setting: barriers and criteria.

OBJECTIVE: The aim of this study was to explore the barriers to transitioning patients taking clozapine from the public to private psychiatrist or general practitioner (GP) shared-care setting, as well as the criteria used by staff to identify patients suitable for transitioning. METHOD: The experience of clinicians managing people taking clozapine was explored through circulation of a feedback questionnaire. The clozapine transition questionnaire (CTQ) was developed as the primary measure following extensive consultation with clinical staff with expertise in clozapine treatment. A total of 215 clinicians were sent questionnaires (60 community mental health service staff, 120 private psychiatrists registered to prescribe clozapine, and 35 GPs from the Bayside Health clozapine GP shared-care programme), with overall 80 (46.2%) returned. RESULTS: Over 64% of participants had managed patients who had been transitioned from public to private psychiatrist or GP shared-care settings. Around half of these said that it was a 'worthwhile treatment option' and that 'it went smoothly' and 'the patient was satisfied'. The most significant barriers to successful transitioning were the cost of private service, the patient's level of disorganization, and the need for ongoing care coordination. The most important criteria for transitioning patients was compliance with medication, ability to independently attend appointments and access appropriate pharmacies to receive medication, and willingness to transition out of the public system. CONCLUSIONS: Transitioning suitable public psychiatric patients taking clozapine into private psychiatrist/GP shared-care offers an important model to improve the efficiency and effectiveness of care, but requires careful planning, preparation, and monitoring to ensure sustained success.

Theoretical and practical barriers to practitioners' willingness to seek training in empirically supported treatments.

To identify barriers to the dissemination of empirically supported treatments (ESTs), a random sample of psychologists in independent practice (N=1291) was asked to complete measures of attitudes towards ESTs and willingness to attend a 3-hour, 1-day, or 3-day workshop in an EST of their choice. The strongest predictor of unwillingness to obtain EST training was the amount of time and cost required for the workshop, followed by objections to the need for EST training. Psychodynamic (compared to cognitive-behavioral) and more experienced practitioners agreed more strongly with the objections to ESTs overall, as did those whose graduate schools had not emphasized psychotherapy research. Results suggest that both practical and theoretical barriers are significant obstacles to EST dissemination.

Evaluation of common operator errors in panoramic radiography in Trinidad and Tobago: a comparison of formally vs informally trained operators.

AIM: To evaluate and compare the frequency of common operator errors seen on panoramic radiographs in dental private practices and in the dental hospital (taken by informally and formally trained operators, respectively) in Trinidad and Tobago. METHOD: One thousand panoramic radiographs of patients over the age of 10 years were included in this study. These comprised 500 from the dental hospital and 500 from dental private practices. The radiographs were reviewed using standardized criteria to identify the most common operator errors. RESULTS: There were only 21 (4.2%) error free radiographs in the dental private practice sample and 29 (5.80%) in the dental hospital sample. Frequencies of specific errors were significantly higher in the dental private practice sample in each category except for "Chin tipped too low" (Chi-square p < 0.05) CONCLUSION: This study supports the need for the introduction of statutory guidelines with respect to the use of ionizing radiation in dentistry in Trinidad and Tobago and in particular, the implementation of formally assessed dedicated dental radiography training for all operators of dental X-ray equipment.