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Carmichael J, Abdi S, Balaskas K, Costanza E, Blandford A. Assessment of optometrists' referral accuracy and contributing factors: A review. Ophthalmic Physiol Opt 2023; 43:1255-1277. [PMID: 37395045 PMCID: PMC10946769 DOI: 10.1111/opo.13183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 05/14/2023] [Accepted: 05/31/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE In the UK, ophthalmology has the highest number of outpatient appointments within the National Health Service. False-positive referrals from primary care are one of the main factors contributing to the oversubscription of hospital eye services (HESs). We reviewed the accuracy of referrals originating from primary care optometrists and contributing factors, such as condition type and years since registration. RECENT FINDINGS Of the 31 studies included in the review, 22 were retrospective analyses of referrals and appointments at the HES. Eight were prospective studies, and one used online clinical vignettes. Seven assessed the accuracy of referrals for all ocular conditions. The remaining studies focused on glaucoma (n = 11), cataracts (n = 7), emergency conditions (n = 4), neovascular age-related macular degeneration (n = 1) and paediatric binocular vision (n = 1). The diagnostic agreement for suspected emergency ocular conditions was the lowest, with only 21.1% of referrals considered to require urgent attention in one study. For glaucoma, the first-visit discharge rate was high (16.7%-48%). Optometrist referral accuracy was overall 18.6% higher than General Medical Practitioners'; however, the two mainly referred different ocular conditions. Female optometrists made more false-positive referrals than males (p = 0.008). The proportion of false positives decreased by 6.2% per year since registration (p < 0.001). SUMMARY There was significant variation in referral accuracy across different ocular conditions, partly due to differences when defining accurate referrals. Optometrists working in primary care are generally more limited in their resources than the HES. Thus, choosing the cautious option of referral when they are unsure could be in the patients' best interests. The possible effect of increased use of advanced imaging on referrals requires evaluation. Although interventions such as refinement schemes have been put in place, these vary across regions, and their approaches such as virtual referral triaging may reduce unnecessary HES face-to-face appointments and promote communication between primary and secondary care.
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Affiliation(s)
- Josie Carmichael
- University College London Interaction Centre (UCLIC), UCLLondonUK
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCLInstitute of OphthalmologyLondonUK
| | - Sarah Abdi
- University College London Interaction Centre (UCLIC), UCLLondonUK
| | - Konstantinos Balaskas
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCLInstitute of OphthalmologyLondonUK
| | - Enrico Costanza
- University College London Interaction Centre (UCLIC), UCLLondonUK
| | - Ann Blandford
- University College London Interaction Centre (UCLIC), UCLLondonUK
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Ramesh S, James MT, Holroyd-Leduc JM, Wilton SB, Seely EW, Wheeler DC, Ahmed SB. Sex Hormone Status in Women With Chronic Kidney Disease: Survey of Nephrologists' and Renal Allied Health Care Providers' Perceptions. Can J Kidney Health Dis 2017; 4:2054358117734534. [PMID: 29123913 PMCID: PMC5661668 DOI: 10.1177/2054358117734534] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 06/19/2017] [Indexed: 11/16/2022] Open
Abstract
Background Chronic kidney disease (CKD) in reproductive-age women is accompanied by menstrual and fertility disorders and premature menopause. Objective We sought to determine nephrologists' and allied health care providers' perceptions on management of sex hormone status in women with CKD. Methods An anonymous, Internet-based survey was sent to nephrology society members from Canada, Australia, New Zealand, and the United Kingdom, and the Canadian Association of Nephrology Nurses and Technologists (February-November 2015). We assessed reported perceptions and management of sex hormone status in women with CKD. Results One hundred seventy-five nephrologists (21% response rate) and 121 allied health care providers (30%; 116 nurses, 5 pharmacists) responded. Sixty-eight percent of nephrologists and 46% of allied providers were between the ages of 30 and 50 years, and 38% of nephrologists and 89% of allied workers were female. Ninety-five percent of nephrologists agreed that kidney function impacts sex hormone status, although only a minority of nephrologists reported often discussing fertility (35%, female vs male nephrologists, P = .06) and menstrual irregularities with their patients (15%, female vs male nephrologists,P = .02). Transplant nephrologists reported discussing fertility more often than did nontransplant nephrologists (53% vs 30%, P = .03). Physicians were more likely to report discussing fertility (33% vs 7.5%, P < .001) and menstrual irregularities (15% vs 9%, P = .04) with patients than allied health care providers. Forty-three percent of physicians reported uncertainty about the role for postmenopausal hormone therapy in women with CKD. Conclusion Nephrologists and allied health care providers recognize an impact of CKD on sex hormones in women but report not frequently discussing sex hormone-related issues with patients. Our international survey highlights an important knowledge gap in nephrology.
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Affiliation(s)
| | - Matthew T James
- Faculty of Medicine, University of Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, Calgary, Canada.,Alberta Kidney Disease Network, Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Jayna M Holroyd-Leduc
- Faculty of Medicine, University of Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Stephen B Wilton
- Faculty of Medicine, University of Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Ellen W Seely
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard University, Boston, MA, USA
| | | | - Sofia B Ahmed
- Faculty of Medicine, University of Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, Calgary, Canada.,Alberta Kidney Disease Network, Calgary, Canada
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Davey CJ, Scally AJ, Green C, Mitchell ES, Elliott DB. Factors influencing accuracy of referral and the likelihood of false positive referral by optometrists in Bradford, United Kingdom. JOURNAL OF OPTOMETRY 2016; 9:158-65. [PMID: 26614021 PMCID: PMC4911451 DOI: 10.1016/j.optom.2015.10.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 10/12/2015] [Accepted: 10/12/2015] [Indexed: 05/16/2023]
Abstract
AIMS Levels of false positive referral to ophthalmology departments can be high. This study aimed to evaluate commonality between false positive referrals in order to find the factors which may influence referral accuracy. METHODS In 2007/08, a sample of 431 new Ophthalmology referrals from the catchment area of Bradford Royal Infirmary were retrospectively analysed. RESULTS The proportion of false positive referrals generated by optometrists decreases with experience at a rate of 6.2% per year since registration (p<0.0001). Community services which involved further investigation done by the optometrist before directly referring to the hospital were 2.7 times less likely to refer false positively than other referral formats (p=0.007). Male optometrists were about half as likely to generate a false positive referral than females (OR=0.51, p=0.008) and as multiple/corporate practices in the Bradford area employ less experienced and more female staff, independent practices generate about half the number of false positive referrals (OR=0.52, p=0.005). CONCLUSIONS Clinician experience has the greatest effect on referral accuracy although there is also a significant effect of gender with women tending to refer more false positives. This may be due to a different approach to patient care and possibly a greater sensitivity to litigation. The improved accuracy of community services (which often refer directly after further investigation) supports further growth of these schemes.
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Affiliation(s)
| | - Andrew J Scally
- School of Health Studies, University of Bradford, Bradford, UK
| | - Clare Green
- Bradford Teaching Hospitals Foundation Trust, Bradford Royal Infirmary, Bradford, UK
| | - Edwin S Mitchell
- Shipley Ophthalmic Assessment Programme, Windhill Green Medical Centre, Shipley, UK
| | - David B Elliott
- Bradford School of Optometry and Vision Science, University of Bradford, Bradford, UK
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Bernardes SF, Costa M, Carvalho H. Engendering Pain Management Practices: The Role of Physician Sex on Chronic Low-Back Pain Assessment and Treatment Prescriptions. THE JOURNAL OF PAIN 2013; 14:931-40. [DOI: 10.1016/j.jpain.2013.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 03/06/2013] [Accepted: 03/11/2013] [Indexed: 10/26/2022]
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Abstract
CONTEXT Women are in the majority in terms of entry to medical schools worldwide and will soon represent the majority of working doctors. This has been termed the 'feminising' of medicine. In medical education, such gender issues tend to be restricted to discussions of demographic changes and structural inequalities based on a biological reading of gender. However, in contemporary social sciences, gender theory has moved beyond both biology and demography to include cultural issues of gendered ways of thinking. Can contemporary feminist thought drawn from the social sciences help medical educators to widen their appreciation and understanding of the feminising of medicine? DISCUSSION Post-structuralist feminist critique, drawn from the social sciences, focuses on cultural practices, such as language use, that support a dominant patriarchy. Such a critique is not exclusive to women, but may be described as supporting a tender-minded approach to practice that is shared by both women and men. The demographic feminising of medicine may have limited effect in terms of changing both medical culture and medical education practices without causing radical change to entrenched cultural habits that are best described as patriarchal. Medical education currently suffers from male biases, such as those imposed by 'andragogy', or adult learning theory, and these can be positively challenged through post-structuralist feminist critique. CONCLUSIONS Women doctors entering the medical workforce can resist and reformulate the current dominant patriarchy rather than reproducing it, supported by male feminists. Such a feminising of medicine can extend to medical education, but will require an appropriate theoretical framework to make sense of the new territory. The feminising of medical education informed by post-structuralist frameworks may provide a platform for the democratisation of medical culture and practices, further informing authentic patient-centred practices of care.
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Van den Brink M. Scouting for talent: appointment practices of women professors in academic medicine. Soc Sci Med 2011; 72:2033-40. [PMID: 21636196 DOI: 10.1016/j.socscimed.2011.04.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Revised: 04/15/2011] [Accepted: 04/18/2011] [Indexed: 11/17/2022]
Abstract
This paper contributes to current literature on the under-representation of women in academic medicine by critically examining appointment practices for medical professors in the Netherlands. By opening the black box of these highly secretive appointments, it is shown how allegedly gender-neutral practices contribute to the perpetuation of gender inequalities in academic medicine. The methods employed include quantitative analysis of 286 appointment reports and qualitative interviews with 21 scouts. The analysis revealed a dominant pattern of recruitment by invitation by male scouts, leading to three gender mechanisms of inclusion and exclusion through formal/informal networking. When candidates are recruited through homogeneous male networks, the pool of potential candidates is drastically restricted. Women are not seen as obvious choices for professorships since their commitment to the job is questioned. Furthermore, women do not correspond to the image of the ideal manager since they do not appear to conform to the gendered preconceptions of leadership held by the predominantly male scouts.
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Affiliation(s)
- Marieke Van den Brink
- Radboud University Nijmegen, Institute for Management Research, Thomas van Aquinostraat 3, Nijmegen, Netherlands.
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Tabenkin H, Eaton CB, Roberts MB, Parker DR, McMurray JH, Borkan J. Differences in cardiovascular disease risk factor management in primary care by sex of physician and patient. Ann Fam Med 2010; 8:25-32. [PMID: 20065275 PMCID: PMC2807384 DOI: 10.1370/afm.1071] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The purpose of this study was to evaluate differences in the management of cardiovascular disease (CVD) risk factors based upon the sex of the patient and physician and their interaction in primary care practice. METHODS We evaluated CVD risk factor management in 4,195 patients cared for by 39 male and 16 female primary care physicians in 30 practices in southeastern New England. RESULTS Many of the sex-based differences in CVD risk factor management on crude analysis are lost once adjusted for confounding factors found at the level of the patient, physician, and practice. In multilevel adjusted analyses, styles of CVD risk factor management differed by the sex of the physician, with more female physicians documenting diet and weight loss counseling for hypertension (odds ratio [OR] = 2.22; 95% confidence interval [CI], 1.12-4.40) and obesity (OR = 2.14; 95% CI, 1.30-3.51) and more physical activity counseling for obesity (OR = 2.03; 95% CI, 1.30-3.18) and diabetes (OR = 6.55; 95% CI, 2.01-21.33). Diabetes management differed by the sex of the patient, with fewer women receiving glucose-lowering medications (OR = 0.49; 95% CI, 0.25-0.94), angiotensin-converting enzyme inhibitor therapy (OR = 0.39; 95% CI, 0.22-0.72), and aspirin prophylaxis (OR = 0.30; 95% CI, 0.15-0.58). CONCLUSION Quality of care as measured by patients meeting CVD risk factors treatment goals was similar regardless of the sex of the patient or physician. Selected differences were found in the style of CVD risk factor management by sex of physician and patient.
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Affiliation(s)
- Hava Tabenkin
- Department of Family Medicine, HaEmek Medical Center, Afula, Israel
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Govender V, Penn-Kekana L. Gender biases and discrimination: a review of health care interpersonal interactions. Glob Public Health 2009; 3 Suppl 1:90-103. [PMID: 19288345 DOI: 10.1080/17441690801892208] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
A good interpersonal relationship between a patient and provider, as characterized by mutual respect, openness, and a balance in their respective roles in decision-making, is an important marker of quality of care. This review is undertaken from a gender and health equity perspective and illustrates that gender biases and discrimination occur at many levels in the healthcare delivery environment, and affects the patient-provider interaction which can result in health inequities affecting individual health seeking behaviour, access to good quality healthcare, and, ultimately, health outcomes. Interventions will have to be introduced at multiple levels, from health system legislation and policy and gender sensitive training to the development of women and men centred services and health literacy programmes.
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Affiliation(s)
- V Govender
- Health Economics Unit, School of Public Health, University of Cape Town, South Africa.
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Abstract
Aims: A broad range of socio-cultural issues have been recognized as determinants for health and disease. A notion of gender neutrality is still alive in the medical culture, suggesting that gender issues are not relevant within this field. Methods: We have explored the claim that doctors encounter their patients as human beings, not as men or women, and discuss causes and consequences of such a claim. Results: Empirical evidence does not support such a claim — gender seems to have a strong impact on medical knowledge and practice. The concept andronormativity signifies a state of affairs where male values are regarded as normal to the extent that female values disappear or need to be blatantly highlighted in order to be recognized. We have applied this frame of reference to understand how the idea of gender neutrality has been established in medicine. The average medical practitioner, teacher, or researcher is a man. We suggest that notions of normality subtly construct gender in medicine in ways where men become normal, while women become deviant. Finally, we discuss strengths and pitfalls of three different strategies which have been used by gender researchers in health to challenge andronormativity: demonstrating gender differences, revealing the consequences of gendered power inequalities, and deconstructing the meaning of gender. Conclusions: We conclude that gender still matters in medicine.
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Affiliation(s)
- Bibi Hølge-Hazelton
- University of Aarhus, Department of Pedagogy, Copenhagen, Denmark, The Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark,
| | - Kirsti Malterud
- The Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark, Research Unit for General Practice, Unifob Health, Bergen, Norway
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Fullen BM, Baxter GD, O'Donovan BGG, Doody C, Daly LE, Hurley DA. Factors impacting on doctors' management of acute low back pain: a systematic review. Eur J Pain 2008; 13:908-14. [PMID: 19110456 DOI: 10.1016/j.ejpain.2008.11.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2008] [Revised: 11/02/2008] [Accepted: 11/11/2008] [Indexed: 12/12/2022]
Abstract
The aim of this review was to determine the factors that impact on doctors' management of patients with acute low back pain. A methodological assessment of databases (Medline, EMBASE, Psychinfo, BIOSIS, CINAHL, and the Cochrane Central Register of Controlled Trials) identified papers which were screened for inclusion criteria by two independent reviewers. Data were extracted from accepted papers, and the internal validity and strength of the evidence were determined using valid and reliable scales. The search generated a total of 28 papers [quantitative (n=27), qualitative (n=1) methodologies]. Themes were identified from the accepted papers: education (n=18), knowledge of clinical guidelines and impact on management (n=7), and doctors' demographics (n=4). There was consistent evidence that doctors did not adhere to clinical guidelines when performing a spinal assessment. There was inconsistent evidence that education increased adherence with acute LBP guideline recommendations in terms of referral rates to physiotherapy, for investigations, to secondary care and for maintaining patients at work. Strategies to address the factors impacting on doctors' management of acute LBP are required; these would lead to improvement in patient outcomes and reduce healthcare costs.
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Affiliation(s)
- Brona M Fullen
- School of Physiotherapy and Performance Science, University College Dublin, Ireland.
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Geneau R, Lehoux P, Pineault R, Lamarche P. Understanding the work of general practitioners: a social science perspective on the context of medical decision making in primary care. BMC FAMILY PRACTICE 2008; 9:12. [PMID: 18284700 PMCID: PMC2263046 DOI: 10.1186/1471-2296-9-12] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2007] [Accepted: 02/19/2008] [Indexed: 11/10/2022]
Abstract
Background The work of general practitioners (GPs) is increasingly being looked at from the perspective of the strategies and factors shaping it. This reflects the importance given to primary care services in health care system reform. However, the literature provides little insight into the medical decision-making processes in general practice. Our main objective was to better understand how organizational and environmental factors influence the work of GPs. Methods We interviewed 28 GPs working in contrasting organizational settings and environments. The data analysis involved using structuration theory to enrich the interpretation of empirical material. Results We identified four main factors that influence the practice of GPs: mode of remuneration, peer-to-peer interactions, patients' demands and the availability of other medical resources in the environment. These four conditions of action – what we call primary effects – can directly influence the performance of medical acts and time management, as well as the degree of specialization of GPs. Decisions related to each of those aspects can have a variety of both intentional and non-intentional consequences – what we call secondary effects – that are then likely to become conditions for subsequent action. Conclusion This qualitative study helps shed light on the complex causal loops of interrelated factors that shape the work of GPs.
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Affiliation(s)
- Robert Geneau
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Kublickiene K, Agewall S. Gender issues in cardiovascular medicine. Gynecol Endocrinol 2007; 23:363-5. [PMID: 17701764 DOI: 10.1080/09513590701524507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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