Adult Physicians Research Articles

Caring for adults with congenital cardiac disease: successes and challenges for 2007 and beyond

Patients with congenital cardiac disease require lifelong medical care. Current challenges that face practitioners who care for adults with congenital heart disease include identifying the best location for procedures, which could be a children's hospital, an adult hospital, or a tertiary care facility; providing appropriate antenatal management of pregnant women with congenitally malformed hearts, and continuing this care in the peripartum period; and securing the infrastructure and expertise of the non-cardiac subspecialties, such as nephrology, hepatology, pulmonary medicine, and haematology. The objectives of this review are to outline the common problems that confront this population of patients and the medical community, to identify challenges encountered in establishing a programme for care of adults with congenitally malformed hearts, and to review the spectrum of disease and operations that have been identified in a high volume tertiary care centre for adult patients with congenital cardiac disease. Three chosen examples of the fundamental problems facing the practitioner and patient in the United States of America in 2007 are the neglected patient with congenital cardiac disease, weak infrastructure for adults with congenital cardiac disease, and family planning and management of pregnancy for patients with congenital cardiac disease. Patients with adult congenital cardiac disease often do not receive appropriate surveillance. Three fundamental reasons for this problem are, first, that most adults with congenitally malformed hearts have been lost to follow-up by specialists, and are either receiving community care or no care at all. Second, patients and their families have not been educated about their malformed hearts, what to expect, and how to protect their interests most effectively. Third, adult physicians have not been educated about the complexity of the adult with a congenitally malformed heart. This combination can be fatal for adults with complications related to their congenitally malformed heart, or its prior treatment. Two solutions would improve surveillance and care for the next generation of patients coming out of the care of paediatric cardiologists. The first would be to educate patients and their families during childhood and adolescence. They would learn the names of the diagnoses and treatments, the problems they need to anticipate and avoid, the importance of expert surveillance, career and family planning information, and appropriate self-management. The second solution would be to encourage an orderly transfer of patients from paediatric to adult practice, usually at about 18 years of age, and at the time of graduation from high school. Clinics for adults with congenital cardiac disease depend upon multidisciplinary collaboration with specialties in areas such as congenital cardiac imaging, diagnostic and interventional catheterization, congenital cardiac surgery and anaesthesia, heart failure, transplantation, electrophysiology, reproductive and high risk pregnancy services, genetics, pulmonary hypertension, hepatology, nephrology, haematology, and others. None of these services are easily available "off the rack", although with time, experience, and determination, these services can develop very well. Facilities with experienced personnel to provide competent care for adults with congenital cardiac disease are becoming increasingly available. Parents and patients should learn that these facilities exist, and be directed to one by their paediatric caregivers when the time comes for transition to adult care. With the steady increase in the number of adults with congenital heart disease, an ever increasing number of women with such disease are becoming pregnant. Services are not widely available to assess competently and plan a pregnancy for those with more complex disease. It is essential to have a close interplay between the obstetrician, the adult congenital cardiologist, the fetal medicine perinatologist, and neonatologist. In both a community based programme and a tertiary care centre, the nuances and complexities of congenital cardiac anatomy, coupled with the high probability of previous operation during childhood, makes the trained congenital cardiothoracic surgeon best suited to deal with the surgical needs of this growing population. It is clear that the majority of adults with congenital heart disease are not "cured", but require lifelong comprehensive care from specialists who have expertise in this complex arena. There is a growing cadre of healthcare professionals dedicated to improving the care of these patients. More information has become available about their care, and will be improved upon in the next decade. With the support of the general paediatric and paediatric cardiologic communities, and of the Adult Congenital Heart Association, and with the persistence of the providers of care for adults with congenital cardiac disease currently staffing clinics, the care of these patients should become more secure in the next decade as we mature our capabilities.

Doses and steroids to be used in primary and central hypoadrenalism

Traditionally hydrocortisone has been the first choice for replacement therapy in patients with adrenal insufficiency. Paediatricians have used body surface area adjusted dosing and adult physicians have tended to use fixed doses twice or thrice daily. Cortisol secretion has a distinct circadian rhythm being low at the time sleep onset, rising from between 02.00 h and 04.00 h in the morning to peak just after the time of waking then falling during the day. The pharmacokinetics of immediate release hydrocortisone means that no treatment regimen is capable of simulating the normal circadian rhythm of cortisol. Recent data with hydrocortisone infusions suggests that circadian delivery of hydrocortisone can improve biochemical control of patients with adrenal insufficiency. It is anticipated in the future that modified release formulations of hydrocortisone will provide more optimal replacement therapy.

MyChart —A New Mode of Care Delivery: 2005 Personal Health Link Research Report

MyChart is one of the new, innovative features of Kaiser Permanente (KP) HealthConnect—the comprehensive, integrated, organizational, and personal electronic health and medical record. MyChart, an Epic Systems Corporation (Verona, WI) product, is a secure member Web site where registered patients can view portions of their medical record, and exchange secure messages with their primary care physician (PCP) and other recently visited clinicians. The KP Northwest (KPNW) Region, in Portland, Oregon, was the first KP Region to implement MyChart. Starting in late 2002, KPNW initiated a pilot project of MyChart as a stand-alone Web address in two medical offices.1 KPNW named this feature Personal Health Link (PHL). By early 2005, all adult primary care physicians and affiliated clinicians (both groups are PCPs in this paper) were trained and set up to use PHL. Patients who registered for PHL could send secure e-mail messages directly to their primary care clinician, incurring no copayment or fees. MyChart is now available to KP patients in all Regions, except Ohio, through KP HealthConnect online at www.kp.org.

La drépanocytose : de l'enfance à l'âge adulte

Sickle cell disease, a hemoglobin disorder with autosomal recessive transmission, is one of the most common genetic diseases screened in France. Thanks to early management, 95% of sickle cell patients reach adulthood and require transition from pediatric care to adult care. Through a retrospective study of records from serious sickle cell patients over 17 years old, followed in the hematology-oncology pediatric unit of Reims University Hospital Center in France, we analyzed transition conditions, compared pediatric and adult management, and proposed a plan for transition care. As of 1 January 2016, out of 19 sickle cell patients meeting the inclusion criteria, 12 had made the transition from pediatric care to adult medicine. Among the transition group, the transition was proposed by the pediatrician in 92% of cases. The average age of transition was 19.4 years. The time between receiving the information and the last pediatric visit was 2.4 months. Seven out of the 12 patients were informed of their transition during the last pediatric visit. The age of the first adult visit was 20.3 years. There was no alternate or joint consultation. The treatments prescribed during the last pediatric visit were not modified during the first adult visit. The average number of hospitalizations per patient was 2.7 in pediatric care and 3.4 in adult care with a median value of 2 in both groups. Three out of 12 patients died, the average age of death being 26.7 years. Transition is an important milestone in chronic disease patients. More than age, the maturity of the patient must be taken into account. The transition to the adult structure requires early preparation in the teenage years and investment of the adolescent and his family as well as investment of pediatric and adult caregivers. This study points out the need to establish a transition plan within our hospital in collaboration with adult physicians. Continuity of care is necessary to increase the quality of managing patients and cannot be done without a close relationship between pediatric specialists and adult physicians.

BSACI guidelines for the management of chronic urticaria and angio‐oedema

This guidance for the management of patients with chronic urticaria and angio-oedema has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The guideline is based on evidence as well as on expert opinion and is aimed at both adult physicians and paediatricians practising in allergy. The recommendations are evidence graded. During the development of these guidelines, all BSACI members were included in the consultation process using a web-based system. Their comments and suggestions were carefully considered by the SOCC. Where evidence was lacking a consensus was reached by the experts on the committee. Included in this guideline are clinical classification, aetiology, diagnosis, investigations, treatment guidance with special sections on children with urticaria, and the use of antihistamines in women who are pregnant or breastfeeding. Finally, we have made recommendations for potential areas of future research.

Glucocorticoids as an adjuvant treatment to intravenous antibiotics for cystic fibrosis pulmonary exacerbations: A UK Survey

Oral glucocorticoids are widely used to treat exacerbations of asthma and COPD. A role for their use in treating exacerbations in Cystic Fibrosis (CF) is not proven. We describe the current practice, amongst UK adult CF physicians, of oral glucocorticoid use as an adjuvant to intravenous (IV) antibiotic treatment during CF pulmonary exacerbation (P EX). The survey also examined whether physicians thought a randomised controlled trial (RCT) was necessary and their willingness to participate patients in such a trial. Eighty one percent of physicians replied. All of them used corticosteroids with P EX. Most physicians supported the need for a RCT and would be willing to enrol consenting patients in the trial. This survey highlighted the need for a RCT which would examine the role of adjuvant corticosteroids to IV antibiotics in CF P EX.

Measuring Performance in Primary Care: What Patient Outcome Indicators Do Physicians Value?

Determining which patient outcome indicators may be appropriate to include in a primary care, practice performance tool is a difficult task. Unfortunately, no published studies currently document the opinions of these physicians regarding which indicators they most value. To ascertain the level of agreement among primary care physicians regarding the most salient patient outcome indicators for measuring performance in primary care. A random population survey of 115 adult primary care physicians. The survey consisted of a comprehensive list of health characteristics included in 8 validated instruments (eg, SF-36, Sickness Impact Profile), as well as 10 common clinical indicators and 6 health behaviors. Each item was ranked using a 5-point Likert scale regarding its value for inclusion in a performance measure. Analysis of 93 returned surveys (RR 81%) indicated strong agreement (> or = 75%) that 19 health characteristics were important or very important. These characteristics fit into 8 domains: physical functioning, psychological functioning, social functioning, pain, quality of life, physiologic symptoms, health behaviors, and clinical indicators. Notably absent were measures of social support and health perceptions. Strong agreement exists among practicing primary care physicians regarding the most valued patient outcome indicators. Development of practice performance measures should be influenced by such data.

Differences in Medical Decision Making in Adult and Pediatric Hematopoietic Stem Cell Transplantation (HCT).

There are no studies investigating individual physician practice variation in HCT. We conducted an international Internet-based survey of transplant physicians to explore the spectrum of medical decision making in adult and pediatric HCT practice. The questions were constructed separately for adult and pediatric physicians and where appropriate, questions were identical for the two groups. Eight questions presented clinical scenarios and elicited treatment recommendations. Adult transplant physicians were also asked 6 questions about choice of myeloablative vs. reduced intensity conditioning in specified situations. Response options were closed-ended offering several management approaches. The response rate was 526/627 (84%) of eligible physicians who confirmed receipt of the invitation or 526/1823 (29%) of all invitations. The sample was predominantly male (74%), practiced in an academic center (73%) and was very clinically involved with a median of 2.5 days in clinic and 4 months on the inpatient ward. The median age was 47 years, and 57% practiced in the U.S.; 27% performed pediatric and 73%, adult transplants. Pediatricians spent less time in direct patient care, practiced at smaller centers (median annual transplant center volume 40 vs. 80, p<0.0001), were more likely to practice in the United States (68% vs. 52%, p=0.0015) and be female (38% vs. 18%, p<0.0001). Pediatric and adult transplant physicians differed in their management strategies for chronic myeloid leukemia, acute and chronic graft versus host disease (GVHD), and choice of graft source for patients with aplastic anemia. Specifically, pediatric transplant physicians were more likely to recommend allogeneic HCT over a trial of imatinib for an 18 year old man with chronic phase CML (69.6% vs. 34.9%, p<0.0001) and bone marrow over peripheral blood for aplastic anemia (89.7% vs. 68%, p<0.0001) compared to adult transplant physicians. Pediatricians favored higher dose steroids >2 mg/kg, daclizumab and infliximab for steroid-refractory acute GVHD whereas adult transplant physicians endorsed mycophenolate mofetil and rabbit anti-thymocyte globulin. Although half of both groups would use mycophenolate mofetil for steroid-refractory chronic GVHD, pediatric transplant physicians also used higher dose steroids and pentostatin, whereas adult transplant phyisicians would use sirolimus and extracorporeal photopheresis. Among adult transplant physicians, there was little consensus on the patient factors for recommending reduced intensity conditioning as opposed to myeloablative conditioning. When presented with a 30 year old man with multiple myeloma in a minimal disease state after conventional chemotherapy who has an HLA-identical sibling, 41.4% recommended autologous HCT followed by non-myeloablative HCT, 25.9% a single autologous HCT, 17.7% an allogeneic HCT, and 15% a tandem autologous HCT. These results emphasize the heterogeneity of worldwide transplant practices and the recognition that local preferences or biases likely result in similar patients being offered different transplant and related treatment procedures. The degree of practice variation also highlights the need for clinical trials, where feasible, to clarify areas of controversy.

Development of glomerulations in younger women with interstitial cystitis

Objectives To evaluate the consistency of cystoscopic findings with hydrodistension in younger women with a clinical diagnosis of interstitial cystitis. Methods A retrospective chart review was conducted of patients aged younger than 26 years old at the time of initial cystoscopy and hydrodistension at a single institution. Data included approximate duration of symptoms, development of visible terminal hematuria, presence of ulcers, and semiquantitive evaluation of degree of glomerulations (negligible, moderate, diffuse), and bladder capacity under anesthesia. Results Eighteen women aged 15 to 25 years old (mean, 17.5 years) were identified. The mean duration of symptoms was 38 months, with an estimated mean age of onset of 16 years. No patient had Hunner’s ulcers, and 13 had visible terminal hematuria with moderate-to-diffuse glomerulations. Ten women had repeat cystoscopies, and the mean time to repeat cystoscopy was 17 months. Three women underwent repeat cystoscopy and initially had a relatively normal bladder mucosa, with none or only rare glomerulations, but moderate-to-diffuse glomerulations were seen on the subsequent cystoscopy in addition to the development of terminal hematuria. One patient, conversely on subsequent cystoscopy, showed resolution of glomerulations. Conclusions Interstitial cystitis symptoms can develop before an age where adult urologists or primary care physicians familiar with the diagnosis and treatment are usually involved with care. The cystoscopic appearance of the bladder wall after hydrodistension may not be constant over time, and the absence of initial findings of glomerulations or terminal hematuria does not preclude further development of these hallmarks of the disease on subsequent evaluation.

Patient-centred screening for primary immunodeficiency: a multi-stage diagnostic protocol designed for non-immunologists

Efficient early identification of primary immunodeficiency disease (PID) is important for prognosis, but is not an easy task for non-immunologists. The Clinical Working Party of the European Society for Immunodeficiencies (ESID) has composed a multi-stage diagnostic protocol that is based on expert opinion, in order to increase the awareness of PID among doctors working in different fields. The protocol starts from the clinical presentation of the patient; immunological skills are not needed for its use. The multi-stage design allows cost-effective screening for PID within the large pool of potential cases in all hospitals in the early phases, while more expensive tests are reserved for definitive classification in collaboration with an immunologist at a later stage. Although many PIDs present in childhood, others may present at any age. The protocols presented here are therefore aimed at both adult physicians and paediatricians. While designed for use throughout Europe, there will be national differences which may make modification of this generic algorithm necessary.

A survey of factors affecting clinician acceptance of clinical decision support

BackgroundReal-time clinical decision support (CDS) integrated into clinicians' workflow has the potential to profoundly affect the cost, quality, and safety of health care delivery. Recent reports have identified a surprisingly low acceptance rate for different types of CDS. We hypothesized that factors affecting CDS system acceptance could be categorized as relating to differences in patients, physicians, CDS-type, or environmental characteristics.MethodsWe conducted a survey of all adult primary care physicians (PCPs, n = 225) within our group model Health Maintenance Organization (HMO) to identify factors that affect their acceptance of CDS. We defined clinical decision support broadly as "clinical information" that is either provided to you or accessible by you, from the clinical workstation (e.g., enhanced flow sheet displays, health maintenance reminders, alternative medication suggestions, order sets, alerts, and access to any internet-based information resources).Results110 surveys were returned (49%). There were no differences in the age, gender, or years of service between those who returned the survey and the entire adult PCP population. Overall, clinicians stated that the CDS provided "helps them take better care of their patients" (3.6 on scale of 1:Never – 5:Always), "is worth the time it takes" (3.5), and "reminds them of something they've forgotten" (3.2). There was no difference in the perceived acceptance rate of alerts based on their type (i.e., cost, safety, health maintenance). When asked about specific patient characteristics that would make the clinicians "more", "equally" or "less" likely to accept alerts: 41% stated that they were more (8% stated "less") likely to accept alerts on elderly patients (> 65 yrs); 38% were more (14% stated less) likely to accept alerts on patients with more than 5 current medications; and 38% were more (20% stated less) likely to accept alerts on patients with more than 5 chronic clinical conditions. Interestingly, 80% said they were less likely to accept alerts when they were behind schedule and 84% of clinicians admitted to being at least 20 minutes behind schedule "some", "most", or "all of the time".ConclusionEven though a majority of our clinical decision support suggestions are not explicitly followed, clinicians feel they are of benefit and would be even more beneficial if they had more time available to address them.

The case for dedicated sickle cell centres

In Jamaica the word transition means death, but in the sickle cell vocabulary of the United States it refers to the transfer from paediatrician to adult physician. Most patients with sickle cell disease are now identified at birth and are followed by paediatricians with an interest in and knowledge of the disease. Then at an arbitrary age—12, 16, or 18 years, depending on the institution—patients must leave the doctor they have known from birth and are referred to a usually unknown doctor. The result is that many patients default from follow-up at a critical time of adolescence, when they face problems of delayed physical and sexual development, enuresis, leg ulcers, priapism, and an increasing incidence of bone pain crises. Is this disruption in clinical care necessary? Yes, the administrators say; but then we should ask whether the patients are there for the system or the system is there to serve the patients. Is it possible to provide a seamless service for clinical care of sickle cell disease? Are the demands of managing these patients sufficiently different from those of other …

Engaging Australian physicians in evidence‐based medicine: a representative national survey

To assess Australian adult physicians' views about evidence-based medicine (EBM) and quality improvement (QI). Cross-sectional postal survey of two hundred and forty-four randomly selected Australian physicians (78.5% response rate). Physicians' views about the promotion of EBM and QI and their impact on patient care, strategies to support better clinical practice and self-reported understanding of EBM terms. Sixty-eight per cent (95% confidence interval (CI): 62-74%) of physicians had a positive view of the current promotion of EBM in Australia. Significantly fewer (45%; 95% CI: 38-51%) were so positive about QI (P <0.001). Although 74% (95% CI: 68-79%) indicated that EBM improves patient care, significantly fewer (46%; 95% CI: 40-53%) held this view with respect to QI (P <0.001). Although 70% (95% CI: 64-76%) of physicians agreed they had adequate skills to search for evidence, significantly fewer (21%; 95% CI: 17-27%) agreed they had sufficient time to do so (P <0.001). EBM skills were positively associated with involvement in teaching. Physicians were significantly more positive about approaches exclusive to themselves compared with those involving other disciplines. Although Australian physicians have positive views of EBM, QI appears less well regarded. Initiatives to improve quality and safety that incorporate principles and language of EBM will likely be received better by physicians than isolated QI. Further enhancement of EBM requires concomitant attention to physician training, workplace infrastructure and supportive professional development.

Cystic Adenomatoid Malformation of the Lung Presenting in Adulthood

Cystic adenomatoid malformation is an uncommon embryonic developmental abnormality usually diagnosed in neonates and infants. Its presentation in adulthood is rare, with only 27 cases reported up to now. Due to its rarity, it is seldom suspected and adult physicians are not familiar with its clinical and radiologic features. We report two cases of cystic adenomatoid malformation presenting in adults, one as a recurrent pneumonia, and another as a coincidental finding on a chest roentgenogram. We describe the clinical features, radiologic and computed tomographic findings, and the histopathologic characteristics in this article, along with a review of the literature.

An Ongoing Six-Year Innovative Osteoporosis Disease Management Program: Challenges and Success in an IPA Physician Group Environment

The goal of this ongoing comprehensive osteoporosis disease management initiative is to provide the adult primary care physicians' (PCPs) offices with a program enabling them to systematically identify and manage their population for osteoporosis. For over six years, Hill Physicians Medical Group (Hill Physicians) has implemented multiple strategies to develop a best practice for identifying and treating members who were candidates for osteoporosis therapy. Numerous tools were used to support this disease management effort, including: evidence- based clinical practice guidelines, patient education sessions, the Simple Calculated Osteoporosis Risk Estimation (SCORE) questionnaire tool, member specific reports for PCPs, targeted member mailings, office-based Peripheral Instantaneous X-ray Imaging (PIXI) test and counseling, dual x-ray absorptiometry (DEXA) scan guidelines, and web-based Electronic Simple Calculated Osteoporosis Risk Estimation (eSCORE) questionnaire tools. Hill Physicians tabulated results for patients who completed 2649 SCORE tests, screened 978 patients with PIXI tests, and identified 338 osteopenic and 124 osteoporotic patients. The preliminary results of this unique six-year ongoing educational initiative are slow but promising. New physician offices express interest in participating and those offices that have participated in the program continue to screen for osteoporosis. Hill Physicians' message is consistent and is communicated to the physicians repeatedly in different ways in accordance with the principles of educational outreach. Physicians who have conducted the program have positive feedback from their patients and office staff and have begun to communicate their experience to their peers. (Disease Management 2004;7:216–225)

An Ongoing Six-Year Innovative Osteoporosis Disease Management Program: Challenges and Success in an IPA Physician Group Environment

The goal of this ongoing comprehensive osteoporosis disease management initiative is to provide the adult primary care physicians' (PCPs) offices with a program enabling them to systematically identify and manage their population for osteoporosis. For over six years, Hill Physicians Medical Group (Hill Physicians) has implemented multiple strategies to develop a best practice for identifying and treating members who were candidates for osteoporosis therapy. Numerous tools were used to support this disease management effort, including: evidence-based clinical practice guidelines, patient education sessions, the Simple Calculated Osteoporosis Risk Estimation (SCORE) questionnaire tool, member specific reports for PCPs, targeted member mailings, office-based Peripheral Instantaneous X-ray Imaging (PIXI) test and counseling, dual x-ray absorptiometry (DEXA) scan guidelines, and web-based Electronic Simple Calculated Osteoporosis Risk Estimation (eSCORE) questionnaire tools. Hill Physicians tabulated results for patients who completed 2649 SCORE tests, screened 978 patients with PIXI tests, and identified 338 osteopenic and 124 osteoporotic patients. The preliminary results of this unique six-year ongoing educational initiative are slow but promising. New physician offices express interest in participating and those offices that have participated in the program continue to screen for osteoporosis. Hill Physicians' message is consistent and is communicated to the physicians repeatedly in different ways in accordance with the principles of educational outreach. Physicians who have conducted the program have positive feedback from their patients and office staff and have begun to communicate their experience to their peers.

Transitional care of GH deficiency: when to stop GH therapy.

While the benefits of growth hormone (GH) therapy in adult hypopituitary patients with GH deficiency (GHD) are established, the role of continued GH therapy after final height in adolescent GH-deficient patients remains unclear. Preliminary data suggest that cessation of GH on completion of linear growth may be associated with impairment of somatic development and adverse changes in body composition. For the present time, the decision whether to continue GH treatment in adolescent patients with GHD is best made on an individual basis. For such patients, continuity of care is crucial. Children and adults with GHD are usually managed by physicians in separate departments, who may focus on different aspects of treatment and care. Close collaboration between paediatric and adult physicians is essential to ensure smooth transition and to minimize the drop-out rate from follow-up. Given the previous period of treatment during childhood, paediatric physicians should be best placed to discuss the potential benefits of continuing GH therapy and instigate retesting of GH secretion. Many children with isolated idiopathic GHD will produce normal GH responses if retested at adult height. Patients with multiple pituitary hormone deficits are more likely to have ongoing GHD, as are patients who have received CNS irradiation. Quality of life does not appear to be decreased in adolescents with GHD who stop treatment, so achievement of satisfactory bone mass is a major determinant of the decision whether to continue therapy.

Economic profiling of primary care physicians: consistency among risk-adjusted measures.

To investigate whether different risk-adjustment methodologies and economic profiling or "practice efficiency" metrics produce differences in practice efficiency rankings for a set of primary care physicians (PCPs). Twelve months of claims records (inpatient, outpatient, professional, and pharmacy) for an independent practice association HMO. Patient risk scores obtained with six profiling risk-adjustment methodologies were used in conjunction with claims cost tabulations to measure practice efficiency of all primary care physicians who managed 25 or more members of an HMO. For each of the risk-adjustment methodologies, two measures of "efficiency" were constructed: the standardized cost difference between total observed (standardized actual) and total expected costs for patients managed by each PCP, and the ratio of the PCP's total observed to total expected costs (O/E ratio). Primary care physicians were ranked from most to least efficient according to each risk-adjusted measure, and level of agreement among measures was tested using weighted kappa. Separate rankings were constructed for pediatricians and for other primary care physicians. Moderate to high levels of agreement were observed among the six risk-adjusted measures of practice efficiency. Agreement was greater among pediatrician rankings than among adult primary care physician rankings, and, with the standardized difference measure, greater for identifying the least efficient than the most efficient physicians. The O/E ratio was shown to be a biased measure of physician practice efficiency, disproportionately targeting smaller sized panels as outliers. Although we observed moderate consistency among different risk-adjusted PCP rankings, consistency of measures does not prove that practice efficiency rankings are valid, and health plans should be careful in how they use practice efficiency information. Indicators of practice efficiency should be based on the standardized cost difference, which controls for number of patients in a panel, instead of O/E ratio, which does not.

Adolescent access to healthcare

Adolescent access to healthcare

Physicians as barriers to successful transitional care.

There has been a dramatic increase in the number of sufferers of chronic childhood diseases surviving into adulthood. Effective transition of these children from paediatric to adult medical services is a considerable challenge. A lack of integrated planning for this event can present barriers to successful transition. These barriers may be generated by the patient, his family or by political or logistical factors. However, physicians themselves can also become barriers in this process. Paediatricians may resist the transition process as they lack confidence in their adult colleagues. Emotional, academic, financial and cultural issues will also influence both child and adult physician's attitude to the hand-over of care. Increasingly poor understanding of their disease process by Paediatric trained doctors, makes transfer of care essential for adolescents. The move towards a culture of personal responsibility for health care is also crucial for the promotion of the maturing patient's independence. Development of adolescent services and closer links between the services could do much to enhance the transition experience of emerging adults.