Differences In Practice Style Research Articles

General practitioners’ role in safeguarding patients with dementia in their use of dietary supplements. A qualitative study

Objective The use of dietary supplements (DS) may cause harm through direct and indirect effects. Patients with dementia may be particularly vulnerable. This study aims to explore general practitioners’ (GPs’) experiences with DS use by these patients, the GPs perceived responsibilities, obstacles in taking on this responsibility, their attitudes toward DS, and suggestions for improvements to safeguard the use of DS in this patient group. Design Qualitative individual interview study conducted February - December 2019. Data were analysed using systematic text condensation. Setting Primary healthcare clinics in Norway. Subjects Fourteen Norwegian GPs. Findings None of the informants were dismissive of patients using DS. They were aware of the possible direct risks and had observed them in patients. Most GPs showed little awareness of potential indirect risks to patients with dementia who use DS. They acknowledged the need for caretaking of these patients. Although there were differences in practice styles, most of the GPs wished to help their patients safeguarding DS use but found it difficult due to the lack of quality assurance of product information. Furthermore, there were no effective ways for the GPs to document DS use in the patients’ records. Several suggestions for improvement were given by the GPs, such as increased attention from GPs, inclusion of DS in the prescription software, and stricter regulatory systems for DS from the authorities. Conclusion The GPs had initially little awareness of this safety risk, but there were differences in practice style and attitudes towards DS. The GPs did not perceive themselves as main responsible for safe use of DS in patient with dementia. The most important reason to disclaim responsibility was lack of information about the products. One suggestion for improvement was better integration of DS in patients’ medical record.

The impact of physician exits in primary care: A study of practice handovers

Recent studies on physician exits suggest that general practitioners (GPs) have an important impact on health care utilization and costs, but the transmission channels - interpersonal dis- continuities of care, practice style differences and deterioration in access - are usually not clear. Our objective is to estimate the short-run and long-run impacts of switches in GPs on patients’ health care utilization and costs, while all other factors of the health care setting remain the same. To do this, we collect data on handovers of primary care practices in Switzerland, occurring between 2007 and 2015. We link this data to rich insurance claims to construct a panel dataset of roughly 240,000 patients. Employing a difference-in-difference type framework, we find transitory increases in overall visits and costs, which are likely caused by the entering GP's initial re-assessment of patients’ health care needs. Additionally, we find long-term increases in specialist health care utilization and ambulatory costs. The latter finding can be explained by changes in practice styles between the exiting GP and her successor, who is typically much younger and more likely to be female. In contrast to the literature on practice closures, we do not find evidence on reduced overall utilization rates. An important lesson for health policy is thus to preserve patients’ access to care in the case of GP exits.

Extended Length of Stay After Lumbar Spine Surgery: Sick Patients, Postoperative Complications, or Practice Style Differences Among Hospitals and Physicians?

The degree to which extended length of stay (LOS) after surgery represents patient illness or postoperative complications is unknown. The aim of this study was to investigate the influence of postoperative complications and patient comorbidities on variance in extended length of hospital stay after lumbar spine surgery. Data from the American College of Surgeons National Surgical Quality Improvement Program were analyzed from January 1, 2008, through December 31, 2014. Study participants were 23,102 patients undergoing a 1-level or 2-level lumbar decompression and fusion procedure. Multivariable logistic regression analysis was used to determine the odds ratio for risk-adjusted extended length of hospital stay, defined as patients with a hospital stay greater than the 75th percentile (LOS >5 days) for the cohort. The primary outcome was the extent to which extended LOS represented preoperative patient illness or postoperative complications. Of 23,102 participants, 3794 (16.42%) had extended LOS. Most patients (2849 patients; 75.10%) with extended LOS did not have a documented postoperative complication. Only a minority of patients with extended LOS had a history of comorbidities known to influence outcomes in patients undergoing spine surgery, including diabetes (24%), chronic obstructive pulmonary disease (7%), congestive heart failure (0.69%), myocardial infarction (0.20%), acute renal failure (0.26%), and stroke (2.23%). This study suggests that much of the variation in LOS after lumbar spine surgery is not attributable to baseline patient illness or complications and most likely represents differences in practice style or surgeon preference.

Extended Length of Stay in Elderly Patients After Lumbar Decompression and Fusion Surgery May Not Be Attributable to Baseline Illness Severity or Postoperative Complications

Hospital leaders are seeking ways to improve resource utilization and minimize long postoperative hospital stays. Common explanations for extended length of stay (LOS) are baseline patient illness, postoperative complications, and physician practice differences. The degree to which extended LOS represents illness severity or postoperative complications is unknown. We investigated influence of postoperative complications and patient comorbidities on extended LOS after lumbar spine surgery in elderly patients. This retrospective cohort study from 2008 to 2014 analyzed data from the American College of Surgeons National Surgical Quality Improvement Program for elderly patients undergoing lumbar spine surgery. Patient demographics, comorbidities, LOS, and complications were recorded. Multivariable logistic regression analysis was used to determine odds ratio for risk-adjusted LOS. Primary outcome was the degree extended LOS represented patient illness or postoperative complications. Of 9482 patients, 1909 (20.13%) had extended LOS. A few patients with extended LOS had a history of relevant comorbidities, including diabetes (21.76%), chronic obstructive pulmonary disease (8.17%), congestive heart failure (0.94%), myocardial infarction (0%), acute renal failure (0.47%), and stroke (2.23%). Of patients with normal LOS, 93% had no complications, 5.19% had 1complication, and 1.69% had >1 complication. Among patients with extended LOS, 73.65% had no complications, 18.96% had 1 complication, and 7.39% had >1 complication (P < 0.000). Our study suggests that much of the variation in LOS for elderly patients undergoing lumbar spine surgery is not attributable to baseline patient illness or postoperative complications and most likely represents differences in practice style or surgeon preference.

Extended Length of Stay in Elderly Patients after Anterior Cervical Discectomy and Fusion Is Not Attributable to Baseline Illness Severity or Postoperative Complications

Health care systems are increasing efforts to minimize postoperative hospital stays to improve resource use. Common explanations for extended postoperative stay are baseline patient sickness, postoperative complications, or physician practice differences. However, the degree to which extended length of stay (LOS) represents patient illness or postoperative complications remains unknown. The aim is to investigate the influence of postoperative complications and elderly patient comorbidities on extended LOS after anterior cervical discectomy and fusion. This retrospective study was performed from January 1, 2008, to December 31, 2014, on data from the American College of Surgeons National Surgical Quality Improvement Program. Patient demographics, comorbidities, LOS, and inpatient complications were recorded. Multivariable logistic regression analysis was used to determine the odds ratio for risk-adjusted extended LOS. The primary outcome was the degree extended LOS represented patient illness or postoperative complications. Of 4730 participants, 1351 (28.56%) had extended LOS. A minority of patients with extended LOS had a history of relevant comorbidities-diabetes (29.53%), chronic obstructive pulmonary disease (9.4%), congestive heart failure (1.04%), myocardial infarction (0.33%), acute renal failure (0.3%), and stroke (5.92%). Among patients with normal LOS, 96.8% had no complications, 2.7% had 1 complication, and 0.5% had greater than 1 complication. In patients with extended LOS, 79.4% had no complications, 14.5% had 1 complication, and 6.1% had greater than 1 complication (P < 0.0001). Our study suggests much of LOS variation after an anterior cervical discectomy and fusion is not attributable to baseline patient illness or complications and most likely represents differences in practice style or surgeon preference.

Implementation of an integrated computerized prescriber order-entry system for chemotherapy in a multisite safety-net health system.

The development of a computerized prescriber order-entry (CPOE) system for chemotherapy in a multisite safety-net health system and the challenges to its successful implementation are described. Before CPOE for chemotherapy was first implemented and embedded in the electronic medical record system of Harris Health System (HHS), pharmacy personnel relied on regimen-specific preprinted order sets. However, due to differences in practice styles and workflow logistics, the paper orders across the 3 facilities were mostly site specific, with varying clinical content. Many of these order sets had not been approved by the oncology subcommittee. In addition, disparities in clinical knowledge and lack of communication contributed to inconsistencies in order set development. Led by medical directors from medical oncology departments at the 3 facilities, pharmacy administrators, and information technology representatives, HHS committed resources to supporting the adoption and use of a CPOE system for chemotherapy. Five practical lessons of broad applicability have been learned: engagement of interprofessional stakeholders, optimization of workflow before CPOE implementation, requirement of verification tool for CPOE, consolidation of protocols, and commitment to ongoing training and support. Evaluation of the CPOE system demonstrated a systemwide reduction in medication errors by 75% (p < 0.05). Satisfaction with the CPOE system varied among sites and was unchanged institutionwide 6 months after the CPOE implementation. The development and implementation of CPOE for chemotherapy at a multisite safety-net health system created opportunities to optimize patient care and reduce variations through interprofessional collaborations. Initial evaluation suggested that CPOE reduced the medication-order error rate and improved user satisfaction in 1 of 3 facilities.

Distributional Differences between Family Physicians and General Internists.

While differences in practice style and costs between family medicine and internal medicine are relatively well known, the differences in geographic distribution between the two remain underexplored. This study aims to examine differences in distribution of family physicians and general internists by geographic and demographic characteristics. Data sources are the 2016 American Medical Association Physician Master File and 2015 American Community Survey. Results show that internists are more dominant in urban areas, especially in the Northeast; they are also more likely to practice in the West and South. Family physicians are more likely to practice in rural areas and primary care Health Professional Shortage Areas than internists; their distribution also varies significantly with respect to areas whose residents are members of racial/ethnic minority groups, live in poverty, and are uninsured. Such differences should be a consideration for planning to address regional and national primary care workforce shortages.

The quality of feedback during formative OSCEs depends on the tutors' profile.

BackgroundDuring their pre-clinical years, medical students are given the opportunity to practice clinical skills with simulated patients. During these formative objective structured clinical encounters (OSCEs), tutors from various backgrounds give feedback on students’ history taking, physical exam, and communication skills. The aim of the study was to evaluate whether the content and process of feedback varied according to the tutors’ profile.MethodsDuring 2013, all 2nd and 3rd year medical students and tutors involved in three formative OSCEs were asked to fill in questionnaires, and their feedback sessions were audiotaped. Tutors were divided into two groups: 1) generalists: primary care, general internist and educationalist physicians 2) specialists involved in the OSCE related to their field of expertise. Outcome measures included the students’ perceptions of feedback quality and utility and objective assessment of feedback quality.ResultsParticipants included 251 medical students and 38 tutors (22 generalists and 16 specialists). Students self-reported that feedback was useful to improve history taking, physical exam and communication skills. Objective assessment showed that feedback content essentially focused on history taking and physical exam skills, and that elaboration on clinical reasoning or communication/professionalism issues was uncommon. Multivariate analyses showed that generalist tutors used more learner-centered feedback skills than specialist tutors (stimulating student’s self-assessment (p < .001; making the student active in finding solutions, p < .001; checking student’s understanding, p < .001) and elaborated more on communication and professionalism issues (p < 0.001). Specialists reported less training in how to provide feedback than generalists.ConclusionThese findings suggest that generalist tutors are more learner-centered and pay more attention to communication and professionalism during feedback than specialist tutors. Such differences may be explained by differences in feedback training but also by differences in practice styles and frames of references that should be further explored.Electronic supplementary materialThe online version of this article (doi:10.1186/s12909-016-0815-x) contains supplementary material, which is available to authorized users.

Sleep Consolidation of Musical Competence

Previous research has shown that sleep facilitates skill acquisition by consolidating recent memories into a stabilized form. The way in which sleep benefits the acquisition of a musical skill, however, is unclear. This is because previous studies have not dissociated the extent to which sleep consolidates learned motoric patterns from the conceptual structure of the music. We thus designed two experiments in which pianists performed short pieces – designed to separate conceptual from motoric errors – over the course of a day. In Experiment 1, participants were trained in the morning and tested immediately, 12 hours, and 24 hours after training. While both motor and conceptual errors increased over a waking retention interval, only conceptual errors were significantly reduced after sleep. Moreover, individuals who reported spending more time “playing by ear” showed greater reductions of conceptual errors after sleep. A second control experiment, in which participants were trained in the evening and tested immediately – as well as 12 hours – after training, confirmed that the results from Experiment 1 could not be attributed solely to circadian confounds or to elapsed time since training. Together, these results suggest that conceptual and motor errors consolidate differently and interact with differences in practice style.

Why the Geographic Variation in Health Care Spending Can't Tell Us Much about the Efficiency or Quality of Our Health Care System

Examining the geographic variation in Medicare and non-Medicare health spending, I find little support for the view that most of the variation can be attributed to differences in practice styles. Instead, I find that socioeconomic factors that affect the need for medical care, as well as interactions between the Medicare system and other parts of the health system, can account for most of the variation in spending. I also find that controlling for health attributes at the state level explains more of the state-level variation associated with omitted health attributes than controlling for them at the individual level, an econometric difference that likely explains much of the difference between my results and those of the Dartmouth group. More broadly, I find that geographic variations in health spending do not provide a useful way to examine the inefficiencies of our health system. States where Medicare spending is high differ in multiple ways from states where it is low, and it is difficult to isolate the effects of health spending intensity from the effects of the underlying state characteristics. I show, for example, that previous findings about the relationships between health spending, the share of physicians who are general practitioners, and health care quality, are likely the result of omitted factors rather than the result of causal relationships.

The impact of non-economic damages caps on obstetrics: Incentives versus practice style

This paper uses 1989–2010 county-level data to reexamine the effect of non-economic damages caps on the field of obstetrics. Previous literature found that caps on damages lead to both changes in the number of physicians and changes in treatment patterns. This paper investigates whether the changes in procedures are attributable to changes in incentives or to selection when new entrants could have a different practice style than incumbents. First, I find that the relationship between non-economic damages caps and the number of physicians and procedures identified in previous literature is not robust to the inclusion of the newer policy changes. Second, over the period when such changes were observed, the impact on procedures is concentrated in areas with the greatest changes in the number of obstetricians/gynecologists per capita, suggesting that most of the effect on procedures is driven by differences in practice style between entrants and incumbents.

Why the Geographic Variation in Health Care Spending Cannot Tell Us Much about the Efficiency or Quality of Our Health Care System

Examining the geographic variation in Medicare and non-Medicare health spending, I find little support for the view that most of the variation can be attributed to differences in practice styles. Instead, I find that socioeconomic factors that affect the need for medical care, as well as interactions between the Medicare system and other parts of the health system, can account for most of the variation in spending. I also find that controlling for health attributes at the state level explains more of the state-level variation associated with omitted health attributes than controlling for them at the individual level, an econometric difference that likely explains much of the difference between my results and those of the Dartmouth group. More broadly, I find that geographic variations in health spending do not provide a useful way to examine the inefficiencies of our health system. States where Medicare spending is high differ in multiple ways from states where it is low, and it is difficult to isolate the effects of health spending intensity from the effects of the underlying state characteristics. I show, for example, that previous findings about the relationships between health spending, the share of physicians who are general practitioners, and health care quality, are likely the result of omitted factors rather than the result of causal relationships.

Extended length of stay after surgery: complications, inefficient practice, or sick patients?

With the health policy focus on shifting risk to hospitals and physicians, hospital leaders are increasing efforts to reduce excessive resource use, such as patients with extended length of stay (LOS) after surgery. However, the degree to which extended LOS represents complications, patient illness, or inefficient practice style is unclear. To examine the influence of complications on the variance in hospitals' extended LOS rates after colorectal resections. In this retrospective cohort study performed from January 1 through December 31, 2009, we analyzed data from the 2009 American College of Surgeons National Surgical Quality Improvement Program. Study participants were 22 664 adults undergoing colorectal resections in 199 hospitals. Inpatient complications recorded in the American College of Surgeons National Surgical Quality Improvement Program registry. Inpatient complications were identified by the association of the complication's postoperative date with the patient's surgical discharge date. Hospitals' risk-adjusted extended LOS rates, defined as the proportion of patients with a hospital stay greater than the 75th percentile for the entire cohort. A total of 2177 patients (42.8%) with extended LOSs did not have a documented inpatient complication. Although there was wide variation in risk-adjusted extended LOS (14.5%-35.3%) and risk-adjusted inpatient complication (12.1%-28.5%) rates, there was only a weak correlation (Spearman ρ = 0.56, P < .001) between the two. Only 52.0% of the variation in hospitals' extended LOS rates was attributable to hospitals' inpatient complication rates. Much of the variation in hospitals' risk-adjusted extended LOS rates is not attributable to patient illness or complications and therefore most likely represents differences in practice style. Efforts to reduce excess resource use should focus on efficiency of care, such as increased adoption of enhanced recovery pathways.

The Anatomy of Primary Care and Mental Health Clinician Communication: A Quality Improvement Case Study

The high prevalence of comorbid physical and mental illnesses among veterans is well known. Therefore, ensuring effective communication between primary care (PC) and mental health (MH) clinicians in the Veterans Affairs (VA) health care system is essential. The VA's Patient Aligned Care Teams (PACT) initiative has further raised awareness of the need for communication between PC and MH. Improving such communication, however, has proven challenging. To qualitatively understand barriers to PC-MH communication in an academic community-based clinic by using continuous quality improvement (CQI) tools and then initiate a change strategy. An interdisciplinary quality improvement (QI) work group composed of 11 on-site PC and MH providers, administrators, and researchers identified communication barriers and facilitators using fishbone diagrams and process flow maps. The work group then verified and provided context for the diagram and flow maps through medical record review (32 patients who received both PC and MH care), interviews (6 stakeholders), and reports from four previously completed focus groups. Based on these findings and a previous systematic review of interventions to improve interspecialty communication, the team initiated plans for improvement. Key communication barriers included lack of effective standardized communication processes, practice style differences, and inadequate PC training in MH. Clinicians often accessed advice or formal consultation based on pre-existing across-discipline personal relationships. The work group identified collocated collaborative care, joint care planning, and joint case conferences as feasible, evidence-based interventions for improving communication. CQI tools enabled providers to systematically assess local communication barriers and facilitators and engaged stakeholders in developing possible solutions. A locally tailored CQI process focusing on communication helped initiate change strategies and ongoing improvement efforts.

Implications of Physician Ethics, Billing Norms, and Service Cost Structures for Medicare's Fee Schedule

Medicare Part B pays physicians through a fixed fee schedule designed loosely as a system of average-cost reimbursement. This paper examines four difficulties faced by systems of this kind. First, Medicare's payment model would be improved if it accounted for the medical value and cost-effectiveness of treatments in addition to their cost. Second, uniformly applied fee schedules are inefficient when physicians vary in their approaches to medical practice. Allowing Medicare to account for regional differences in practice styles, which are substantial, may have significant benefits. Third, differences in physicians' billing practices have similar, largely unstudied, implications. Proficient billers receive relatively high payments for incremental service provision, resulting in high-powered incentives. Costs associated with variation in billing norms and in the application of physicians' ethics highlight that welfare could be improved by training physicians more uniformly in these respects. Fourth, differences in services' cost structures point to an additional weakness in Medicare Part B's payment model. Average-cost reimbursement implies larger profit margins for capital-intensive services than for labor-intensive services. As implemented, Medicare's fee schedule has encouraged significant expansions in the adoption, utilization, and development of capital-intensive tests and treatments. Note: This paper was prepared for use in the course 'Economics 140: The Economics of Health Care Producers,' at the University of California at San Diego. The course fulfills a general education requirement, which limits the explicit use of calculus.

Why the Geographic Variation in Health Care Spending Can't Tell Us Much About the Efficiency or Quality of Our Health Care System

This paper examines the geographic variation in Medicare and non-Medicare health spending and finds little support for the view that most of the variation is attributable to differences in practice styles. Instead, I find that socioeconomic factors that affect the need for medical care, as well as interactions between the Medicare system, Medicaid, and private health spending, can account for most of the variation in Medicare spending. Furthermore, I find that the health spending of the non-Medicare population is not well correlated with Medicare spending, suggesting that Medicare spending is not a good proxy for average health spending by state. Finally, there is a negative correlation between the level and growth of Medicare spending: Low-spending states are not low-growth states and are thus unlikely to provide the key to curbing excess cost growth in Medicare. The paper also explores the econometric differences between controlling for health attributes at the state level vs the individual level. I show that a state-level approach is better at controlling for health attributes and argue that this econometric difference likely explains most of the difference between my results and those of the Dartmouth group. More broadly, the paper shows that the geographic variation in health spending does not provide a useful measure of the inefficiencies of our health system. States where Medicare spending is high are very different in multiple dimensions from states where Medicare spending is low, and thus it is difficult to isolate the effects of differences in health spending intensity from the effects of the differences in the underlying state characteristics. I show, for example, that the relationships between health spending, physician composition and quality are likely the result of omitted factors rather than the result of causal relationships.

Differences in Initial Benign Prostatic Hyperplasia Management Between Primary Care Physicians and Urologists

The introduction of efficacious pharmacotherapies has effectively transformed benign prostatic hyperplasia into a chronic disease that requires ongoing medical care. With this transformation primary care physicians have become more involved in the management of benign prostatic hyperplasia. The impact of the increasing role of the primary care physician on the use of benign prostatic hyperplasia related health services remains unknown. We performed a retrospective cohort study using medical claims from a nonprofit managed care organization. Between 1997 and 2005 we identified incident cases of benign prostatic hyperplasia and the provider responsible for the initial care. We fitted logistic regression models to measure the association between subject receipt of an evaluative process and the treating physician specialty. Furthermore, we examined differences between primary care physicians and urologists with respect to the use of medical therapy. Less than a third of incident cases received initial care from a urologist. Use of office based procedures and urodynamic tests was exclusive to urology. Urologists performed urinalysis testing and transrectal ultrasonography more frequently than primary care physicians (p <0.001). The odds of having a laboratory study doubled with treatment by a urologist (OR 2.03, 95% CI 1.51-2.74). Men seen by a urologist were also more likely to be prescribed a benign prostatic hyperplasia medication (p <0.001). Among those who received medical therapy, prescription of selective alpha-adrenergic blockers, 5alpha-reductase inhibitors and combination therapy was higher among urologists (p = 0.002). On average, urologists had a higher intensity practice style for benign prostatic hyperplasia than primary care physicians. Further studies are needed to determine how these practice style differences relate to patient clinical outcomes.

Weekend Admission and Treatment of Patients With Renal Colic: A Case of Avoidable Variation?

To determine whether, for symptomatic urolithiasis, the thresholds to intervene and the nature of the intervention might be susceptible to practice style differences that vary by day of presentation. Weekend hospital admission is associated with different and poorer quality care in certain clinical settings. Using the Florida State Inpatient Database for 2005, we identified admissions (n = 8589) for symptomatic urolithiasis using the "International Classification of Diseases, 9th revision" diagnosis codes. A multiple logistic regression model was fit, measuring the association between weekend admission and surgical intervention, controlling for patient differences. Among the surgically treated patients, the relationship between weekend admission and the likelihood of having definitive (vs temporizing) surgery was measured. Weekend admission was associated with a lower likelihood of surgery (odds ratio 0.88, 95% confidence interval 0.80-0.97). Patients with complicating factors, such as fever, were more likely to undergo surgery than those without such characteristics (adjusted odds ratio 1.28, 95% confidence interval 1.16-1.41). However, when surgery was performed, the use of definitive surgery was similar between the patients admitted on the weekend and those admitted on weekdays (adjusted odds ratio 1.02, 95% confidence interval 0.90-1.17). Patients with symptomatic urolithiasis who are admitted on the weekend are less likely to undergo surgery than those admitted during the week. However, the likelihood of intervention was similar among the patients with complicating factors. Physicians appear to treat the sickest patients the same, regardless of weekend admission; more elective surgical care may occur during the week.

A preventive approach to obstetric care in a rural hospital: association between higher rates of preventive labor induction and lower rates of cesarean delivery.

Annual cesarean delivery rates in North America are increasing. Despite the morbidity associated with cesarean delivery, a safe preventive strategy to reduce the use of this procedure has not been forthcoming. During the 1990s, clinicians in a rural hospital developed a method of care involving prostaglandin-assisted preventive labor induction. An inverse relationship was noted between yearly hospital rates of labor induction and cesarean delivery. The purpose of our study was to compare cesarean delivery rates between practitioners who often used preventive induction and practitioners who did not, while controlling for patient mix and differences in practice style. Between 1993 and 1997, different hospital practitioners used risk-guided prostaglandin-assisted preventive labor induction with differing intensity. We used a retrospective cohort design, based on the practitioner providing prenatal care, to compare birth outcomes in women exposed to this alternative method of care with those in women not exposed. Multiple logistic regression analysis controlled for patient characteristics and clustering by practitioner. The exposed group (n = 794), as compared with the nonexposed group (n = 1,075), had a higher labor induction rate (31.4% vs 20.4%, P <.001), a greater use of prostaglandin E2 (23.3% vs 15.7%, P <.001), and a lower cesarean delivery rate (5.3% vs 11.8%, P <.001). Adjustment for cluster effects, patient characteristics, and the use of epidural analgesia did not eliminate the significant association between exposure to this preventive method of care and a lower cesarean delivery rate. Rates of other adverse birth outcomes were either unchanged or reduced in the exposed group. A preventive approach to reducing cesarean deliveries may be possible. This study found that practitioners who often used risk-guided, prostaglandin-assisted labor induction had a lower cesarean delivery rate without increases in rates of other adverse birth outcomes. Randomized controlled trials of this method of care are warranted.

Effects of Differences in Practice Style of Kendo on Changes of Urinary Substances and Blood Lactate Concentration

Effects of Differences in Practice Style of Kendo on Changes of Urinary Substances and Blood Lactate Concentration