Unpeeling the onion: Digital triage and monitoring of general practice, private psychiatry, and psychology.

OBJECTIVE: The Australian federal government is considering a 'digital front door' to mental healthcare. The Brain and Mind Centre at the University of Sydney has published a discussion paper advocating that the government should adopt a comprehensive model of digital triage and monitoring (DTM) based on a government-funded initiative Project Synergy ($30 million). We critically examine the final report on Project Synergy, which is now available under a Freedom of Information request. CONCLUSION: The DTM model is disruptive. Non-government organisations would replace general practitioners as care coordinators. Patients, private psychiatrists, and psychologists would be subjected to additional layers of administration, assessment, and digital compliance, which may decrease efficiency, and lengthen the duration of untreated illness. Only one patient was deemed eligible for DTM, however, during the 8-month regional trial of Project Synergy (recruitment rate = 1/500,000 across the region). Instead of an unproven DTM model, the proposed 'digital front door' to Australian mental healthcare should emphasise technology-enabled shared care (general practitioners and mental health professionals) for the treatment of moderate-to-severe illness.

Deployment of advanced nursing practice in Île-de-France. / Le déploiement de la pratique infirmière avancée en Île-de-France.

Advanced practice nurses (APNs) are finding it difficult to establish themselves once they have completed their training. Nearly half (49%) of graduates interviewed in a survey said they were not working as APNs, which raises real questions about the future of new graduates and their establishment in local areas. Under such conditions, the future of IPAs sometimes seems compromised, especially those in private practice.

Clinician perspectives on rapid transition to telehealth during COVID-19 in Australia - a qualitative study.

Objective The coronavirus disease 2019 (COVID-19) pandemic precipitated a major shift in the use of telehealth in Australia. The changes highlighted gaps in our knowledge regarding the efficacy of, and clinician attitudes to, the use of telehealth. The current study expands and deepens the available evidence as a result of being collected in unique circumstances that removed one of the major barriers (lack of Medicare rebates) and also one major enablers (willingness) of telehealth uptake. Methods Using a semi-structured interview, we invited clinicians (N = 39) to share their perspectives, attitudes and experiences of using telehealth. Topics covered included perceptions of the strengths and challenges of telehealth, and how experience of using telehealth during the COVID-19 pandemic had influenced clinicians' views and intentions regarding their future practice. Participants included clinicians from five disciplines across public and private practice: paediatrics, neurology, immunology, rural general practice, and orthopaedics. Results We found three key dimensions for consideration when assessing the suitability of telehealth for ongoing practice: the attributes of the patient population, the attributes of the clinical context and environment, and the risks and benefits of a telehealth approach. These findings map to the existing literature and allow us to infer that the experiences of clinicians who previously would have chosen telehealth did not differ significantly from those of our 'pandemic-conscripted' clinicians. Conclusions Our findings map clearly to the existing literature and allow us to infer that the experiences of the clinicians who have chosen telehealth (and are already represented in the literature) did not differ significantly from those trying out telehealth under the unique circumstances of the removal of the Medicare Benefits Scheme barrier and external pressure that over-rides the 'willingness' enabling factor in uptake decisions.

Changes in private psychiatric practice in Australia: An analysis of trends in claims for outpatient Medicare item numbers over 14 years.

OBJECTIVE: The Better Health Access Initiative added 32 Medicare Benefits Schedule (MBS) item numbers in 2006 to increase the number of people with access to mental health care. We investigated trends in the provision of outpatient Medicare-subsidised psychiatric services since the introduction of these item numbers in 2006 through 2019. METHODS: Medicare Benefits Schedule aggregated item-number claims data were obtained from the Services Australia Medicare website, between January 2006 and December 2019 inclusive, for face-to-face psychiatrist consultations. Item number rates were collated and graphed per 100,000 population according to year and item number. RESULTS: There has been an increase in the number of claims for new patient assessments (291-296) and a reduction in most ongoing care Medicare item numbers, especially longer appointments that are often associated with psychotherapy provision (306-308). CONCLUSION: There have been changes in private psychiatric practice in Australia over the past 14 years. There are several possible causes for these changes and further research is required to determine the impact on patient care.

[Thermal pulsation system (LipiFlow®) for treatment of meibomian gland dysfunction (MGD) from the perspective of an ophthalmologist in private practice]. / Thermo-Pulsations-System (LipiFLow®) zur Behandlung der Meibom-Drüsen-Dysfunktion (MDD) aus der Sicht eines niedergelassenen Augenfacharztes.

PURPOSE: Thermal pulsation (LipiFlow®, Johnson&Johnson, Santa Ana, CA, USA) has been advocated for meibomian gland dysfunction (MGD) treatment and was found to be useful in many studies. The aim of this study was to show the efficacy of the method and to compare it to a daily eyelid margin massage in a non-university institution. METHODS: A non-blinded, single-center interventional study comparing thermal pulsation with eyelid margin massage for the treatment of MDD. In this study 30 patients were recruited during daily office hours. Symptoms (OSDI) and ocular surface (NIK-BUT, tear ferning test, tear meniscus height, LIPCO folds, meibography, meibomian gland evaluator) were assessed before treatment. A total of 15 patients (9 women) underwent thermal pulsation (single session), while 15 patients (8 women) performed eyelid margin massage (once daily) as instructed for 3 months. RESULTS: Before the two treatment methods, there were no differences in the above parameters, gender and age were also normally distributed. After treatment, both subjective and objective criteria improved in the two groups but significantly more in the thermal pulsation arm. In particular, the limited compliance of 30% in the eyelid margin massage arm should be noted. Safety parameters, such as visual acuity and intraocular pressure (IOP) remained normal in all patients. CONCLUSION: A single session of thermal pulsation showed significantly better results in the efficacy and safety profile after 3 months compared to eyelid margin massage once daily; however, the high costs for the patients due to the single use mode of the activators must be taken in account.

Complications After Clinic-Based Wide Awake Local Anesthesia No Tourniquet Hand Surgery at a Single Private Practice.

BACKGROUND: This study was designed to analyze the results of all wide awake local anesthesia no tourniquet (WALANT) procedures performed on the hand and wrist at a single practice hand surgery practice with a focus on quantifying and qualifying complications. METHODS: This retrospective chart review included 424 patients who underwent WALANT hand procedures in the minor procedure room of our private practice between 2015 and 2017. Patients were divided into groups based on the type of procedure, including carpal tunnel release, A1 pulley release, first dorsal compartment release, extensor tendon repair, mass excision, and foreign body removal. Data pertaining to patient demographics and complications were recorded. RESULTS: The overall complication rate for all procedures was 2.8% for 424 patients: A1 pulley release (n = 314, 2.5%), first dorsal compartment release (n = 11, 9%), extensor tendon repairs (5.5%), and mass excision (4%). The carpal tunnel release and foreign body removal groups experienced no complications. No adverse events (arrhythmias, vasovagal, etc.) were observed during the use of the WALANT technique. CONCLUSIONS: Clinic-based WALANT hand surgery procedures are equally safe compared to the same procedures performed in the operating room at an ambulatory surgery center or hospital.

COVID-19: The experience from Iran.

The first cases of coronavirus disease 2019 (COVID-19) in Iran were detected on February 19, 2020. Soon the entire country was hit with the virus. Although dermatologists were not immediately the frontline health care workers, all aspects of their practice were drastically affected. Adapting to this unprecedented crisis required urgent appropriate responses. With preventive measures and conserving health care resources being the most essential priorities, dermatologists, as an integral part of the health system, needed to adapt their practices according to the latest guidelines. The spectrum of the challenges encompassed education, teledermatology, lasers, and other dermatologic procedures, as well as management of patients who were immunosuppressed or developed drug reactions and, most importantly, the newly revealed cutaneous signs of COVID-19. These challenges have paved the way for new horizons in dermatology.

Ethical Issues in Private Practice: A Phenomenological Investigation of Music Therapy Business Owners.

As a music therapy private practice is both a business and a healthcare service, it should adhere to ethical standards from both disciplines. However, this topic has rarely been examined in the music therapy literature. The purpose of this phenomenological study was to explore ethical dilemmas experienced by music therapy business owners (MTBOs) in their private practice and how MTBOs avoid or address ethical dilemmas. Utilizing convenience and snowball sampling techniques, 21 MTBOs in the United States were interviewed using semi-structured interviews. To answer the two areas of inquiry, we identified three themes and 12 subthemes: (1) Ethical issues related to client welfare, (2) Ethical issues related to business relationships and operation, and (3) Strategies to address or avoid ethical dilemmas. MTBOs also shared how they ensure ethical behavior in themselves, with their employees or independent contractors, and when interacting with professionals outside the private practice. These findings provide a better understanding of MTBOs' lived experiences of ethics in their private practice and may benefit other music therapists who are in private practice or are wanting to go into private practice. Limitations and recommendations for further research are provided.

Increased Australian outpatient private practice psychiatric care during the COVID-19 pandemic: usage of new MBS-telehealth item and face-to-face psychiatrist office-based services in Quarter 3, 2020.

OBJECTIVE: The Australian federal government introduced new COVID-19 psychiatrist Medicare Benefits Schedule (MBS) telehealth items to assist with providing private specialist care. We investigate private psychiatrists' uptake of video and telephone telehealth, as well as total (telehealth and face-to-face) consultations for Quarter 3 (July-September), 2020. We compare these to the same quarter in 2019. METHOD: MBS-item service data were extracted for COVID-19-psychiatrist video and telephone telehealth item numbers and compared with Quarter 3 (July-September), 2019, of face-to-face consultations for the whole of Australia. RESULTS: The number of psychiatry consultations (telehealth and face-to-face) rose during the first wave of the pandemic in Quarter 3, 2020, by 14% compared to Quarter 3, 2019, with telehealth 43% of this total. Face-to-face consultations in Quarter 3, 2020 were only 64% of the comparative number of Quarter 3, 2019 consultations. Most telehealth involved short telephone consultations of ⩽15-30 min. Video consultations comprised 42% of total telehealth provision: these were for new patient assessments and longer consultations. These figures represent increased face-to-face consultation compared to Quarter 2, 2020, with substantial maintenance of telehealth consultations. CONCLUSIONS: Private psychiatrists continued using the new COVID-19 MBS telehealth items for Quarter 3, 2020 to increase the number of patient care contacts in the context of decreased face-to-face consultations compared to 2019, but increased face-to-face consultations compared to Quarter 2, 2020.

The experiences of privately practising midwives in Australia who have been reported to the Australian Health Practitioner Regulation Agency: A qualitative study.

BACKGROUND: In Australia the majority of homebirths are attended by privately practising midwives (PPMs). In recent years PPMs have been increasingly reported to the Australian Health Practitioner Regulation Agency (AHPRA) mostly by other health professionals. PURPOSE: to explore the experiences of PPMs in Australia who have been reported to the AHPRA. METHODS: A qualitative interpretive approach, employing in-depth interviews with eight PPMs was undertaken and analysed using thematic analysis. A feminist theoretical framework was used to underpin the research. RESULTS: The majority of reports made to AHPRA occurred when midwives supported women who chose care considered outside the recommended Australian College of Midwives (ACM) Consultation and Referral Guidelines. During data analysis an overarching theme emerged, "Caught between women and the system", which described the participants' feelings of working as a PPM in Australia. There were six themes and several sub-themes: The suppression of midwifery, A flawed system, Lack of support, Devastation on so many levels, Making changes in the aftermath and Walking a tight rope forever. The findings from this study reveal that midwives who are under investigation suffer from emotional and psychological distress. Understanding the effects of the process of investigation is important to improve the quality of professional and personal support available to PPMs who are reported to AHPRA and to streamline processes. CONCLUSION: It is becoming increasingly difficult for PPMs to support the wishes and needs of individual women and also meet the requirements of the regulators, as well as the increasingly risk averse health service.

Australian private practice metropolitan telepsychiatry during the COVID-19 pandemic: analysis of Quarter-2, 2020 usage of new MBS-telehealth item psychiatrist services.

OBJECTIVE: The Australian Commonwealth Government introduced new psychiatrist Medicare-Benefits-Schedule (MBS)-telehealth items in the first wave of the COVID-19 pandemic to assist with previously office-based psychiatric practice. We investigate private psychiatrists' uptake of (1) video- and telephone-telehealth consultations for Quarter-2 (April-June) of 2020 and (2) total telehealth and face-to-face consultations in Quarter-2, 2020 in comparison to Quarter-2, 2019 for Australia. METHODS: MBS item service data were extracted for COVID-19-psychiatrist-video- and telephone-telehealth item numbers and compared with a baseline of the Quarter-2, 2019 (April-June 2019) of face-to-face consultations for the whole of Australia. RESULTS: Combined telehealth and face-to-face psychiatry consultations rose during the first wave of the pandemic in Quarter-2, 2020 by 14% compared to Quarter-2, 2019 and telehealth was approximately half of this total. Face-to-face consultations in 2020 comprised only 56% of the comparative Quarter-2, 2019 consultations. Most telehealth provision was by telephone for short consultations of ⩽15-30 min. Video consultations comprised 38% of the total telehealth provision (for new patient assessments and longer consultations). CONCLUSIONS: There has been a flexible, rapid response to patient demand by private psychiatrists using the new COVID-19-MBS-telehealth items for Quarter-2, 2020, and in the context of decreased face-to-face consultations, ongoing telehealth is essential.

The impact of planning for COVID-19 on private practising midwives in Australia.

PROBLEM: The COVID-19 pandemic response has required planning for the safe provision of care. In Australia, privately practising midwives are an important group to consider as they often struggle for acceptance by the health system. BACKGROUND: There are around 200 Endorsed Midwives eligible to practice privately in Australia (privately practising midwives) who provide provide the full continuum of midwifery care. AIM: To explore the experience of PPMs in relation to the response to planning for the COVID-19 pandemic. METHODS: An online survey was distributed through social media and personal networks to privately practising midwives in Australia in April 2020. RESULTS: One hundred and three privately practising midwives responded to the survey. The majority (82%) felt very, or well informed, though nearly half indicated they would value specifically tailored information especially from professional bodies. One third (35%) felt prepared regarding PPE but many lacked masks, gowns and gloves, hand sanitiser and disinfectant. Sixty four percent acquired PPE through social media community sharing sites, online orders, hardware stores or made masks. Sixty-eight percent of those with collaborative arrangements with local hospitals reported a lack of support and were unable to support women who needed transfer to hospital. The majority (93%) reported an increase in the number of enquiries relating to homebirth. CONCLUSION: Privately practising midwives were resourceful, sought out information and were prepared. Support from the hospital sector was not always present. Lessons need to be learned especially in terms of integration, support, education and being included as part of the broader health system.

Music Therapy Private Practice in the United States: Updated Financial and Marketing Recommendations.

More and more music therapists in the United States are entering into private practice. For a private practice to survive, a therapist must make sound financial and marketing decisions that can have wide-ranging implications on the success of the business. Clear and current recommendations from music therapists in private practice can help those wanting to go into private practice as well as those already in private practice. The purpose of this study was to identify a current descriptive profile of music therapists in private practice in the United States as well as marketing and financial recommendations. In addition, comparing this survey with previous surveys can reveal possible trends in the field. Music therapists (N = 745) who self-identified as being self-employed or in private practice were sent a survey designed by the researchers. A total of 193 respondents returned the survey revealing that current therapists in private practice are better educated and value the internet and social media for marketing and session implementation more than respondents of previous surveys. Respondents recommend that music therapists in private practice continually learn by taking business classes and consulting with business experts; diversify funding sources, service options, and populations served; and connect with music therapists and nonmusic therapists in the community.

The characteristics of Queensland private physiotherapy practitioners' interprofessional interactions: a cross-sectional survey study.

Effective interprofessional collaboration (IPC) contributes to superior patient outcomes, facilitates cost-efficient health care, and increases patient and practitioner satisfaction. However, there is concern that IPC may be difficult to implement in clinical settings that do not conform to formal team-based processes, such as mono-professional physiotherapy private practice facilities. The aim of this study was to describe the characteristics of private physiotherapy practitioners' interprofessional interactions, including their experiences and perceptions regarding IPC. A custom developed cross-sectional online survey instrument was used to collect data from physiotherapists employed in private practice facilities in Queensland, Australia. In all, 49 (20% response rate) physiotherapists completed the survey. Only a small proportion (14%) indicated that their interprofessional interactions were a daily occurrence, and less than one-third of all respondents (31%) participated in formal, multi-professional face-to-face planned meetings. Most participants (76%) reported a moderate-to-high level of satisfaction regarding their interprofessional interactions. Despite low self-reported levels of interprofessional activity and other data indicating that IPC is necessary for holistic patient care, this study shows that physiotherapists were predominately satisfied when interacting with health practitioners from various professional backgrounds. Further research is required to inform the implementation of robust strategies that will support sustainable models of IPC in physiotherapy private practice.

[Patient orientation of websites of otorhinolaryngologists in private practice in Bavaria]. / Patientenorientierung von Websites niedergelassener Hals-Nasen-Ohren-Ärzte in Bayern.

OBJECTIVE: The internet plays an important role in the search for health-specific information. So far, only a few studies exist on the user-friendliness of medical websites. This study thus examines the web presence of otorhinolaryngologists in private practice in Bavaria. METHODS: All otorhinolaryngologists registered with statutory health insurance in Bavaria were evaluated using a standardized checklist. IBM SPSS version 25 (IBM Corp., Armonk, NY, USA) statistical software was used for the analysis. RESULTS: Among all otorhinolaryngologists (n = 448), 73.0% (n = 327) had their own functioning website. Only a minority of websites (1.5%) had options to adjust the font size. Regarding functional possibilities of the websites, 18.3% of the physicians offered an online appointment calendar and 3.7% the possibility of feedback. A liability disclaimer was missing on 21.6% of all websites. CONCLUSION: The results exhibit an inadequate use of criteria catalogues for web presence. A patient-oriented website configuration could help to improve customer acquisition and satisfaction, which is particularly relevant for cities with a high density of physicians.

JCL Roundtable: Lipid clinic operations.

Until 1990, lipid clinics in the United States existed only in academic medical centers, generally in close relationship with laboratory-based research programs. The advent of statin therapy, the success of major clinical trials to prevent or stabilize atherosclerotic cardiovascular disease, and organizational efforts highlighted by regional Lipid Disorders Training Centers and the newly formed National Lipid Association boosted the formation of lipid clinics and preventive cardiology clinics in private and academic settings. This roundtable discussion with 4 experts examines multiple aspects of lipid clinic operations: obtaining referrals, adapting to either the academic or community setting, organizing a team of providers, incorporating diet and lifestyle counseling as well as medication, establishing the pharmacist role, and gaining financial stability. Some issues are as yet unsettled, including the subspecialty home of lipidology, if any, and the diagnostic and management boundaries of practical lipid clinics. Achieving official recognition as a subspecialty has taken some steps forward but remains a challenge. Opportunities for advocacy need to be seized.

Motivations for Adopting and Maintaining a Yoga Practice: A National Cross-Sectional Survey.

Background: Yoga practice is becoming increasingly popular around the world, yet little is known regarding why people adopt the practice of yoga or how their reasons for practice change with continued practice. Furthermore, whether those who practice different types of yoga have different motives remains unknown. Methods: To address these issues, the authors conducted a national cross-sectional online survey of 1,702 yoga practitioners in Germany, asking about demographic information and motives for initiating and continuing yoga practice. Results: The most common primary reasons for starting yoga were relaxation (26.6%) and prevention (25.5%), which were also the most common secondary reasons. Nine hundred and forty-one (55.3%) reported a different primary reason for maintaining than for adopting yoga practice. Prevention (38.4%) and spirituality (26.4%) were the most commonly reported primary reasons for maintaining yoga practice. More highly educated participants and those practicing longer than 5 years at the time of the survey were more likely to have reported a different current primary reason for yoga practice than that for which they started practicing. Conclusions: These results shed light on yoga's appeal to novices and regular practitioners, with important implications for making yoga appealing to beginners as well as promoting the practice as a long-term lifestyle behavior.

Strategy to sensitize private practitioners on RNTCP through medico-social workers in urban field practice area of a Medical College in Bengaluru, Karnataka.

BACKGROUND: India accounts for 25% of global TB burden and majority of TB patients seek care from private practitioners. It becomes imperative to involve private practitioners with newer strategies to strengthen the Revised National Tuberculosis Control Program (RNTCP). A study was conducted to assess the knowledge, attitude and practices among private practitioners with regards to tuberculosis case detection and referral and to demonstrate the feasibility of utilizing existing medico-social worker of a medical college in sensitizing the private practitioners. METHODS: An intervention study was conducted during 2017. In an urban field practice area of a medical college, 34 allopathic private practitioners (PP) from six slums formed the study population. The RNTCP trained Medico social workers (MSW) of medical college provided repeated sensitization to private practitioners on case referrals. The data of KAP among private practitioners was collected. The output of repeated sensitization was measured by comparing the number of cases referred by Private Practitioners to DMC during the pre and post intervention period. RESULTS: Only 1 in 2 practitioners were aware about the duration of cough in presumptive TB cases. Nearly 44% of them were not aware about the first investigation of choice under RNTCP; 53% of the doctors did not know about the total number of sputum samples to be collected. After the sensitization of PPs by MSWs the number of presumptive pulmonary cases was increased by more than two folds. CONCLUSION: The strategy of utilizing the services of medico-social workers employed in a medical college to sensitize the private practitioners is feasible and has demonstrated the increase in number of presumptive TB case referrals to DMCs.

Residency Program Characteristics and Individual Physician Practice Characteristics Associated With Family Physician Scope of Practice.

PURPOSE: A family physician's ability to provide continuous, comprehensive care begins in residency. Previous studies show that patterns developed during residency may be imprinted upon physicians, guiding future practice. The objective was to determine family medicine residency characteristics associated with graduates' scope of practice (SCoP). METHOD: The authors used (1) residency program data from the 2012 Accreditation Council for Graduate Medicine Education Accreditation Data System and (2) self-reported data supplied by family physicians when they registered for the first recertification examination with the American Board of Family Medicine (2013-2016)-7 to 10 years after completing residency. The authors used linear regression analyses to examine the relationship between individual physician SCoP (measured by the SCoP for primary care [SP4PC] score [scale of 0-30; low = small scope]) and individual, practice, and residency program characteristics. RESULTS: The authors sampled 8,261 physicians from 423 residencies. The average SP4PC score was 15.4 (standard deviation, 3.2). Models showed that SCoP broadened with increasing rurality. Physicians from unopposed (single) programs had higher SCoP (0.26 increase in SP4PC); those from major teaching hospitals had lower SCoP (0.18 decrease in SP4PC). CONCLUSIONS: Residency program characteristics may influence family physicians' SCoP, although less than individual characteristics do. Broad SCoP may imply more comprehensive care, which is the foundation of a strong primary care system to increase quality, decrease cost, and reduce physician burnout. Some residency program characteristics can be altered so that programs graduate physicians with broader SCoP, thereby meeting patient needs and improving the health system.

Comparing costs of a senior wellness care redesign in group and independent physician practices of an accountable care organization.

Primary care redesign for older adult patients is currently ongoing in countries with aging populations. One of the main challenges of this type of transformations is how to estimate implementation costs in different types of health care delivery organizations. This study compares start-up and incremental expenses of implementing a primary care redesign across 2 organization types: integrated group (n = 31) practices and independent practice association (IPA) sites (n = 213). Administrators involved with implementing the redesign completed a cost capture template to quantifying expenses. The potential impact of measurement error, recollection bias, and implementation models across sites and geographic regions was examined in sensitivity analyses. Marginal start-up and incremental expenses were higher for Group sites ($122-$328) compared to IPA sites ($31-$227). Group and IPA sites, however, implemented the redesign with different intensities. According to our analyses, if IPA sites implemented the redesign with the same intensity as Group sites, marginal costs would have been $5 to $13 higher for IPA sites than for Group sites. This study shows how a flexible approach to estimate the cost of a wellness care redesign is needed when the intensity of the transformation differs across 2 different types of health care organizations.