Knowledge and behavior changes in clinician after training of partnership for Diabetes Control in Indonesia.

BACKGROUND AND AIMS: One of the main determinants of successful diabetes management is the quality of healthcare provider including general practitioner and internist which can be increased through medical training. This study aimed to describe the changes of clinician's knowledge and behavior of comprehensive diabetes management training program around Indonesia. METHOD: We conducted a three-day training program for general practitioners and internists for 3.5 years, 2013 to 2016. All clinicians invited as voluntary participant to send their patient data from medical record. Each participant was expected to submit a minimum of 25 type 2 diabetes (T2DM) set patient data before and 6 months after training program to analyze the impact of program in physician knowledge and behavior related to diabetes management. RESULT: 120 of 489 voluntary participants submitted completed baseline data with 4676 patient data. Meanwhile, only 32 participants that submitted completed data of 6 months before after training with 886 patient data. Most of parameters were improve before and after program. The greatest and lowest improvement were on A1c measurement (21%) and smoking assessment (2%). CONCLUSION: Intensive seminar and training was not enough to empower diabetes management. This research might push the creation of clinical practice program that were tailored to each care facilities and integrated within routine care aimed at continual improvement of its healthcare worker.

Forging successful partnerships in psychosis research: lessons from the Cavan-Monaghan First Episode Psychosis Study.

Embedding psychosis research within community mental services is highly desirable from several perspectives but can be difficult to establish and sustain, especially when the clinical service has a rural location at a distance from academic settings with established research expertise. In this article, we share the experience of a successful partnership in psychosis research between a rural Irish mental health service and the academic department of a Dublin medical school that has lasted over 30 years. We describe the origins and evolution of this relationship, the benefits that accrued and the challenges encountered, from the overlapping perspectives of the academic department, the mental health service and psychiatric training. We discuss the potential learning that arose from the initiative, particularly for national programme planning for early intervention in psychosis, and we explore the opportunities for enhanced training, career development and professional reward that can emerge from this type of partnership.

America's Health Care System is Broken: What Went Wrong and How We Can Fix It. Part 3: Hospitals and Doctors.

Thirty-two percent of US health care spending goes to hospital care, and 20% goes to physicians' charges. The cost of hospital care in the United States is 2-3 times greater than in most similar countries. A large part of the high cost is due to a very large administrative overhead. Both higher quality and lower cost would be achieved if complex procedures were done in fewer centers. Hospitals with a geographic or prestige monopoly receive higher payments than warranted. As physicians are increasingly employed by hospitals rather than independent, costs go up with no added benefit to patients. The United States has too many specialists and too few primary care physicians. Practice guidelines are slanted to favor expensive treatments, often with little solid evidence behind the recommendations.

The impact of walk-in centres and GP co-operatives on emergency department presentations: A systematic review of the literature.

BACKGROUND: Internationally, non-urgent presentations are increasing the pressure on Emergency Department (ED) staff and resources. This systematic review aims to identify the impact of alternative emergency care pathways on ED presentations - specifically GP cooperatives and walk-in clinics. METHODS: Based on a structured PICO enquiry with either walk-in clinic or GP cooperative as the intervention, a search was made for peer-reviewed publications in English, between 2000 and 2014. Medline plus, OVID, PubMed, and Google Scholar were searched. The Critical Appraisal Skills Program (CASP) guidelines were used to assess study quality and data was extracted using an adapted JBI Qualitative Assessment and Review Instrument (QARI). Subsequent reporting followed the PRISMA guideline. RESULTS: Eleven high quality quantitative studies met the inclusion criteria. Walk-in clinics do have the potential to reduce non-urgent emergency department presentations, however evidence of this effect is low. GP cooperatives offer an alternative care stream for patients presenting to the ED and do significantly reduce local ED attendances. Community members need to be made aware of these options in order to make informed treatment choices. CONCLUSION: GP cooperatives in particular do have the potential to reduce ED workload. Further research is required to uncover recent trends and patient outcomes for walk-in clinics and GP cooperatives.

Improving physical activity program adoption using integrated research-practice partnerships: an effectiveness-implementation trial.

Integrated research-practice partnerships (IRPPs) may improve adoption of evidence-based programs. The aim of this study is to compare adoption of an IRPP-developed physical activity (PA) program (Fit Extension, FitEx) to a typical efficacy-effectiveness-dissemination pipeline model program (Active Living Every Day, ALED). Guided by the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework, a randomized controlled trial assigned health educators (HEs) to FitEx (n = 18) or ALED (n = 18). Fourteen HEs adopted FitEx, while two HEs adopted ALED (χ 2 = 21.8; p < 0.05). FitEx HEs took less time to deliver (p < 0.05), stated greater intentions for continued program delivery (p < 0.05), and reached more participants (n = 1097 total; 83 % female; 70 % Caucasian; M age = 44 ± 11.8) per HE than ALED (n = 27 total; 60 % female; 50 % Caucasian; M age = 41 ± 11.3). No significant difference existed in FitEx or ALED participants' increased PA (M increase = 9.12 ±29.09  min/day; p > 0.05). IRPP-developed programs may improve PA program adoption, implementation, and maintenance and may also result in programs that have higher reach-without reducing effectiveness.

An effective medical partnership in Nagasaki, Japan for patients with rheumatoid arthritis.

OBJECTIVES: A clear division of the roles of inpatient facilities and outpatient clinics treating patients with rheumatoid arthritis (RA) is needed. To address this, we created a medical partnership between a university hospital and 43 community clinics in Nagasaki, Japan. METHODS: We recruited the clinic physicians and compiled a list of the RA medications used (i.e. methotrexate [MTX], other disease-modifying antirheumatic drugs [DMARDs], and biologics). When a patient's low disease activity or remission was confirmed at the university hospital, the hospital/clinic partnership provided double follow-up/medical care with semiannual meetings between the hospital and clinic physicians. RESULTS: We enrolled 149 patients who maintained clinical remission at 43 clinics over a 54-month period, without rare serious events. Among the nine patients who returned to the university hospital due to relapse, 66.7% had exacerbated RA within 18 months. An average 8.8-9.6 mg/week (max. 14 mg/week) MTX dose was prescribed at the clinics. The biologic usage rate was 22.1%, with a yearly increase. Among the patients treated with biologics, the DAS28ESR at enrollment was 2.65, with 58% treated with an MTX/biologic combination. A significant reduced number of patients with RA per rheumatologist were observed. CONCLUSIONS: Maintenance of DAS remission without major adverse events was attained in the medical partnership.

A profile of solo/two-physician practices.

Understanding practice behaviors of solo/dual physician ownership and associated factors at the national level is important information for policymakers and clinicians in response to the Affordable Care Act (ACA) of 2010, but poorly understood in the literature. We analyzed nationally representative data (n = 4,720). The study results reveal nearly 33% of the sample reported solo/two-physician practices. Male/minority/older physicians, psychiatrists, favor small practices. Greater market competition was perceived and less charity care was given among solo/two-physician practitioners. The South region was favored by small physician practitioners. Physicians in solo or two-person practices provided fewer services to chronic patients and were dissatisfied with their overall career in medicine. Small practices were favored by international medical graduates (IMGs) and primary care physicians (PCPs). Overall our data suggest that the role of solo/dual physician practices is fading away in the delivery of medicine. Our findings shed light on varied characteristics and practice behaviors of solo/two-physician practitioners, but more research may be needed to reevaluate the potential role of small physician practitioners and find a way to foster a private physician practice model in the context of the newly passed ACA of 2010.

Practice improvement, part II: trends in employment versus private practice.

A growing percentage of physicians are selecting employment over solo practice, and fewer family physicians have hospital admission privileges. Results from surveys of recent medical school graduates indicate a high value placed on free time. Factors to consider when choosing a practice opportunity include desire for independence, decision-making authority, work-life balance, administrative responsibilities, financial risk, and access to resources. Compensation models are evolving from the simple fee-for-service model to include metrics that reward panel size, patient access, coordination of care, chronic disease management, achievement of patient-centered medical home status, and supervision of midlevel clinicians. When a practice is sold, tangible personal property and assets in excess of liabilities, patient accounts receivable, office building, and goodwill (ie, expected earnings) determine its value. The sale of a practice includes a broad legal review, addressing billing and coding deficiencies, noncompliant contractual arrangements, and potential litigations as well as ensuring that all employment agreements, leases, service agreements, and contracts are current, have been executed appropriately, and meet regulatory requirements.

"A powerful intervention: general practitioners'; use of sickness certification in depression".

BACKGROUND: Depression is frequently cited as the reason for sickness absence, and it is estimated that sickness certificates are issued in one third of consultations for depression. Previous research has considered GP views of sickness certification but not specifically in relation to depression. This study aimed to explore GPs views of sickness certification in relation to depression. METHODS: A purposive sample of GP practices across Scotland was selected to reflect variations in levels of incapacity claimants and antidepressant prescribing. Qualitative interviews were carried out between 2008 and 2009. RESULTS: A total of 30 GPs were interviewed. A number of common themes emerged including the perceived importance of GP advocacy on behalf of their patients, the tensions between stakeholders involved in the sickness certification system, the need to respond flexibly to patients who present with depression and the therapeutic nature of time away from work as well as the benefits of work. GPs reported that most patients with depression returned to work after a short period of absence and that it was often difficult to predict which patients would struggle to return to work. CONCLUSIONS: GPs reported that dealing with sickness certification and depression presents distinct challenges. Sickness certificates are often viewed as powerful interventions, the effectiveness of time away from work for those with depression should be subject to robust enquiry.

A partnership evaluation: public mental health and dental services.

OBJECTIVE: This study evaluates the partnership between a mental health service and a public dental hospital in providing timely and efficient access to dentistry to patients with a mental illness. In addition, the factors that contributed to the sustainability of the partnership were examined. METHOD: The partnership was appraised using a survey-based evaluation with 20 patients, 43 community mental health staff and 14 dental staff, and focus groups with mental health and dental staff. RESULTS: The partnership between the services is the key element to the success of improving access to dental services for patients. Overall feedback received from mental health staff highlighted the importance of the partnership and its role in meeting the oral health needs of patients. Generally, patients were satisfied with the treatment they received and valued the dental service. Results highlighted an ongoing problem of poor dietary and lifestyle choices. Dental staff felt that mental health patients were less likely to take care of their teeth and were more likely to cancel appointments. Dental staff also acknowledged frustration with patients with a mental illness not attending appointments or following through with a recommended course of treatment. CONCLUSIONS: The partnership with the local dental hospital has created a sustainable way to ensure improved dental health outcomes for patients of mental health services. This partnership has led to increased access to dental services and improved follow-up.

A comparison of the outcomes of partnership caseload midwifery and standard hospital care in low risk mothers.

BACKGROUND: Maternal and infant clinical outcomes were compared for low risk mothers receiving a partnership caseload model of midwifery care, known as Primary Health Midwifery Care (PHMC), and standard hospital care (SHC). METHODS: Using secondary analysis of data from the Obstet Data System routine collection (PHMC n=976, SHC n=976) from a large metropolitan hospital, maternal and infant clinical outcomes were examined. RESULTS: Odds ratios (OR) demonstrated reduced rates of interventions for multiparous women (OR 0.62 [CI 0.49-0.80]), with multiparous women receiving PHMC being more likely to have a normal delivery (OR 1.75 [CI 1.22-2.5]). A higher proportion of both primiparous and multiparous women receiving PHMC received pethidine during labour (OR 1.78 [1.33-2.39], OR 1.55 [1.19-2.01] respectively). Primiparous women receiving PHMC underwent fewer episiotomies with an associated increase in the proportion of women experiencing perineal tears (OR 1.93, CI 2.35-2.78), although perineum trauma rates were similar for both care models. Similar and very small numbers of infants in both parity groups and care models had an Apgar of less than seven at five minutes or were admitted to the neonatal intensive care unit or special care unit. CONCLUSION: This study, within the limitations of its design, supports the safety of the partnership caseload midwifery care model, in addition to reduced rates of interventions experienced by multiparous women and fewer episiotomies in primiparous low risk English-speaking women receiving caseload care.

Generational differences in practice patterns of dermatologists in the United States: implications for workforce planning.

OBJECTIVE: To examine the effect of age and other demographic factors on dermatologists' practice characteristics. DESIGN: Anonymous practice profile survey. PARTICIPANTS: Dermatologist members of the American Academy of Dermatology Association. MAIN OUTCOME MEASURES: Analyzed survey questions included information about legal practice entity, geographic area served, weekly patient care hours, patients seen per hour, and scope of patient care activities. RESULTS: Of 4090 surveys sent, 1425 (35%) were returned. As the age of the cohorts increased, the percentage practicing in solo practices increased (range, 21%-39%), as did the percentage serving urban areas (range, 31%-46%). Measures of physician productivity increased in the older age cohorts; however, age was not a significant factor after controlling for other variables. More patient-hours per week were associated with male sex (P < .001), solo practices (P < .001), and non-urban-based practices (P = .04), whereas a greater number of patients per hour was associated with non-rural-based practices (P = .02) and male sex (P = .03). As the cohorts progressed in age, more time was spent practicing medical dermatology. The number of hours spent practicing cosmetic dermatology peaked in the 41- to 50-year-old cohort (P = .03). CONCLUSIONS: Practice patterns differ significantly among dermatologists of different ages. As the current cohorts age and new dermatologists emerge from training, changes in scope of practice and generational differences in productivity are likely to cause a contraction in the effective supply of dermatologists, which has important implications for dermatology workforce planning.

Women-centred care and caseload models of midwifery.

OBJECTIVE: A partnership caseload model of midwifery-led practice was developed and introduced as an option of maternity care for low risk women at our local health service. To assess the benefits of this new practice model, aspects of continuity, choice, control and satisfaction were examined in women receiving Primary Health Midwifery Care (PHMC) and standard hospital care (SHC). DESIGN AND SETTING: A descriptive comparative design was used and survey data were collected using a modified version of the Mason Survey of Womens' Experience of Maternity Care from a convenience sample of women receiving PHMC (n = 357) and SHC (n = 202) from a large metropolitan health service. FINDINGS: Overall, more women receiving PHMC experienced key aspects of women-centered care-choice, control and continuity than women receiving SHC. KEY CONCLUSIONS: This study, within the limitations of its design and sample size, confirms that low risk women have positively responded to partnership caseload midwifery practice, and the practice model has supported women-centred care with special benefits for primipara women.

Use of rubber dam and its association with other endodontic procedures in New Zealand.

The use of rubber dam for endodontic treatment in New Zealand was analysed by a national survey of general dental practitioners. The response rate was 79 percent. Rubber dam was used routinely by 57 percent, its use increasing among practitioners graduating since 1969. A greater percentage of practitioners with less than 10 years experience used rubber dam than did more experienced practitioners. Use of rubber dam was associated with sodium hypochlorite and EDTA as canal irrigants. Reamers were the favoured hand instrument of non-users of rubber dam. No significant differences were found in the canal obturation techniques of users and non-users, but rubber dam users used the long-cone paralleling method of radiography significantly more than non-users. Practitioners in solo practice used rubber dam significantly less than those in group practice. Rubber dam users attended significantly more refresher courses in endodontics than non-users.

Hiring of radiation oncologists by physician groups in 1997.

PURPOSE: To determine the hiring activities of physician groups with respect to radiation oncologists. METHODS AND MATERIALS: A survey was mailed to a stratified, random sample of 589 groups in the fall of 1997. A total of 448 surveys were returned from groups with more than one radiation oncologist or diagnostic radiologist. The response rate was 76%. Responses were weighted to represent the total population of approximately 3286 practices in the United States that have multiple radiation oncologists or diagnostic radiologists. Eighty-seven responding groups had radiation oncologists and are the basis of reported data. Findings were compared to results of similar, previous surveys. RESULTS: In the 12 months prior to the survey, groups sought to hire 289 (SE = 76) radiation oncologists, about the same as in 1996 but well above 1994 and 1995. Almost all the 289 jobs were full-time positions; 70% were to fill expansion positions, 10% were replacements for physicians who had left the profession, and the remaining 20% were replacements for physicians who had moved to other radiation oncology positions. During the year, an additional 83 (SE = 36) positions were vacated that groups did not seek to refill. Private, nonacademic groups offered 26% of their full-time positions on a non-partnership-track basis. Seventy-one percent of available positions were in groups that preferred recently trained radiation oncologists to those with 10-20 years experience. Groups succeeded in hiring 220 (SE = 65) radiation oncologists, 76% of those sought. CONCLUSIONS: In 1997, the number of positions available apparently was approximately equal to the number needed, which is the number of graduates plus the number of experienced radiation oncologists moving to new jobs. However, because our sample was small, there might have been a considerable disparity.

Partnership changes in English general practice from 1990 to 1994.

BACKGROUND: The objective of this study was to quantify the rate of partnership change among general practitioners (GPs) in the National Health Service (NHS) in England from 1990 to 1994. METHODS: Time series data on English GPs were analysed on 1 October for the years 1990-1994. The main outcome measures include: (1) proportion of GPs practising in an unchanged partnership from 1 October 1990 to 1 October 1994; (2) proportion of partnerships that were unchanged over the study period; (3) the average yearly rate of partnership changes for England and per Family Health Service Authority (FHSA), calculated using both the individual GP and the practice as the unit of analysis. RESULTS: A total of 6532 (27.1 per cent) of the 24,107 unrestricted GPs practising full time on 1 October 1990 were still practising in the identical partnership on 1 October 1994; 3539 (35.7 per cent) of the 9918 practices in England were unchanged over the same period. The average yearly partnership change rate for all England was 23.1 per cent when calculated using the individual GP as the unit of analysis, and 23.4 per cent when calculated using the practice as the unit of analysis. There is threefold variation found in the average yearly partnership change rate by FHSA, with similar rank ordering of health authorities when using either the individual GP or practice as unit of analysis. CONCLUSIONS: Changes in partnerships are commonplace. The possible influence of such changes on primary care in the NHS should be further investigated.

Medical practice with nursing home residents: results from the National Physician Professional Activities Census.

OBJECTIVE: The study describes the prevalence of medical nursing home practice. Further, it examines the extent to which physician characteristics and local county health care resources predict nursing home involvement. This information is relevant to evaluating and devising strategies that address the future provision of medical care in institutionalized long-term care. DESIGN: A cross-sectional survey. SETTING: A national sample of all licensed practicing physicians was obtained from a special Professional Activities (PPA) survey conducted by the American Medical Association (AMA) in 1991. PARTICIPANTS: Respondents were 21,578 physicians involved in direct patient care. MEASURES: The typical number of hours spent weekly caring for nursing home patients was obtained from the PPA survey, and physician demographics were obtained from the AMA Masterfile. County health care resources were obtained from the National Institutes of Health Area Resources File. RESULTS: Most (77%) physicians reported spending no measurable time caring for nursing home patients. In all disciplines, a majority of physicians with a nursing home practice spent less than 2 hours per week with patients. Logistic regressions indicted that family practitioners and internists were most likely to have a nursing home practice, but general practitioners were most likely to spend more time in practice. Only 15% of specialists reported having a nursing home practice. Prevalence of practice was greatest among solo practitioners and physicians in partnerships and least among academic and hospital-based physicians and physicians in group practice or employed by the government. Most county of practice resources were not associated or were modestly associated with nursing home practice, but having a nursing home practice became much more likely as the number of nursing home residents increased and hospital beds decreased. A pattern was found for nursing home practice to be slightly less likely as the county's per capita income and the proportion of proprietary nursing facilities increased. CONCLUSIONS: With increasing numbers of older and frailer residents, nursing homes will continue to be integral components of the future healthcare system. However, physicians currently spend minimal time caring for nursing home patients, with physician characteristics best predicting involvement. Questions remain about the future of nursing home medical practice and how to best recruit, staff, and train future cadres of physicians to provide sufficient quality care for nursing home patients in an evolving health care system.