Lack Of Financial Incentives Research Articles

General practitioners' attitudes and preparedness towards Clinical Decision Support in e-Prescribing (CDS-eP) adoption in the West of Ireland: a cross sectional study

BackgroundElectronic clinical decision support (CDS) is increasingly establishing its role in evidence-based clinical practice. Considerable evidence supports its enhancement of efficiency in e-Prescribing, but some controversy remains. This study evaluated the practicality and identified the perceived benefits of, and barriers to, its future adoption in the West of Ireland.MethodsThis cross sectional study was carried out by means of a 27-part questionnaire sent to 262 registered general practitioners in Counties Galway, Mayo and Roscommon. The survey domains encompassed general information of individual's practice, current use of CDS and the practitioner's attitudes towards adoption of CDS-eP. Descriptive and inferential analyses were performed to analyse the data collected.ResultsThe overall response rate was 37%. Nearly 92% of respondents employed electronic medical records in their practice. The majority acknowledged the value of electronic CDS in improving prescribing quality (71%) and reducing prescribing errors (84%). Despite a high degree of unfamiliarity (73%), the practitioners were open to the use of CDS-eP (94%) and willing to invest greater resources for its implementation (62%). Lack of a strategic implementation plan (78%) is the main perceived barrier to the incorporation of CDS-eP into clinical practice, followed by i) lack of financial incentives (70%), ii) lack of standardized product software (61%), iii) high sensitivity of drug-drug interaction or medication allergy markers (46%), iv) concern about overriding physicians' prescribing decisions(44%) and v) lack of convincing evidence on the systems' effectiveness (22%).ConclusionsDespite favourable attitudes towards the adoption of CDS-eP, multiple perceived barriers impede its incorporation into clinical practice. These merit further exploration, taking into consideration the structure of the Irish primary health care system, before CDS-eP can be recommended for routine clinical use in the West of Ireland.

Adult weight management: Translating research and guidelines into practice

To provide a practical approach to managing overweight and obese adult patients based on data from research and recommendations from established guidelines. Comprehensive review articles and original research articles identified through Medline and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). There is a great deal of research being conducted on new ways to treat obesity; however, despite all this new information, many primary care providers continue to report that they do not address weight or weight control strategies with their patients. Reasons include too little time, not enough training, lack of financial incentive, and failure to believe that patients can be successful. Weight management essentially comes down to one key concept: negative energy balance (fewer calories in and/or more calories out). Patients can be taught how to achieve a negative energy balance by using a food/exercise diary to track their daily caloric goal to achieve a 1-2 pound weight loss per week. Nurse practitioners (NPs) can implement safe and effective weight management plans for their patients by teaching them how to self-monitor, eat healthy, and exercise. This method is similar to what NPs commonly use for patients with diabetes mellitus.

A novel on-off TRV adjustment model and simulation of its thermal dynamic performance

Field test results show that about 15% to 40% of building heat loss in China is attributable to poor heating systems regulation. The current method for addressing this problem is to install thermostatic radiator valves (TRVs) to the ends of radiators, a method adapted from northern Europe. However, this method has resulted in poor performance from delayed controlling action due to thermal inertia as well as insufficient system control accuracy. This is further compounded by incorrect operation by system users and a lack of financial incentives to regulate the system if users are not billed for their heat consumption. We present a new method for simultaneously heat controlling and metering. The core challenge is to design a control strategy that will maintain the room’s temperature. Thus, we established dynamic heat transfer models for water flow, the radiator and the building so as to obtain the optimal heating strategy. We also simulated the indoor thermal dynamic performance of the heating system with different heating loads, supply water temperatures, and supply water flow rates using three methods: a continuously changing flow rate (Method 1), a step-change flow rate based on temperature deviation (Method 2) and an intelligent step-change flow rate (Method 3) which predicts the duty cycle of the valve in the proceeding period and controls the valve’s on-time. The simulation results indicate the performance of these three methods. For Method 1, as the room temperature is above the set point, the flow rate can be automatically reduced to a level which is proportional to the room temperature deviation. Further, the scale factor of the flow rate is designed according to the +2°C deviation, so it is accepted that the room temperature is higher than the set point by +2°C using this method. However, this low control precision is unsatisfactory. The mean temperature is higher than the set point and greatly affected by the heating load and supply water’s temperature and flow rate. For Method 2, the controlling action is delayed by thermal inertia, the room temperature fluctuates between the highest and lowest levels, and the temperature deviation can be greater than the set value. For Method 3, both the simulation and field test results showed that room temperature deviation was maintained within a ±0.5°C range under the various conditions. This method appears relatively robust and adaptable, and was the best control strategy of the three methods.

Quality improvement in small office settings: an examination of successful practices

BackgroundPhysicians in small to moderate primary care practices in the United States (U.S.) (<25 physicians) face unique challenges in implementing quality improvement (QI) initiatives, including limited resources, small staffs, and inadequate information technology systems 23,36. This qualitative study sought to identify and understand the characteristics and organizational cultures of physicians working in smaller practices who are actively engaged in measurement and quality improvement initiatives.MethodsWe undertook a qualitative study, based on semi-structured, open-ended interviews conducted with practices (N = 39) that used performance data to drive quality improvement activities.ResultsPhysicians indicated that benefits to performing measurement and QI included greater practice efficiency, patient and staff retention, and higher staff and clinician satisfaction with practice. Internal facilitators included the designation of a practice champion, cooperation of other physicians and staff, and the involvement of practice leaders. Time constraints, cost of activities, problems with information management and or technology, lack of motivated staff, and a lack of financial incentives were commonly reported as barriers.ConclusionThese findings shed light on how physicians engage in quality improvement activities, and may help raise awareness of and aid in the implementation of future initiatives in small practices more generally.

Balancing the costs and benefits of opioid analgesics in the United States

In 1919, the US Supreme Court ruled in Webb et al. v. United States that prescribing drugs for an addicted patient ‘not . in the attempted cure of the habit, but . providing the user with morphine sufficient to keep him comfortable by maintaining his customary use’ was illegitimate practice (Webb v. United States, 249 U.S. 96 [1919]). The medical profession largely turned its back on opioid addiction until the 1960s, when methadone maintenance emerged as an effective treatment. Availability of opioid agonist maintenance services has been slow to develop and hindered by concerns of drug diversion. Recent legislation permits buprenorphine to be prescribed for maintenance therapy by general physicians who undergo special training; training that serves as a significant hurdle given the lack of financial incentive to provide this service. Nonetheless, US physicians have long balked at managing addiction, such that many are poorly trained to do so at this time. Opioids prescribed for pain (‘opioid analgesics’), rather than those prescribed for maintenance therapy, represent the vast majority of opioids diverted to the black market.1 Fischer et al. suggest that diversion of opioid analgesics is akin to an informal form of maintenance, and thereby might lessen the harms of illicit opioid use among ‘street drug users’ in the USA. Any reasonable drug policy must prioritize the reduction of related health and safety consequences, and Fischer et al. note that illicit users of opioid analgesics suffer fewer consequences than heroin users. Their thesis is that increased diversion of opioid analgesics in the USAwill result in less injection drug use with an associated decline in transmission of blood-borne diseases, lowered rates of overdose mortality due to known purity and potency of pharmaceutically produced drugs, reduced criminal activity to obtain drugs, and improved contact with healthcare services. Would increased diversion of opioid analgesics decrease the health consequences of heroin injection? Fischer et al. cite three

Problems with Civil and Environmental Engineering Education in the U.S.

Problems with Civil and Environmental Engineering Education in the U.S.

An organizational learning perspective on the assimilation of electronic medical records among small physician practices

Small physician practices play an essential role in the healthcare delivery system but are least likely to adopt health information technologies such as electronic medical records (EMRs). Factors contributing to low adoption include investment cost, productivity loss, and lack of financial incentives. However, these factors do not explain why some small practices, which face similar challenges nonetheless assimilate EMRs, while others do not. We investigated the assimilation of EMRs from the theoretic perspective of organizational learning in a survey of small physician practices and evaluated whether characteristics associated with organizational learning barriers are related to EMR assimilation. We found that learning-related scale, related knowledge, and diversity were positively associated with small physician practices' stage of assimilation of EMR technology. Our findings suggest that some small practices are able to overcome the substantial learning barriers presented by EMRs but that others will require support to develop sufficient learning capacity. We consider implications for practice from this research and areas requiring further research.

Research study into access to recycled water: impediments to recycled water investment

A report by the Australian Academy of Technical Sciences and Energy (AATSE), Water Recycling in Australia (2003-04), and research by CSIRO, Exploring the Institutional Impediments to Conservation and Water Reuse (2004), indicated that a lack of a clear access/entitlement system for recycled water could be impeding investment in recycled water schemes. To test this theory and to identify and gauge the importance of other potential impediments, ACIL Tasman was commissioned by all Australian governments to undertake a literature review and a two-stage survey of key stakeholders in the water supply and sewerage service industry in Australia.The focus of the study was primarily to provide information to governments to assist in their development of policies to encourage the greater use of recycled water. The research paper should also assist stakeholders from the water industry to identify the importance of particular impediments when evaluating the viability of new schemes and develop approaches to overcoming them.In summary, the results of this research indicate that the key perceived impediments to investment in recycled water schemes are: the absolute and relative cost of recycled water, the lack of financial incentives for developing recycled water schemes and complexity in project implementation. Other significant impediments include: unclear liability (and stakeholder responsibility) and public perceptions of health risks in the use of recycled water. It is interesting to note that only a minority across all stakeholder groups saw the issue of access/entitlement to water as a major impediment, however, this minority was adamant about the importance of this issue.

Development of the Housing Allowance Programmes in Hungary in the Context of CEE Transitional Countries1

This paper explores the background of the emerging of housing allowance system in Hungary after 1990 in the context of the Central and Eastern European (CEE) countries. Housing allowance in Hungary was first introduced as a decentralized (local government managed) programme, but it went through a development process. The programme was more a part of the safety net system than a demand side subsidy, and its limited role can be explained by the lack of financial incentives of local governments. A new programme was introduced in 2004, where the cooperation between central government and local governments is better founded and, hence, will lead to a restructuring of the scope of the benefit programme. The Hungarian housing system seems to move towards a housing and welfare regime in which the state (public housing) plays increasingly less role, the transition process puts more and more burden on the families, and the safety net provides help only to the neediest families (very low-income households and those ...

What to Do With a Patient Who Smokes

Despite the reality that smoking remains the most important preventable cause of death and disability, most clinicians underperform in helping smokers quit. Of the 46 million current smokers in the United States, 70% say they would like to quit, but only a small fraction are able to do so on their own because nicotine is so highly addictive. One third to one half of all smokers die prematurely. Reasons clinicians avoid helping smokers quit include time constraints, lack of expertise, lack of financial incentives, respect for a smoker's privacy, fear that a negative message might lose customers, pessimism because most smokers are unable to quit, stigma, and clinicians being smokers. The gold standard for cessation treatment is the 5 As (ask, advise, assess, assist, and arrange). Yet, only a minority of physicians know about these, and fewer put them to use. Acceptable shortcuts are asking, advising, and referring to a telephone "quit line" or an internal referral system. Successful treatment combines counseling with pharmacotherapy (nicotine replacement therapy with or without psychotropic medication such as bupropion). Nicotine replacement therapy comes in long-acting (patch) or short-acting (gum, lozenge, nasal spray, or inhaler) forms. Ways to counter clinicians' pessimism about cessation include the knowledge that most smokers require multiple quit attempts before they succeed, that rigorous studies show long-term quit rates of 14% to 20%, with 1 report as high as 35%, that cessation rates for users of telephone quit lines and integrated health care systems are comparable with those of individual clinicians, and that no other clinical intervention can offer such a large potential benefit.

FITE diabetes: florida initiative in telehealth and education. Approach to diabetes care for children

Remote clinics for children with diabetes in under-served areas are necessary due to increasing numbers of patients, and shortages and centralisation of specialists at tertiary care centres. Lack of resources (professional and financial) to continue travelling to remote clinics. Lack of resources to allow for families to travel to hub clinics. Poor metabolic control and high rate of hospitalisation for the under-served population of the remote clinic. Lack of medical home contributing to a low rate of phone management of acute illness and a high rate of emergency department visits. Disproportionate use of financial resources for a small number of children with poor adherence to the medical plan. Lack of financial incentive and time for diabetes education, coupled with the correlation of adherence with education. Low rate of literacy and ‘new readers’ in the target population to be educated. Lack of adequate education programme to address the needs of this programme. Telemedicine clinic offered semi-monthly allowing improved frequency of patient visits without the necessity for families or providers to travel. Provision of a medical home with clear instructions regarding whom and when to call for additional guidance. Link secondary care providers in the school with the family and health care team for assimilation of all data collected through the day. Improved accountability of non-adherent patients by incorporating all data and increasing interaction with the health care team. Creation of web-based animated instruction covering all aspects of diabetes care. Pre- and post-testing provides the health care team with progress reports on patients enrolled. Access to website for patients and secondary caretakers (for example, teachers, grandparents, school nurses). Continuing education units offered to nurses to increase the understanding of diabetes by the health workforce. Establishment of a medical home and guidelines of when to call has reduced the frequent emergency department visits and hospitalisations for the group. Avoidance of travel costs, and work and school absences for travel to hub clinic by families. Efficiency of the health care team improved by avoiding travel to a remote clinic. Web education of new caretakers, guardians and others does not incur additional cost. Web education is available statewide. Line charges and equipment costs (amortised over five years) were £9993. (The line charges are dramatically reduced now as we are using one or two ISDN lines versus three.) The reduction in hospital days saved £23 572/year. The reduction in emergency department visits saved £1202/year. Additional savings of £34 462/year if Medicaid family transportation costs to the hub were necessary in the absence of the telemedicine clinic. Many academic centres provide health care by travelling to remote centres. Replication of this programme elsewhere has the potential to improve the efficiency of, and save time for, physicians and diabetes treatment teams already trying to meet the demands of their busy schedules. Reduction in line charges, through creative technology such as Internet Protocol encryption, will allow a more cost-effective provision of service than in-person visits to outreach sites. When other cost reductions such as decreased hospitalisation and emergency department use are considered, the costs of telemedicine services are readily justified.

From ventilator-induced lung injury to physician-induced lung injury: why the reluctance to use small tidal volumes?

know that medicine cannot always be a pro-vided by a protocol. Unlike drugs and medicaldevices, which cannot be sold unless their effective-ness has been documented, actual treatment in criticalcare medicine is often dictated by authority, personalexperience, and bias. To effectively practise moderncritical care medicine, clinicians must be knowledge-able of the complete spectrum of clinical disease andthe safety and efficacy of all treatments for any dis-ease. Training critical care physicians requires avoid-ing confusing opinions with evidence or personalignorance with scientific uncertainty (1). The betterwe understand the quality of the evidence we use tomake clinical decisions, the better we are able to judgewhether new scientific evidence should be incorpo-rated into our practice. But, how can we ensure thatthe current generation of physicians are trained tomake clinical decisions based on the judicious use ofthe current best evidence-based practice?Practising evidence-based medicine relies on mak-ing evidence from clinical research available to sup-port medical practice (2). In other words, critically illpatients should be treated by evidence-based clinicalpractice guidelines as standards of care. If medicine isnot based on scientific evidence, one must wonder onwhat it is based. The fact that we generally do a poorjob of translating research into practise is well docu-mented (3). There is the perception that the lack ofeducational initiatives at the departmental level inmany teaching hospitals around the world preventsus from implementing interventions that can improveclinically relevant outcomes. Instead, many of us stillpractise medicine based on our personal experiencesduring training and from treating patients over theyears (4). Although many randomized controlledtrials in critically ill patients have been conductedover the last 20years, some procedures that are welldocumented have still not become part of ‘standardpractice’ (5, 6). Physicians seem to be unwilling tochange their practice (7, 8). Insufficient evidence-based medical education, scientific ignorance, bias,and lack of financial incentives or lack of belief inthe research evidence are among some of the factorsthat may explain this attitude among critical carephysicians (2, 8). As a result, a gap remains betweenwhat the evidence recommends and what is practised.In this commentary, we discuss the evidence regard-ing the impact of mechanical ventilation on outcomein acute respiratory distress syndrome (ARDS) and itsimplementation or more precisely lack of implemen-tation.

Integration of the recommendations of the Canadian Task Force on Preventive Health Care: Obstacles perceived by a group of family physicians

Surveys conducted in North America and in several European countries show that the preventive activities recommended by some groups of experts are difficult to integrate into medical practice. Interventions to correct this problem have produced mitigated results. Our aim was to gain a better understanding of the obstacles perceived by a group of family physicians concerning the integration of prevention into their routine practices. A qualitative design was selected to facilitate the exploration of that topic. Seven focus groups with 35 physicians practising in the Montreal area were conducted. Questions regarding their perception of, and obstacles to, the integration of prevention in their daily work were explored. The text of these interviews was analysed following the content analysis method. Codification of the important themes that were identified was done by two of the researchers. We met with 35 family physicians in two regions in Montreal, Quebec. The lack of motivation on the part of users and the lack of value placed on continuity of care appear to be the main obstacles in the eyes of the physicians, followed by a lack of financial incentives, work overload, and contradictions among the recommendations. In addition, other obstacles were observed by the researchers: limited intervention strategies on the part of physicians to support behaviour modification among patients, non-recognition of the importance of the organization of practice and inability to acknowledge the obstacles that can be ascribed to their own beliefs. The family physicians we met identified several barriers to the integration of prevention in their practices. The interventions proposed to date do not address the barriers perceived by the physicians in our study. Continuing medical education activities focus on knowledge, while the difficulties expressed relate more to communication skills coupled with a feeling of powerlessness. The physicians we met with do not seem to consider recall systems and looking at their organization of practice as possible solutions. The physicians seem to 'cave in' under the weight of the responsibilities that have been assigned to them in terms of health promotion. There may be room for proposing a more realistic menu. This study identifies a need for much more specific and concrete training on communication and counselling skills.

What’s New in the Management of Pain in Children

What’s New in the Management of Pain in Children

Sustainable biomass production for energy in India

The availability of land for biomass production, the various biomass production options, biomass productivity rates, financial viability, investment required to produce biomass for energy and the barriers to biomass production are analysed. The scenarios considered for estimating the biomass potential are incremental biomass demand, sustainable biomass demand and the full biomass demand. Under these scenarios, two situations namely no increase in cropland by 2010 and increase in cropland by 10% over 1995 area have been considered. The land available for biomass production ranges from 9.6 to 36.5 Mha under the different scenarios. Annually 62– 310 Mt of wood could be generated from the surplus land, after meeting all the requirements of biomass, such as domestic fuelwood, industrial wood and sawnwood, with an investment of Rs168–780 billion. An electricity generation potential of 62– 310 TWh annually is estimated. The key barriers to produce biomass sustainably for energy are lack of commercial demand for wood for energy, lack of financial incentives, low productivity of plantations, land tenurial barriers and lack of institutions to integrate biomass production for energy and bioenergy utilities.

Analyses of technical options for mitigating CO&lt;SUB align=right&gt;2 emissions from an urban transport system: a case study of Beijing City

This paper aims to extrapolate the energy consumption and environmental emissions data on the urban passenger transport system in Beijing, to assess the cost-effectiveness and emission reduction potential of promising technology options for transport systems, and to identify options with both reduction potential and cost-effectiveness. Furthermore, it identifies major barriers to the adoption of such options in Beijing. The long-range Energy Alternatives Planning model, the least-cost approach and the Analytical Hierarchy model are used for these three purposes, respectively. The results show that the fuel demand in the Beijing urban passenger transport system will increase rapidly in the future, along with travel demand and vehicle stock. For CO2 mitigation targets, diesel vehicles have both emission reduction potential and cost-effectiveness, followed by mass rapid transport systems. The ranking of barriers is similar for all three technology options, and found to be financial incentive, public awareness, lack of infrastructure, high initial cost and institutional/administrative barriers, in descending order of importance. Lack of financial incentive plays a very important role in the adoption of new technology options.

Pathologists' roles in clinical utilization management. A financing model for managed care.

In ancillary or laboratory utilization management, the roles of pathologists have not been explored fully in managed care systems. Two possible reasons may account for this: pathologists' potential contributions have not been defined clearly, and effective measurement of and reasonable compensation for the pathologist's contribution remains vague. The responsibilities of pathologists in clinical practice may include clinical pathology and laboratory services (which have long been well-defined and are compensated according to a resource-based relative value system-based coding system), laboratory administration, clinical utilization management, and clinical research. Although laboratory administration services have been compensated with mechanisms such as percentage of total service revenue or fixed salary, the involvement of pathologists seems less today than in the past, owing to increased clinical workload and time constraints in an expanding managed care environment, especially in community hospital settings. The lack of financial incentives or appropriate compensation mechanisms for the services likely accounts for the current situation. Furthermore, the importance of pathologist-driven utilization management in laboratory services lacks recognition among hospital administrators, managed care executives, and pathologists themselves, despite its potential benefits for reducing cost and enhancing quality of care. We propose a financial compensation model for such services and summarize its advantages.

Dutch occupational physicians and general practitioners wish to improve cooperation.

OBJECTIVES: To investigate cooperation between occupational physicians (OPs) and general practitioners (GPs). METHODS: Literature review; structured interviews; questionnaires sent to randomised samples of OPs (n = 232) and GPs (n...

Skilling the unskilled – a question of incentives?

The sudden slump in the labour market of the 1990s made it necessary for Switzerland to alter its labour market policy, which from being almost exclusively passive became an active policy. Indeed a lack of suitable qualifications can be considered as one of the main factors prolonging the unemployment of those concerned, in Switzerland. Even so, the policy of relying on massive continuous education and retraining programmes as the most efficient solution to this problem needs to be called into question. For many years a majority of those who now find themselves unemployed neglected the option of seeing to their own continuous education needs. The reasons for this inactivity at the individual level may well lie in the lack of financial incentives. This in turn is the result of a wage structure that is still very much linked to years of service, with education‐related differences in wages being very slight.

Hidden dimensions

Recently I have given some thought to what makes nurses tick and have asked myself why it is that, despite the demands of the job, heavy workloads and lack of financial incentives, many nurses continue to be committed to the care of patients in their chosen fields.