[The interplay between isolation and precariousness, and hospitalization duration in French Guiana]

BACKGROUND

French Guiana faces singular health challenges: poverty, isolation, structural lag, difficulties in attracting health professionals. Hospital stays exceed the recommended durations. The present study aimed to model the impact of precariousness and geographic isolation on the hospital duration performance indicator and to recalculate the indicator after incrementing severity by 1 unit when patients were socially precarious.

METHODS

Cayenne hospital data for 2017 were used to model the hospital duration performance indicator (IP-DMS) using quantile regression to study the impact of geographic and social explanatory variables. This indicator was computed hypothesizing a 1 unit increment of severity for precarious patients and by excluding patients from isolated regions.

RESULTS

Most excess hospitalization days were linked to precariousness: the sojourns of precarious patients represented 47% of activity but generated 71% of excess days in hospital. Quantile regression models showed that after adjustment for potential confounders, patients from western French Guiana and Eastern French Guiana, precarious patients and the interactions terms between residence location and precariousness were significantly associated with IP-DMS increases. Recalculating the IP-DMSafter exclusion of patients from the interior and after increasing severity by 1 notch if the patient was precarious led to IP-DMS levels close to 1.

CONCLUSION

The results show the nonlinear relationship between the IP-DMS and geographical isolation, poverty, and their interaction. These contextual variables must be taken into account when choosing the target IP-DMS value for French Guiana, which conditions funding and number of hospital beds allowed in a context of rapid demographic growth.

Intensivists' Direct Management without Residents May Improve the Survival Rate Compared to High-Intensity Intensivist Staffing in Academic Intensive Care Units: Retrospective and Crossover Study Design

BACKGROUND

Medical staff members are concentrated in the intensive care unit (ICU), and medical residents are essentially needed to operate the ICU. However, the recent trend has been to restrict resident working hours. This restriction may lead to a shortage of ICU staff, and there is a chance that regional academic hospitals will face running ICUs without residents in the near future.

METHODS

We performed a retrospective observational study (intensivist crossover design) of medical patients who were transferred to two ICUs from general wards between September 2017 and February 2019 at one academic hospital. We compared the ICU outcomes according to the ICU type (ICU with resident management under high-intensity intensivist staffing vs. ICU with direct management by intensivists without residents).

RESULTS

Of 314 enrolled patients, 70 were primarily managed by residents, and 244 were directly managed by intensivists. The latter patients showed better ICU mortality (29.9% vs. 42.9%, P = 0.042), lower cardiopulmonary resuscitation (CPR) (10.2% vs. 21.4%, P = 0.013), lower continuous renal replacement therapy (CRRT) (24.2% vs. 40.0%, P = 0.009), and more advanced care planning decisions before death (87.3% vs. 66.7%, P = 0.013) than the former patients. The better ICU mortality (hazard ratio, 1.641; P = 0.035), lower CPR (odds ratio [OR], 2.891; P = 0.009), lower CRRT (OR, 2.602; P = 0.005), and more advanced care planning decisions before death (OR, 4.978; P = 0.007) were also associated with intensivist direct management in the multivariate cox and logistic regression analysis.

CONCLUSION

Intensivist direct management might be associated with better ICU outcomes than resident management under the supervision of an intensivist. Further large-scale prospective randomized trials are required to draw a definitive conclusion.

Does an all-condition case management program for high-risk patients reduce health care utilization in medicaid and medicare beneficiaries with diabetes?

OBJECTIVE

To assess whether an all-condition case management program can improve health care utilization and clinical outcomes in patients with diabetes.

RESEARCH DESIGN AND METHODS

1342 patients with diabetes were enrolled in the Johns Hopkins Community Health Partnership (J-CHiP) Case Management program for high-risk patients with any chronic disease. We categorized participants into two intervention exposure categories based on the number of contacts with case manager (CM) and community health worker (CHW) per month: low contact (≤1 contact/month), and high contact (>1 contacts/month). The primary outcomes were rates of emergency department (ED) visits, hospitalizations, and 30-day hospital readmissions.

RESULTS

In analyses adjusted for age, sex, race, risk score, and baseline health utilization rate, Medicaid participants in the high contact group had 42% (rate ratio (RR): 1.42; 95% CI: 1.08-1.86) and 64% (RR: 1.64; 95% CI: 1.08-2.48) higher risks for hospital admission and readmission, respectively, than the low contact group. Similar increases were seen in the Medicare participants with 20% (RR: 1.20; 95% 1.02-1.42) and 42% (RR:1.42; 95% 1.09-1.84) higher risks for admission and readmission, respectively. The associations were not statistically significant for ED visits. Subsidiary analysis of a subset with HbA1c available (n = 545) revealed a statistically significant decrease in HbA1c among Medicare participants (mean (SD): -0.17% (1.50%)), with a larger decrease in the high contact group (mean (SD): -0.23% (1.59%)).

CONCLUSION

In an all-condition case management program for high-risk patients, the higher intensity of contacts with CHW and CM was not associated with a reduced health care utilization in adults with diabetes.

The impact of patient feedback on the medical performance of qualified doctors: a systematic review

BACKGROUND

Patient feedback is considered integral to quality improvement and professional development. However, while popular across the educational continuum, evidence to support its efficacy in facilitating positive behaviour change in a postgraduate setting remains unclear. This review therefore aims to explore the evidence that supports, or refutes, the impact of patient feedback on the medical performance of qualified doctors.

METHODS

Electronic databases PubMed, EMBASE, Medline and PsycINFO were systematically searched for studies assessing the impact of patient feedback on medical performance published in the English language between 2006-2016. Impact was defined as a measured change in behaviour using Barr's (2000) adaptation of Kirkpatrick's four level evaluation model. Papers were quality appraised, thematically analysed and synthesised using a narrative approach.

RESULTS

From 1,269 initial studies, 20 articles were included (qualitative (n=8); observational (n=6); systematic review (n=3); mixed methodology (n=1); randomised control trial (n=1); and longitudinal (n=1) design). One article identified change at an organisational level (Kirkpatrick level 4); six reported a measured change in behaviour (Kirkpatrick level 3b); 12 identified self-reported change or intention to change (Kirkpatrick level 3a), and one identified knowledge or skill acquisition (Kirkpatrick level 2). No study identified a change at the highest level, an improvement in the health and wellbeing of patients. The main factors found to influence the impact of patient feedback were: specificity; perceived credibility; congruence with physician self-perceptions and performance expectations; presence of facilitation and reflection; and inclusion of narrative comments. The quality of feedback facilitation and local professional cultures also appeared integral to positive behaviour change.

CONCLUSION

Patient feedback can have an impact on medical performance. However, actionable change is influenced by several contextual factors and cannot simply be guaranteed. Patient feedback is likely to be more influential if it is specific, collected through credible methods and contains narrative information. Data obtained should be fed back in a way that facilitates reflective discussion and encourages the formulation of actionable behaviour change. A supportive cultural understanding of patient feedback and its intended purpose is also essential for its effective use.

End of life care for people with dementia: The views of health professionals, social care service managers and frontline staff on key requirements for good practice

Background

Evidence consistently shows that people with advanced dementia experience suboptimal end of life care compared to those with cancer; with increased hospitalisation, inadequate pain control and fewer palliative care interventions. Understanding the views of those service managers and frontline staff who organise and provide care is crucial in order to develop better end of life care for people with dementia.

Methods and findings

Qualitative interviews and focus groups were conducted from 2013 to 2015 with 33 service managers and 54 staff involved in frontline care, including doctors, nurses, nursing and care home managers, service development leads, senior managers/directors, care assistants and senior care assistants/team leads. All were audio recorded and transcribed verbatim. Participants represented a diverse range of service types and occupation. Transcripts were subject to coding and thematic analysis in data meetings. Analysis of the data led to the development of seven key themes: Recognising end of life (EOL) and tools to support end of life care (EOLC), Communicating with families about EOL, Collaborative working, Continuity of care, Ensuring comfort at EOL, Supporting families, Developing and supporting staff. Each is discussed in detail and comprise individual and collective views on approaches to good end of life care for people with dementia.

Conclusions

The significant challenges of providing good end of life care for people with dementia requires that different forms of expertise should be recognised and used; including the skills and knowledge of care assistants. Successfully engaging with people with dementia and family members and helping them to recognise the dying trajectory requires a supportive integration of emotional and technical expertise. The study strengthens the existing evidence base in this area and will be used with a related set of studies (on the views of other stakeholders and observations and interviews conducted in four services) to develop an evidence-based intervention.

Clinician/Patient Connections in Ethnoculturally Nonconcordant Encounters With Political-Asylum Seekers: A Comparison of Physicians and Nurses

The article compares the ability of nurses and physicians to connect with patients in ethnoculturally nonconcordant clinical encounters with 41 randomly selected political-asylum seekers (PAS) residing at five Finnish reception centers in summer 2002. Doctors and nurses were equally unlikely to draw congruent assessments of the patient’s past and present health condition, mixed use of biomedical/ethnocultural practices, adherence with medication and eat/drink instructions, (dis)satisfaction, and future confidence in recommended biomedical and ethnocultural approaches. Nurses were considerably more likely to hold views that were congruent with the patient’s reported health care effectiveness in Finland. The findings suggest that doctors should request and place special weight on the insights of the principal attending nurse when assessing the potential contributions of personal, family, and host-society health care assets and inhibitors to a migrant patient’s overall health plan. The results also suggest that culturally sensitive health care training offers specific advantages to nurses who attend to PAS.

Patient satisfaction in dermatology: a qualitative assessment

Patient satisfaction is of growing interest to the medical field. Qualities essential to patient satisfaction with primary care providers have been characterized, but little work has been done to assess factors that affect patient satisfaction in dermatology. The objective of this study was to determine factors essential to patient satisfaction in dermatology. Qualitative data from an online survey were collected and organized thematically relying on a previously established coding scheme for patient satisfaction comments. Themes studied include the character of the physician, communication, time, care, and qualities of the office staff. Doctors with good character who communicated effectively and spent sufficient time with patients received high satisfaction. An efficient and friendly office staff also contributed to high satisfaction. Poor patient satisfaction was mainly linked to flaws in physician demeanor, lack of communication, and rushed appointments. A limitation to the study included potential bias of an online survey sample, although the widespread use of the tool to capture more respondents in dermatology may mitigate this limitation. To achieve high patient satisfaction, it is vital that a physician is cognizant of the profound effects of how his or her character, communication style, time investment, and office staff appear to patients because patients consider these factors in addition to clinical outcomes when evaluating physicians.

[The level of personnel awareness of HIV infection and the principal directions of its prophylaxis in a state-owned institution of forensic medical expertise]

The propagation of HIV infection in this country creates the threat of its penetration into state forensic-medical institutions. This study had the objective of estimating the degree of awareness of the personnel of such institutions of the HIV/AIDS problem including their knowledge of emergency preventive measures in extraordinary situations during autopsy studies and other investigations. Anonymous questionnaires were distributed among the respondents involved in the study. The awareness of the personnel of the state-governed institutions of forensic medical expertise was described as insufficient. Simultaneously, the high rate of occupational traumatism among the staff during execution of their offices was documented. Recommendations are proposed for the prevention of HIV infection among the personnel of the state-governed institutions of forensic medical expertise.

[Influenza vaccination of pediatric staff as a predictor for recommendations to children]

BACKGROUND

As of February 2010, the 2009 H1N1 influenza has caused more than 15,000 deaths worldwide. Seasonal influenza vaccination rates among health care workers (HCW) have been universally low; the 2009 H1N1 influenza vaccination of HCW has also been disappointing. In several studies, a correlation between HCW seasonal influenza vaccination status and vaccine recommendation to adult patients was found.

OBJECTIVE

To examine the correlation between the declared influenza vaccination status of pediatric staff and vaccine recommendations to their patients.

INSTRUMENT

Anonymous questionnaire concerning attitudes and practices regarding seasonal and 2009 H1N1 influenza vaccination.

RESPONDENTS

141 pediatric staff attending a conference.

RESULTS

Seventy two percent of the respondents had been or intended to be vaccinated against seasonal influenza, 62% against the 2009 H1N1 influenza, and 56% against both diseases. Ambulatory setting employment was positively associated with the recommendation of seasonal influenza vaccination to all children. By multivariate Logistic regression analysis, the "vaccinated or intending to be vaccinated against seasonal influenza" was the only significant independent variable associated with recommending universal pediatric seasonal influenza vaccine (OR=15, 95% CI 6.1-41.4, p < 0.001). Similarly, "being or intending to be vaccinated against the 2009 H1N1 influenza" was the only significant independent variable associated with recommending universal pediatric vaccination against this disease (OR = 5.2, 95% CI 1.85-14.6, P = 0.002).

CONCLUSION

A strong correlation between the influenza vaccination status of pediatric staff and the recommendation of the vaccines to children emphasizes that intense education of providers is a crucial step in assuring a positive recommendation to families.

Blood glucose testing in the hospital: error sources and risk management

Glucose testing in the hospital with point-of-care devices presents multiple opportunities for error. Any device can fail under the right conditions. For glucose monitoring in the hospital, with thousands of operators, hundreds of devices, and dozens of locations involved, there is ample opportunity for errors that can impact the quality of test results. Errors can occur in any phase of the testing process: preanalytic, analytic, or postanalytic. Common sources of meter error include patient or methodology interferences, operator mistakes, environmental exposure, and device malfunction. Early models of glucose meters had few internal checks or capability to warn the operator of meter problems. The latest generation of glucose monitors has a number of internal checks and controls engineered into the testing process to prevent serious errors or warn the operator by suppressing test results. Some of these control processes are built into the software and data management system of the meters, others require the hospital to do something, such as regularly clean the meter or analyze control samples of known glucose concentration, to verify meter performance. Hospitals need to be aware of the potential for errors by understanding weaknesses in the testing process that could lead to erroneous results and take steps to prevent errors from occurring or to minimize the harm to patients when errors do occur. The reliability of a glucose result will depend on the balance of internal control features available from manufacturers in conjunction with the liquid control analysis and other control processes (operator training, device validation, and maintenance) utilized by the hospitals.

Assisted living facility administrator and direct care staff views of resident mental health concerns and staff training needs

This community needs assessment surveyed 21 administrators and 75 direct care staff at 9 larger and 12 smaller assisted living facilities (ALFs) regarding perceptions of resident mental health concerns, direct care staff capacity to work with residents with mental illness, and direct care staff training needs. Group differences in these perceptions were also examined. Both administrators and directcare staff indicated that direct care staff would benefit from mental health-related training, and direct care staff perceived themselves as being more comfortable working with residents with mental illness than administrators perceived them to be. Implications for gerontological social work are discussed.

[Survey on the understanding of the reporting standards to the hepatitis B and the hepatitis C by the medical staff in Yanbian Prefecture]

OBJECTIVE

To examine the understanding of the reporting criteria of Hepatitis B (HB) and Hepatitis C (HC) of the medical staff in Yanbian Korean Minority autonomous prefecture and provide the advice for reporting HB and HC via network.

METHOD

Questionnaires were distributed to doctors in 7 hospitals by the method of stratified sampling.

RESULTS

48.3% of the medical staff thought that HBsAg carries should also be reported; The understanding of the reporting standards of HB and HC correctly was only 41.4% and 66.4% respectively. The understanding of the reporting standards of HB was different among professional staff in municipal hospital and in county-level hospital, which was lower at the municipal hospital; the reason for misunderstanding is mainly concentrated in HBsAg carriers as the report object; there was not difference of the understanding to the reporting standards of HB and HC among different title and work experience.

CONCLUSION

The medical staff among investigated hospitals had lower knowledgement to the reporting standards of HB and HC. Vigorous training should be conducted according to the criteria of hepatitis diagnosis, to ensure that the epidemic situation of HB and HC science and accuracy.

[Evaluation of the efficiency of medical staff's knowledge in the diagnosis, treatment, and prevention of malaria]

To define the capacity andreadiness of the health care system of Kyrgyzstan to ensure transition of malaria control to elimination in 2005-2007, health administrators scheduled and educated 2089 public health specialists in the problem of management, diagnosis, treatment, and prevention of malaria, followed by their questioning. Areas at high risk for malaria transmission and those with local malaria foci, such as the Kadamzhaisky, Batkensky, Alamedinsky, Sokuluksky, and Issyk-Atinsky Districts and the city of Bishkek, were selected for polling. A research agency developed 5 structured questionnaires to interview respondents. The questionnaires included questions on occupation and those urgent to various groups of specialists. On the basis of the performed analysis, the following recommendations have been formulated: * to increase the duration of trainings in accordance with the amount of contained material; * to develop topical teaching modules for training and to make them more specific and detailed for individual specialists; * to conduct short (3-day) traveling on-site trainings for specialists of therapeutic-and-prophylactic institutions and state sanitary-and-epidemiological surveillance; * to assess the participants' knowledge before and after training (pre- and posttests) during education courses for further training correction.

Going the distance for certified cancer registrars

Cancer registry departments are using electronic technology to solve the local and national Certified Tumor Registrar (CTR) shortages. As demand for CTRs continues to increase without an accompanied increase in the supply of qualified personnel, cancer registry departments are looking for new solutions to this growing local and national trend. In order to solve this problem, some cancer registries have started using telecommunication to fill the empty positions within their departments. This is the case at Roper St. Francis Healthcare (RSFH) in Charleston, SC, where Cancer Registry Manager, Ellen Kolender, RHIA, CTR, used telecommuting to fill one full-time and one part-time CTR position.

The quality of reporting of orthopaedic randomized trials with use of a checklist for nonpharmacological therapies

BACKGROUND

The Consolidated Standards of Reporting Trials statement for the reporting of randomized controlled trials has been limited by its applicability to surgical trials. In response, a Checklist to Evaluate a Report of a Nonpharmacological Trial was recently developed by the Consolidated Standards of Reporting Trials group to address reporting issues in surgical trials. We aimed (1) to apply the checklist for nonpharmacological therapies to orthopaedic randomized controlled trials across multiple journals from 2004 through 2005, and (2) to survey authors when methodological safeguards itemized in the checklist were not reported to determine whether they actually had been performed. We hypothesized that lack of reporting of a methodological safeguard did not necessarily mean it had not been conducted.

METHODS

We searched for relevant orthopaedic randomized controlled trials across eight journals in the period from January 2004 through December 2005. We applied the Checklist to Evaluate a Report of a Nonpharmacological Trial to all eligible studies. We contacted authors to determine what methodological safeguards were actually used, especially when details remained unclear from the publication.

RESULTS

We included eighty-seven randomized controlled trials from eighty-five scientific reports. In assessing the randomized controlled trials with the checklist for nonpharmacological therapies, seventy-three studies (84%) had unclear reporting of treatment allocation concealment. Only seventeen studies (20%) mentioned surgeon skill or experience. The blinding of patients, ward staff, rehabilitation staff, clinical outcome assessors, and nonclinical outcome assessors was unclear in forty-eight (55%), sixty-three (72%), sixty-four (74%), forty (46%), and thirty-three studies (38%), respectively. Authors from forty-three randomized controlled trials responded to our survey. The results of the survey showed that 41% (95% confidence interval, 25% to 58%) of the trials had adequate allocation concealment when this had been unclear from the report. Although the surgical experience of the investigators was rarely reported, most authors (70%) acknowledged that they had defined "surgical expertise criteria" such as minimum case criteria, specialized training, and clinical performance. The survey also showed that 28% to 40% of the trials had blinding of relevant groups despite the fact that the reporting of such blinding had been unclear in the publications.

CONCLUSIONS

The quality of reporting in the orthopaedic literature was highly variable. Readers should not assume that bias-reducing safeguards that were not reported in a randomized controlled trial did not occur. Our study reinforces the need for the consistent use of a tool like the Checklist to Evaluate a Report of a Nonpharmacological Trial to assess the methodology of surgical trials.

The management of poor performance

Identification of poor performance is in an integral part of government policy. The suggested approach for the identification of such problems, advocated by the General Medical Council, is that of appraisal. However, traditionally, there has been a reluctance to deal with poor performers, as all doctors have made mistakes and are usually only too ready to forgive and be non-critical of colleagues. The problems are widespread, and 6% of the senior hospital workforce in any 5-year period may have problems.

Mindful staff increase learning and reduce aggression in adults with developmental disabilities

Aggression by individuals with developmental disabilities may threaten their community placement. In a multiple baseline design across group homes, we provided group home staff with behavioral training and later with mindfulness training to assess the impact on aggressive behaviors and the number of learning objectives mastered by individuals in their care. We also assessed other outcomes including activities engaged in by the individuals, use of restraint by staff, and measures of satisfaction. The effect of varying staff-resident ratios was evaluated on all measures. When compared to baseline, the number of staff interventions for aggression showed some reduction following behavioral training, but decreased substantially only following mindfulness training. There was also some increase in the number of learning objectives mastered by the individuals following behavioral training, but greater and more consistent increases were obtained only after mindfulness training. Improvements also occurred on the other measures assessed after behavioral training, but these were always greater and more consistent following mindfulness training. In addition, consistent gains followed behavioral training only with a high staff-resident ratio whereas the larger gains after mindfulness training occurred with both medium and low staff-resident ratios. Our results suggest that the addition of mindfulness training considerably enhanced the ability of the group home staff to effectively manage the aggressive behavior and learning of the individuals.

Physician Knowledge of the Glasgow Coma Scale

Appropriate triage is critical to optimizing outcome from battle related injuries. The Glasgow Coma Scale (GCS) is the primary means by which combat casualties, who have suffered head injury, are triaged. For the GCS to be reliable in this critical role, it must be applied accurately. To determine the level of knowledge of the GCS among military physicians with exposure and/or training in the scale we administered a prospective, voluntary, and anonymous survey to physicians of all levels of training at military medical centers with significant patient referral base. The main outcome measures were correct identification of title and categories of the GCS along with appropriate scoring of each category. Overall performance on the survey was marginal. Many were able to identify what "GCS" stands for, but far fewer were able to identify the titles of the specific categories, let alone identify the specific scoring of each category. When evaluated based on medical specialties, those in surgical specialties outperformed those in the medical specialties. When comparing the different levels of training, residents and fellows performed better than attending staff or interns. Finally, those with Advanced Trauma Life Support (ATLS) certification performed significantly better than those without the training. Physician knowledge of the GCS, as demonstrated in this study, is poor, even in a population of individuals with specific training in the use of the scale. It is concluded that, to optimize outcome from combat related head injury, methods for improving accurate quantitation of neurologic state need to be explored.

Use of libraries and electronic information resources by primary care staff: outcomes from a survey

OBJECTIVES

To assess the use of existing libraries; usage of the Internet and biomedical databases; and need for training on use of the Internet and biomedical databases for primary care staff.

METHODS

A postal survey of general practitioners (GPs), practice nurses (PNs) and practice managers (PMs) in Nottingham and Rotherham, UK.

RESULTS

Overall, 243 questionnaires were used. The response rate in Nottingham was 24%, in Rotherham it was 34%. Reported use of libraries was low (30%), with PNs reporting significantly higher usage (65%) than others (P < 0.01). Most respondents reported using the Internet (81%), but fewer (44%) reported using databases. GPs and PNs were significantly more likely to report using databases than PMs (P < 0.01). Lack of training was the most reported barrier to using the Internet (67%) and databases (52%). Overall, 52% of respondents reported wanting Internet training, 64% wanted database training. The percentages requesting training on databases were high among GPs and PNs, but significantly lower for PMs (P = 0.02).

CONCLUSIONS

There are differences in the usage of libraries and electronic resources among the primary care team, and in reported training needs. While the reported levels of usage of the Internet and biomedical databases are encouraging, our study identified a training need. If met, this could increase usage further.

[Characteristics of work stimulation of the medical personnel in the treatment-and-prophylactic institutions]

Social and economic relations of the last years that were formed in our country have lead to the changes in approaches to administrative activity. Under conditions of administrative-and-command guidance the patriotism and requirements of production discipline ensured the highly effective work. Today the economic relations between employer and personnel are of the first priority. These principles can be attributed to the military medical collective activity. The algorithm developed during the investigation for stimulating the employees working in the in-patient military medical institutions suggests the following performance of measure complex directed to the improvement of professional training of managerial staff working in the military medical institutions work with subordinates, fulfilment of motivation activity, summing up the medical staff work.

"Getting Everyone on the Same Page": Nursing Home Physicians' Perspectives on End-of-Life Care

PURPOSE

To improve understanding of nursing home physicians' perspectives regarding end-of-life care, and to suggest directions for further research.

METHODS

An exploratory qualitative design based on interviews of 12 nursing home physicians, 10 of whom were medical directors. Medical students served as interviewers.

SAMPLE

A purposeful sampling strategy yielded interviews with 12 physicians. The sample was selected based on "intensity sampling," which seeks information-rich but not extreme cases. Ten of the 12 physicians were nursing home medical directors; all respondents practiced at least 4 years part-time or full-time in a nursing home setting. Respondents varied by age, gender, urban/rural location, and fellowship training (half the sample had completed a geriatrics fellowship). Seven physicians were affiliated with an academic medical center.

RESULTS

Four themes were identified in the analysis of the 12 interview transcripts: extensive familiarity with dying; consensus is integral to good end-of-life care; obstacles can interfere with consensus; and advance directives set the stage for conversations about end-of-life care. The importance of consensus, both in terms of prognosis and in developing a palliative care plan, emerged as the major finding.

CONCLUSIONS

For the 12 physicians in this study consensus about the resident's status and an appropriate care plan are important features of good end-of-life care. Further research is needed to determine if other members of the health care team (i.e., residents, family members, nursing staff, social worker, etc.) also value consensus highly. It will be important to determine what barriers to consensus other team members identify. Based on the understanding generated from this study, a refinement of the general Education for Physicians on End-of-Life Care (EPEC) model describing the relationship between curative and palliative care is proposed for nursing homes. The refinement underscores the points at which the team might consider revisiting consensus about the resident's status and care plan.

The preliminary impact of Maryland's medical director and attending physician regulations

OBJECTIVES

To identify the impact of the regulations implemented in Maryland in 2001, related to nursing home attending physicians and medical directors, and nursing home quality assurance requirements, on Maryland nursing homes, administrators, and physicians.

DESIGN

Two surveys were mailed to all nursing home administrators in Maryland, one for their completion and one to give to their medical directors to complete. These surveys were to be returned by mail to the authors.

SETTING

All nursing homes in all jurisdictions in Maryland.

PARTICIPANTS

Two-fifths of administrators and medical directors in Maryland nursing homes completed and returned the survey.

MEASUREMENTS

Results were tabulated for each question of each survey, and were calculated as percentages of the total responses. Additionally, individual comments were reviewed.

RESULTS

A relatively large sample of administrators and medical directors in Maryland responded. Most respondents were positive or at least neutral about the impact of these regulations on them and their organizations. Many administrators agreed that there had been improvements in medical director participation and performance. There were significant advances in medical director compensation. There were relatively few negative comments about the impact.

CONCLUSION

Requirements for physician and medical director accountability appear to have had a positive impact on medical director performance and relationships with nursing home administrators. Additional study is warranted to measure the impact of that performance on patient care outcomes and facility performance.