Should nurses prescribe blood components?

AIM

To explore the feasibility of nurses prescribing blood components.

METHOD

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

RESULTS

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

CONCLUSION

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

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

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

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

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

Policy for therapeutic massage in an academic health center: a model for standard policy development

CONTEXT

Massage is the most common complementary and alternative medicine (CAM) therapy used in hospitals in the United States. As such, it is often the first CAM therapy to be integrated with conventional medicine. However, few academic medical centers have a written standard policy to guide this integration. This lack of standard policy may impede institutions from offering massage therapy as a clinical service, and may put health care professionals and institutions at risk through a failure to clearly address criteria for practice credentials or malpractice liability.

OBJECTIVE

To create a clinical policy for therapeutic massage that may be used as a template for development of policy in academic health centers.

RESULTS

We present a clinical policy for therapeutic massage, developed by the University of Michigan Health System, that defines therapeutic massage, provides guidelines for the credentialing and professional conduct of massage therapists, lists indications and contraindications for therapeutic massage, and addresses malpractice in accordance with the specific culture and needs of academic health centers. This policy was created by health care professionals after review of existing evidence and consideration of national criteria for massage therapy. This policy is intended to be used as a template for the development of a standard policy for therapeutic massage by health system administrators, medical directors, and massage professionals, to support the integration of therapeutic massage within their institutions.

CONCLUSIONS

With minor modifications of this policy by individual institutions, adoption of this policy may facilitate the thoughtful integration of this CAM therapy into academic health care settings, meeting the unique requirements of academic health care institutions while serving the needs of patients.

Provider management of menopause after the findings of the Women's Health Initiative

OBJECTIVE

A survey was conducted to determine current provider behaviors and concerns related to menopause management.

DESIGN

All gynecology, internal medicine, and family medicine providers (both physicians and nurse practitioners) within a large Midwestern integrated health system were surveyed about current approaches to menopause management, frequency and reasons for hormone therapy (HT) use, approaches to HT discontinuation, treatments for symptom control, bone mineral density testing, and concerns related to menopause management. Descriptive statistics and chi-square tests were performed to examine frequencies and differences based on gender, specialty, and years in practice.

RESULTS

Overall the response rate was 58% with providers from owned clinics, with female providers being the most likely to respond (P < 0.001). Changes in menopause management included using lower dose hormones (74%), encouraging use for shorter time periods (73%), and using different modes of delivery (21%). Most providers (89%) initiate HT use in symptomatic patients, and only 12% initiate use to prevent symptoms. Patients were most likely to discuss HT with gynecologists (78% gynecologists vs 64% family medicine providers and 48% internal medicine providers, P = 0.015). Nearly two thirds of providers (64%) claimed to order bone mineral density testing frequently. Providers' concerns related to information on symptom management, alternative and over-the-counter medications, the risk/benefits of medications, patients' sexual concerns, and maintaining bone health.

CONCLUSIONS

We found that providers were responsive to current literature, shifting the agents and dosages they prescribe. Still they are faced with women reporting symptoms that interfere with their ability to function optimally and must continue to help women maintain healthy bones.

Reconsidering the transfer of patients from the intensive care unit to the ward: a case study approach

Evidence indicates that the poorly managed transfer of a patient from the intensive care unit (ICU) to the ward can lead to physical and psychological complications for the patient, and often require ICU readmission and rehospitalization. Reviewing this patient transfer process to improve the quality of care would be a positive step towards enhancing patients' recovery and providing skills to staff. The aim of this paper is to review case studies of transferring ICU patients to general wards in order to identify the shortcomings of this process. A literature review was conducted to evaluate current practices in the ICU transfer process. The results of this paper have clinical implications, suggest approaches to improve support for patients and their carers, and provide strategies to improve the transfer procedure.

Optometric practice in Norway: a cross-sectional nationwide study

PURPOSE

To describe optometric practitioners and their encountering patients.

METHODS

All members of the Norwegian Association of Optometrists working in the community (n = 761) were invited to participate in a questionnaire survey; questionnaire responders (n = 508) were asked to take part in a practice registration. Data collection was carried out between November 2004 and May 2005 using a questionnaire and a practice registration form.

RESULTS

Five hundred and eight optometrists responded to the questionnaire; of these 212 participated in the practice registration, in which 4052 patient encounters were recorded. All optometrists reported taking patient history in the areas of vision and ocular health; 55% asked questions about general health for all patients. More than 80% collaborated with general practitioners and ophthalmologists. The patient encounters were with 1699 men and 2216 women; 60% of patients were aged 45 years or older. Patients reported a history of ocular disease and other conditions of relevance for ocular health in 12% and 17% of encounters, respectively. One per cent had low vision [best corrected visual acuity (BCVA) < 0.33] and 2% were visually impaired (BCVA < 0.5). Ophthalmoscopy was performed for 88% of patients; dilated fundus examinations were carried out for 2%; clinical findings of cataract were reported for 11%; and retinopathy was suspected in 3%. Six per cent of patients were referred to a general practitioner or ophthalmologist.

CONCLUSION

Optometrists generally collaborate with general practitioners and ophthalmologists. They take history, investigate and assess patients with ocular problems. A significant number of patients had primary or secondary ocular disease. This illustrates the role of optometrists as healthcare workers.

Evidence-based and values-based policy, management and practice in child and adolescent mental health services

Values-based practice is a new approach to working with complex and conflicting values. It is based, primarily, on learnable skills and is being applied across a range of policy, training and service development initiatives in mental health and social care. This article outlines some of the key features of values-based practice including its complementary relationships to both regulatory ethics and evidence-based practice. We describe the systemic links between values-based approaches at the three key levels of policy, service development, prioritization and commissioning, and clinical practice and managing delivery of services, particularly as they are being developed in child and adolescent mental health services. Our article concludes by indicating some of the areas for further development of values-based practice.

Optimizing hemodialysis practices in Canada could improve patient survival

Data from the Canadian Organ Replacement Registry (CORR) and the Dialysis Outcomes and Practice Patterns Study (DOPPS) were used to determine whether practice patterns have changed in Canada since the introduction of the Canadian Society of Nephrology (CSN) Guidelines in 1999. DOPPS data were then used to calculate the impact of not meeting the proposed guideline targets and to estimate the potential life years gained if all Canadian hemodialysis patients achieved guideline targets. For dialysis dose and hemoglobin targets, Canadian facility performance has significantly improved over time. The vascular access use patterns show trends toward a worse pattern with increased catheter use. A calculation of the percentage of attributable risk suggests that 49% of deaths could possibly be averted if all patients currently outside the guidelines achieved them over the next five years. This corresponds to a decrease in the annual death rate from 18 to 10.1 per hundred patient years. These data support the need for improved adherence to guidelines. If Canadian caregivers were to optimize practice patterns, patient outcomes could be improved.

The Bee Kind Garden: a qualitative description of work with maltreated children

Although overwhelming numbers of children experience maltreatment in the U.S.A., less than half receive mental health services. Furthermore, those seeking treatment frequently find a lack of available and/or appropriate services, thus many communities look for alternative ways to provide services to maltreated children. In this article we describe the Bee Kind Garden, an innovative project for maltreated children. Because the combination of strategies employed in the Garden was not found in any other comparable, published program, our goal is to describe the program from treatment providers' perspectives and to provide a theoretical basis for the program's conceptualization. We conducted semistructured interviews with providers from a wide variety of professional backgrounds and roles (e.g. child therapists, animal-assisted therapists, environmental educators). Through qualitative analyses, we identified five primary themes that encompassed providers' descriptions: Metaphorical environment, garden environment, one-on-one relationship, child-centered focus, and challenging representational models. Results and conclusions describing this innovative program are presented in the context of current child maltreatment literature. Discussion of collaboration between community-based organizations and academic researchers is suggested.

Attitudes to evidence-based medicine of primary care physicians in Asir region, Saudi Arabia

A questionnaire survey was made of primary health care physicians in Asir region, Saudi Arabia in 1999 to explore their awareness of and attitude towards evidence-based medicine. The 272 respondents welcomed the principles of evidence-based medicine. Awareness and use of extracting journals, review publications and databases was low. Pharmaceutical company sponsored journals were the most commonly read. Bibliographic databases could only be accessed by 13% of respondents and the Internet by only 6%. There was only partial understanding of technical terms used in evidence-based medicine. Absence of a local library and increased patient workload were seen by most respondents as the main obstacles to practising evidence-based medicine.

Pediatric health care providers' self-reported practices in recognizing and treating maternal depression

Screening for maternal depression with appropriate intervention has been emphasized through pediatric guidelines, but engaging providers to implement such procedures remains challenging. This study examined self-reported practice in recognizing and treating maternal depression in 98 pediatric health care providers. Over 85% agreed that recognizing maternal depression was their responsibility, yet only half reported confidence in their ability to do so. Fewer than 10% reported asking mothers about depression or using a screening tool. Clear differences in practice, treatment, and perceived barriers by confidence level were found. Implications for practice, research, and training are discussed.

Cancer adolescent pathway in France between 1988 and 1997

We report an adolescent cancer pathway from referral, through diagnosis and treatment, to follow-up in France. All cases of cancer among 15-19 years, diagnosed from 1988 to 1997, recorded by nine French population-based cancer registries (10% of French population) were included. The management of adolescent cancer by paediatricians was rare. An adolescents' pathway through cancer care can be summarized as first visit to general practitioner, referral to adult oncologist for haematological malignancy and medical or surgical specialists for solid tumours, treatment in adult unit, and follow-up by adult oncologist, adult medical or surgical specialist, or general practitioner. Only 9% of the 15-19 years are entered into a clinical trial (respectively 6% and 3% into adult and paediatric clinical trial). The inclusion rate changes according to the diagnosis, higher for acute lymphoblastic leukaemia (39%), non-Hodgkin's lymphomas (NHL) (27%), and acute non-lymphoblastic leukaemia (20%). Only 4% of adolescent cancers were managed on shared adult/paediatric departments, especially for soft-tissue sarcomas (14.9%), malignant bone tumours (13.4), central nervous system tumours (6.2%), and NHL (4.4%). Whatever the reasons for lack of participation in clinical trials, an ideal model requiring communication and cooperation between all adult and paediatric specialists involved in adolescent cancer treatment should reduce the large gap in access to cooperative groups.

Valuing the Professional Work of Diagnostic Radiologic Services

The challenges to the technical component (TC) of radiology services as a result of the Deficit Reduction Act of 2005 have been widely publicized, but a number of regulatory changes will affect the professional component (PC) of our physician work. The third 5-year review is complete, and although there were no major reductions in work relative value units (RVUs) for radiology, proposed budget-neutrality adjustments to physician work RVUs will potentially reduce payments for both the PC and global payments. Additionally, if there is no congressional intervention, reductions in the conversion factor will further decrease Medicare payments. In the article, the history of the radiology relative value scale and the methodology of American Medical Association/Specialty Society Relative Value Scale Update Committee's valuation of physician work are reviewed. The results of the third 5-year review are presented. Future challenges to radiology physician work valuation are discussed, including outsourcing, the Medicare Payment Advisory Commission's search for overvalued services, and the bundling of physician services. Whereas the TC is compensation for performing a diagnostic test, ultimately, it is our physician work that defines our specialty, and challenges to our physician work will be vigorously defended by the ACR without compromise.

Influences on patients' ratings of physicians: Physicians demographics and personality

OBJECTIVE

There is considerable interest in the influences on patients' ratings of physicians.

METHODS

In this cross-sectional study, patients (n = 4616; age range: 18-65 years) rated their level of satisfaction with their primary care physicians (n = 96). Patients and physicians were recruited from primary care practices in the Rochester, NY metropolitan area. For analytic purposes, length of the patient-physician relationship was stratified (< or =1, 1-4, > or =5 years). Principal components factor analysis of items from the Health Care Climate Questionnaire, the Primary Care Assessment Survey and the Patient Satisfaction Questionnaire yielded a single factor labeled "Satisfaction" that served as the sole dependent variable. Higher scores mean greater satisfaction. Predictors of interest were patient demographics and morbidity as well as physician demographics and personality, assessed with items from the NEO-FFI.

RESULTS

Patients treated by a physician for 1 year or less rated male physicians higher than female physicians. This gender difference disappeared after 1 year, but two physician personality traits, Openness and Conscientiousness, were associated with patients' ratings in lengthier patient-physician relationships. Patients report being more satisfied with physicians who are relatively high in Openness and average in Conscientiousness. Older patients provide higher ratings than younger patients, and those with greater medical burden rated their physicians higher.

CONCLUSION

Patients' ratings of physicians are multidetermined. Future research on patient satisfaction and the doctor-patient relationship would benefit from a consideration of physician personality. Identifying physician personality traits that facilitate or undermine communication, trust, patient-centeredness, and patient adherence to prescribed treatments is an important priority.

PRACTICE IMPLICATIONS

Learning environments could be created to reinforce certain traits and corresponding habits of mind that enhance patient satisfaction. Such a shift in the culture of medical education and practice could have implications for patient care.

Addressing immunization barriers, benefits, and risks

Vaccines have been highly effective in eliminating or significantly decreasing the occurrence of many once-common diseases. Barriers to immunization are a significant factor in the rising incidence rates of some vaccine-preventable diseases. Cost, reduced accessibility to immunizations, increasingly complex childhood and adolescent/adult immunization schedules, and increasing focus on the potential adverse effects of vaccines all contribute to difficulty in meeting the 2010 immunization goals. Physicians must not only be knowledgeable about vaccines but they must incorporate systems in their offices to record, remind, and recall patients for vaccinations. They must also clearly communicate vaccine benefits and risks while understanding those factors that affect an individual's acceptance and perception of those benefits and risks.

Primary care in a post-communist country 10 years later Comparison of service profiles of Lithuanian primary care physicians in 1994 and GPs in 2004

OBJECTIVES

The study aimed, firstly, to assess changes in the service profile of primary care physicians between 1994, when features of the Soviet health system prevailed, and 2004, when retraining of GPs was completed. Secondly, to compare service profiles among current GPs, taking into account their positions before being retrained.

METHODS

A cross-sectional repeated measures study was conducted among district therapists and district pediatricians in 1994 and GPs in 2004. A questionnaire was used containing identical items on the physicians' involvement in curative and preventive services. The response rates in both years were 87% and 73%, respectively.

RESULTS

In 2004, physicians had much more office contacts with patients than in 1994. Modest progress was made with the provision of technical procedures. Involvement in disease management was also stronger in 2004 than in 1994, particularly among former pediatricians. Involvement in screening activities remained stable among former therapists and increased among former pediatricians. At present, GPs who used to be therapists provide a broader range of services than ex pediatricians. GPs from the residency programme hold an intermediate position.

CONCLUSIONS

Lithuanian GPs have taken up new tasks but variation can be reduced. The health care system is still in the midst of transition.