Multidisciplinary Group Practice Research Articles

General health and working conditions of Flemish primary care professionals

BackgroundThe Quintuple aim explicitly includes ‘health and wellbeing of the care team’ as requirement for the care of patients. Therefore, we examined working conditions, work engagement and health status of professionals active in primary care in Belgium (Flanders), and how these are interrelated.MethodsData of the cross-sectional ‘Health professionals survey of the Flemish Primary care academy’ of 2020 were examined. We performed logistic regression analyses to study the relationship between working conditions and self-reported dichotomized health of primary care professionals (sample size = 1033).ResultsThe majority of respondents (90%) reported having a good to very good general health and has a strong work engagement. Quality of employment was high, in particular regarding job security and supportive relations with colleagues, while less in terms of proper rewards and job career opportunities. Working as self-employee (vs. as salaried employee), and in a multidisciplinary group practice (vs. other organizational settings) were positively related to health. Work engagement and all dimensions of employment quality were related to general health, but work family balance, proper rewards, and perceived employability were independently positively related to self-reported health.ConclusionNine out of 10 Flemish primary care professionals working in diverse conditions, employment arrangements and organizational settings report good health. Work family balance, proper rewards, and perceived employability were important for primary care professionals’ health, and could provide opportunities to further strengthen the job quality and health of primary care professionals.

Effect of a Multifaceted Clinical Pharmacist Intervention on Medication Safety After Hospitalization in Persons Prescribed High-risk Medications

The National Action Plan for Adverse Drug Event (ADE) Prevention identified 3 high-priority, high-risk drug classes as targets for reducing the risk of drug-related injuries: anticoagulants, diabetes agents, and opioids. To determine whether a multifaceted clinical pharmacist intervention improves medication safety for patients who are discharged from the hospital and prescribed medications within 1 or more of these high-risk drug classes. This randomized clinical trial was conducted at a large multidisciplinary group practice in Massachusetts and included patients 50 years or older who were discharged from the hospital and prescribed at least 1 high-risk medication. Participants were enrolled into the trial from June 2016 through September 2018. The pharmacist-directed intervention included an in-home assessment by a clinical pharmacist, evidence-based educational resources, communication with the primary care team, and telephone follow-up. Participants in the control group were provided educational materials via mail. The study assessed 2 outcomes over a 45-day posthospital discharge period: (1) adverse drug-related incidents and (2) a subset defined as clinically important medication errors, which included preventable or ameliorable ADEs and potential ADEs (ie, medication-related errors that may not yet have caused injury to a patient, but have the potential to cause future harm if not addressed). Clinically important medication errors were the primary study outcome. There were 361 participants (mean [SD] age, 68.7 [9.3] years; 177 women [49.0%]; 319 White [88.4%] and 8 Black individuals [2.2%]). Of these, 180 (49.9%) were randomly assigned to the intervention group and 181 (50.1%) to the control group. Among all participants, 100 (27.7%) experienced 1 or more adverse drug-related incidents, and 65 (18%) experienced 1 or more clinically important medication errors. There were 81 adverse drug-related incidents identified in the intervention group and 72 in the control group. There were 44 clinically important medication errors in the intervention group and 45 in the control group. The intervention did not significantly alter the per-patient rate of adverse drug-related incidents (unadjusted incidence rate ratio, 1.13; 95% CI, 0.83-1.56) or clinically important medication errors (unadjusted incidence rate ratio, 0.99; 95% CI, 0.65-1.49). In this randomized clinical trial, there was not an observed lower rate of adverse drug-related incidents or clinically important medication errors during the posthospitalization period that was associated with a clinical pharmacist intervention. However, there were study recruitment challenges and lower than expected numbers of events among the study population. ClinicalTrials.gov Identifier: NCT02781662.

Health mediators as members of multidisciplinary group practice: lessons learned from a primary health care model programme in Hungary

BackgroundA Model Programme of primary care group practices was implemented in Hungary between 2013 and 2017 – where virtually all GPs had worked in single practices – aiming to increase preventive service uptake and reduce inequalities based on a bilateral agreement between the Swiss and Hungarian governments. Group practices employed a wide variety of health professionals as well as support workers called health mediators. Employment of the latter was based on two decades of European experience of health mediators who specifically facilitate access to and use of health services in Roma minority groups. Health mediators had been recruited from local communities, received training on the job, and were tasked to increase uptake of new preventive services provided by the group practices by personal contacts in the local minority populace. The paper describes the contribution of the work of health mediators to the uptake of two new services provided by group practices.MethodsQuantitative analysis of depersonalized administrative data mandatorily reported to the Management of the Programme during 43 months of operation was carried out on the employment of health mediators and their contribution to the uptake of two new preventive services (health status assessment and community health promoting programmes).Results80% of all clients registered with the GPs participated at health status assessment by invitation that was 1.3–1.7 times higher than participation at the most successful national screening programmes in the past 15 years. Both the number of mediator work minutes per client and participation rate at health status assessment, as well as total work time of mediators and participants at community health events showed high correlation. Twice as many Roma minority patients were motivated for service use by health mediators compared to all patients. The very high participation rate reflects the wide impact of health mediators who probably reached not only Roma minority, but vulnerable population groups in general.ConclusionThe future of general practices lays in multidisciplinary teams in which health mediators recruited from the serviced communities can be valuable members, especially in deprived areas.

Could general practitioners play a part in the public health concern onfighting microplastics?

Plastic production is overwhelming, worldspread (around 300millions tons a year) and liable to triple by 2050. Science is currently trying to assess the environmental impact of microplastics: particles that are smaller than 5 mm and end up in oceans, invading thus the marine ecosystems. By 2025, 250millions tons of accumulated plastic waste are expected to be found in the oceans, althought these oceans provide food, well-being and therapeutics for human beings. Health actors are thus enticed to study with more depth and attention potentials risks of toxicity (additives, contaminants, etc.), sources of microplastics, and the becoming in human body of the thinnest particles (nanoplastics).General practionners could use their public health skills by staying alert and operating a preventive action in the Community (through communication, coordination and cooperation amongst local institutions, eg. school) to use plastics with more relevance. Versatility and multiple practicing (eg. Multidisciplinary group practice, well-followed recommandations…) as well as the maping of territorial networks bring hope for a diffused and assessable action, under control of health authorities.

Southeastern Regional Health Information System: a mapping tool for public health actors

Abstract Issue/problem Local public health actors often need to identify public health priorities in their territories to guide public health policy and/or action. Description of the problem The Southeastern Health Regional Observatory (ORS Paca) has been developing since 2006 a health information system for Southeastern France (SIRSéPACA). The objective of this mapping tool is to give access to regional and local public health actors to public health indicators for various population groups and geographical scales (municipality, districts...) within the region. Results Indicators are displayed under the format of maps and tables on the following topics: morbidity, mortality, health social, economic or environmental determinants. Indicators are constructed using national and regional databases (open or accessible through agreements). SIRSéPACA is in free access (www.sirsepaca.org) and regularly updated. A function allows the users to obtain a portrait for a defined geographical area and to obtain in one click a description of various indicators (socio-economic and demographic characteristics, mortality and morbidity causes, health care and prevention, environmental health). Indicators for a given territory can be compared to the regional average (or another area). SIRSéPACA is regularly used to provide a description of the main public health characteristics of territories (“territorial diagnose”), e.g. to help health professionals intending to set up of a multidisciplinary group practice designing their project. Lessons Trainings on how to use the tool, interpret the maps produced, and about territorial diagnoses implementation are regularly done. We are also developing a similar tool for all French regions for the Ministry of Health. Key messages SIRSéPACA facilitates access to and overview of a lot of indicators and data for local public health actors. This regional experience has been expanded to national level.

A Simple Framework for Weighting Panels Across Primary Care Disciplines: Findings From a Large US Multidisciplinary Group Practice.

Background:Health system redesign necessitates understanding patient population characteristics, yet many primary care physicians are unable to identify patients on their panel. Moreover, accounting for differential workload due to patient variation is challenging. We describe development and application of a utilization-based weighting system accounting for patient complexity using sociodemographic factors within primary care at a large multidisciplinary group practice.Methods:A retrospective observational study was conducted of 27 clinics across primary care serving more than 150 000 patients. Before and after implementation, we measured empanelment by comparing weighted to unweighted panel size and the number of physicians who could accept patients. Perceived access was measured by the number of patients strongly agreed that an appointment was available when needed.Results:After instituting weighting, the percentage of physicians with open panels decreased for family physicians and pediatricians, but increased for general internists; the number of active patients increased by 2%. One year after implementation, perceived access improved significantly in family and general internal medicine clinics (P < .05). There were no significant changes for general pediatric and adolescent medicine patients.Conclusions:The creation of a weighing system accounting for complexity resulted in changes in practice closure, increased total patients, and improved access.

Hypertension control after an initial cardiac event among Medicare patients with diabetes mellitus: A multidisciplinary group practice observational study.

Patients with diabetes mellitus and cardiovascular disease have a high risk of mortality and/or recurrent cardiovascular events. Hypertension control is critical for secondary prevention of cardiovascular events. The objective was to determine rates and predictors of achieving hypertension control among Medicare patients with diabetes and uncontrolled hypertension after hospital discharge for an initial cardiac event. A retrospective analysis of linked electronic health record and Medicare data was performed. The primary outcome was hypertension control within 1year after hospital discharge for an initial cardiac event. Cox proportional hazard models assessed sociodemographics, medications, utilization, and comorbidities as predictors of control. Medicare patients with diabetes were more likely to achieve hypertension control when prescribed beta-blockers at discharge or with a history of more specialty visits. Adults ≥80 were more likely to achieve control with diuretics. These findings demonstrate the importance of implementing guideline-directed multidisciplinary care in this complex and high-risk population.

Capacity for Cancer Care Delivery Research in National Cancer Institute Community Oncology Research Program Community Practices: Availability of Radiology and Primary Care Research Partners

PurposeCancer care spans the spectrum from screening and diagnosis through therapy and into survivorship. Delivering appropriate care requires patient transitions across multiple specialties, such as primary care, radiology, and oncology. From the program’s inception, the National Cancer Institute Community Oncology Research Program (NCORP) sites were tasked with conducting cancer care delivery research (CCDR) that evaluates structural, organizational, and social factors, including care transitions that determine patient outcomes. The aim of this study is to describe the capacity of the NCORP to conduct multidisciplinary CCDR that includes radiology and primary care practices. MethodsThe NCORP includes 34 community and 12 minority and underserved community sites. The Landscape Capacity Assessment was conducted in 2015 across these 46 sites, composed of the 401 components and subcomponents designated to conduct CCDR. Each respondent had the opportunity to designate an operational practice group, defined as a group of components and subcomponents with common care practices and resources. The primary outcomes were the proportion of adult oncology practice groups with affiliated radiology and primary care practices. The secondary outcomes were the proportion of those affiliated radiology and primary care groups that participate in research. ResultsEighty-seven percent of components and subcomponents responded to at least some portion of the assessment, representing 230 practice groups. Analyzing the 201 adult oncology practice groups, 85% had affiliated radiologists, 69% of whom participate in research. Seventy-nine percent had affiliated primary care practitioners, 31% of whom participate in research. Institutional size, multidisciplinary group practice, and ownership by large regional or multistate health systems was associated with research participation by affiliated radiology and primary care groups. Research participation by these affiliated specialists was not significantly different between the community and the minority and underserved community sites. ConclusionsResearch relationships exist between the majority of community oncology sites and affiliated radiology practices. Research relationships with affiliated primary care practices lagged. NCORP as a whole has the opportunity to encourage continued and expanded engagement where relationships exist. Where no relationship exists, the NCORP can encourage recruitment, particularly of primary care practices as partners.

The importance of frequent return visits and hypertension control among US young adults: a multidisciplinary group practice observational study.

Young adults (aged 18 to 39years) have the lowest hypertension control rates compared with older adults. Shorter follow-up encounter intervals are associated with faster hypertension control rates in older adults; however, optimal intervals are unknown for young adults. The study objective was to evaluate the relationship between ambulatory blood pressure encounter intervals (average number of provider visits with blood pressures over time) and hypertension control rates among young adults with incident hypertension. A retrospective analysis was conducted of patients aged 18 to 39 years (n = 2990) with incident hypertension using Kaplan-Meier survival and Cox proportional hazards analyses over 24months. Shorter encounter intervals were associated with higher hypertension control: <1month (91%), 1 to 2 months (76%), 2 to 3 months (65%), 3 to 6 months (40%), and >6months (13%). Young adults with shorter encounter intervals also had lower medication initiation, supporting the effectiveness of lifestyle modifications. Sustainable interventions for timely young adult follow-up are essential to improve hypertension control in this hard-to-reach population.

Does enrollment in multidisciplinary team-based primary care practice improve adherence to guideline-recommended processes of care? Quebec’s Family Medicine Groups, 2002–2010

BackgroundWe investigated whether multidisciplinary team-based primary care practice improves adherence to process of care guidelines, in the absence of financial incentives related to pay-for-performance. MethodsWe conducted a natural experiment including 135,119 patients, enrolled with a general practitioner (GP) in a multidisciplinary team Family Medicine Group (FMG) or non-FMG practice, using longitudinal data from Quebec's universal insurer over the relevant time period (2000–2010). All study subjects had diabetes, chronic obstructive pulmonary disease, or heart failure and were followed over a 7-year period, 2 years prior to enrollment and 5 years after. We constructed indicators on adherence to disease-specific guidelines and composite indicators across conditions. We evaluated the effect of FMGs using propensity score methods and Difference-in-Differences (DD) models. ResultsRates of adherence to chronic disease guidelines increased for both FMG and non-FMG patients after enrollment, but not differentially so. Adherence to prescription-related guidelines improved less for FMG patients (DD [95% CI]=−2.83% [−4.08%, −1.58%]). We found no evidence of an FMG effect on adherence to consultation-related guidelines, (DD [95% CI]=−0.24% [−2.24%; 1.75%]). ConclusionsWe found no evidence that FMGs increased adherence to the guidelines we evaluated. Future research is needed to assess why this reform did not improve performance on these quality-of-care indicators.

Achieving Weight Loss and Hypertension Control Among Obese Adults: A US Multidisciplinary Group Practice Observational Study.

Among adults with hypertension, obesity independently contributes to cardiovascular disease. Weight loss and hypertension control are critical to reduce cardiovascular events. The purpose of this study was to evaluate rates and predictors of achieving weight loss among adults who achieved hypertension control within 1 year of developing incident hypertension. Retrospective electronic health record analysis was performed of ≥18 year olds with a body mass index ≥30.0kg/m(2), who received regular primary care from 2008 to 2011 and achieved hypertension control. Exclusions were less than 60 days follow-up, prior hypertension diagnosis, prior antihypertensive prescription, or pregnancy. The primary outcome was clinically significant weight loss (≥5kg); the secondary outcome was modest (2.0-4.9kg) weight loss. Multinomial logistic regression identified predictors of achieving weight loss (≥5 or 2.0-4.9kg) compared to no significant weight loss (<2kg). Of the 2,906 obese patients who achieved hypertension control, 72% (n = 2,089) did not achieve at least 2.0kg weight loss. Overall, 12% (n = 351) achieved ≥5kg weight loss. Young adults (18-39 year olds; odds ratio (OR): 2.47, 95% confidence interval (CI): 1.63-3.47), middle-aged adults (40-59 year olds; OR: 2.32, 95% CI: 1.59-3.37), and patients prescribed antihypertensive medication (OR: 1.37, 95% CI: 1.07-1.76) were more likely to achieve clinically significant weight loss and hypertension control. Age remained a significant predictor for 2.0-4.9kg weight loss. Despite achieving hypertension control, the majority of obese patients did not achieve clinically significant weight loss. Effective weight loss interventions with dedicated hypertension treatment are needed to decrease cardiovascular events in this high-risk population.

Association of anxiety and depression with hypertension control: a US multidisciplinary group practice observational study.

The presence of a mental health disorder with hypertension is associated with higher cardiovascular disease mortality than hypertension alone. Although earlier detection of hypertension has been demonstrated in patients with anxiety and depression, the relationship of mental health disorders to hypertension control is unknown. Our objective was to evaluate rates and predictors of incident hypertension control among patients with anxiety and/or depression compared with patients without either mental health diagnosis. A 4-year retrospective analysis included 4362 patients, at least 18 years old, who received primary care in a large academic group practice from 2008 to 2011. Patients met The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure criteria and had a hypertension diagnosis. Kaplan-Meier analysis estimated the probability of achieving control for patients with and without anxiety and/or depression. Cox proportional hazard models were fit to identify predictors of time to control. Overall, 13% (n = 573) had a baseline diagnosis of anxiety and/or depression. Those with anxiety and/or depression demonstrated more primary care and specialty visits than those without either condition. After adjustment, patients with anxiety and/or depression had faster rates of hypertension control (hazard ratio [HR] 1.22; 1.07-1.39] than patients without either diagnosis. Other associations of faster hypertension control included female gender (HR 1.32; 1.20-1.44), absence of tobacco use (HR 1.17; 1.03-1.33), Medicaid use (HR 1.27; 1.09-1.49), and a higher Adjusted Clinical Group Risk Score (HR 1.13; 1.10-1.17), a measure of healthcare utilization. Greater healthcare utilization among patients with anxiety and/or depression may contribute to faster hypertension control.

L’infection par le VIH : une maladie chronique redéfinissant la collaboration entre généralistes et spécialistes. Obstacles et opportunités

With the development of antiretroviral therapy, Human Immunodeficiency Virus [HIV) infection has become a chronic disease. In order to develop an efficient response to this new challenge, there is a need for closer collaboration between specialized units and general practitioners. This article identifies the opportunities for and the barriers to this collaboration. Semi-structured interviews were conducted with patients living with HIV, general practitioners working in multidisciplinary group practice using the capitation system and infectiologists from one Belgian urban area. Interviews focused one xperiences and expectations in relation to diagnosis, follow-up and collaboration between general practitioners and infectiologists. Overall, infectiologists and general practitioners aspire to improved communication and collaboration. There are overlaps between general practitioner's and infectiologist's field of action. The general practitioner's intervention is sometimes restricted to common uncomplicated or psychosocial problems, in the context of unplanned and short contacts.Infectiologists prefer to focus on HIV problems, leaving general practitioners to take care of these patients' other health problems. The patient may be an obstacle to greater involvement of general practitioners due to fear of stigmatization from his family and social circle or lack of confidence in the general practitioner's skills. This research underlines the difficulties and gaps in the care of HIV patients and provides preliminary explanations for the lack of active cooperation between general practitioners and infectiologists. Overlaps between the areas of professional skills can result in uncovered aspects of care, which can have a negative impact on patients, but also on general practitioners and infectiologists. Collaboration between general practitioners and infectiologists should be based on a concerted decision, with clear allocation of tasks, taking into account the patient's expectations.

Diagnosis and treatment of incident hypertension among patients with diabetes: a U.S. multi-disciplinary group practice observational study.

Early hypertension control reduces the risk of cardiovascular complications among patients with diabetes mellitus. There is a need to improve hypertension management among patients with diabetes mellitus. We aimed to evaluate rates and associations of hypertension diagnosis and treatment among patients with diabetes mellitus and incident hypertension. This was a 4-year retrospective analysis of electronic health records. Adults ≥ 18 years old (n = 771) with diabetes mellitus, who met criteria for incident hypertension and received primary care at a large, Midwestern academic group practice from 2008 to 2011 were included Cut-points of 130/80 and 140/90 mmHg were used to identify incident cases of hypertension. Kaplan-Meier analysis estimated the probability of receiving: 1) an initial hypertension diagnosis and 2) antihypertensive medication at specific time points. Cox proportional-hazard frailty models (HR; 95 % CI) were fit to identify associations of time to hypertension diagnosis and treatment. Among patients with diabetes mellitus who met clinical criteria for hypertension, 41 % received a diagnosis and 37 % received medication using the 130/80 mmHg cut-point. At the 140/90 mmHg cut-point, 52 % received a diagnosis and 49 % received medication. Atrial fibrillation (HR 2.18; 1.21-4.67) was associated with faster diagnosis rates; peripheral vascular disease (HR 0.18; 0.04-0.74) and fewer primary care visits (HR 0.93; 0.88-0.98) were associated with slower diagnosis rates. Atrial fibrillation (HR 3.07; 1.39-6.74) and ischemic heart disease/congestive heart failure (HR 2.16; 1.24-3.76) were associated with faster treatment rates; peripheral vascular disease (HR 0.16; 0.04-0.64) and fewer visits (HR 0.93; 0.88-0.98) predicted slower medication initiation. Diagnosis and treatment of incident hypertension were similar using cut-points of 130/80 and 140/90 mmHg. Among patients with diabetes mellitus, even using a cut-point of 140/90 mmHg, approximately 50 % remained undiagnosed and untreated for hypertension. Future interventions should target patients with multiple comorbidities to improve hypertension and diabetes clinical care.

Knowledge and practice in multidisciplinary teams: Struggle, accommodation and privilege

The importance of translating knowledge across occupational boundaries is frequently identified as a means of generating innovation and improving performance. The creation of the multidisciplinary team is an institutional response to enable such translation and synergy, yet few studies examine the processes of knowledge generation and translation in such teams. This article offers a case study that analyses these processes in decisions about the diagnosis and treatment of patients. Polanyi’s concept of tacit integration is used to reveal how meaning is developed and manifest in team decisions and to examine how the discursive resources embedded in tacit knowledge shape clinical practice. We highlight the foundations and dynamics that privilege the knowledge of some team members to be reconstituted as multidisciplinary group practice. Privileged knowledge then becomes embedded in the practices of the group. We conclude that the creation of a multidisciplinary structure may support rather than challenge existing power hierarchies.

Implementing Health Information Technology to Improve the Process of Health Care Delivery: A Case Study

Integration of health information is critical to the provision of effective, quality care in today's fragmented health care system. The increasing prevalence of chronic conditions and the demand for a comprehensive understanding of patient health on the part of providers are driving the need for the integration of health information through electronic health information systems. Two distinct health information systems currently utilized in the health care field include electronic medical records (EMR) and chronic disease management systems (CDMS). The integration of these systems is likely to enable the efficient management of health information and improve the quality of health care as it would provide real-time patient information in a coordinated manner. The lack of real-time information may result in delayed treatment, uninformed decisions, inefficient resource use, and medical errors. Despite their importance and widespread support, these systems have slow provider adoption rates. Our understanding of how health information technology may be used to improve health care is limited by the relative paucity of research on the adoption, integration, and implementation of these 2 types of systems. This paper documents the use of an EMR at Marshfield Clinic, a multidisciplinary group practice in the United States. We review the concomitant use of an EMR for clinical data capture and the implementation of a proprietary CDMS, InformaCare, for care management of chronic diseases. These 2 systems allow providers to deliver health care using evidence-based guidelines that meet the Institute of Medicine's aim of providing safe, efficient, patient-centered, and timely care.

PR_146: Dysphagia in Patients With Inclusion Body Myositis: Management and Clinical Outcome

Objective: To assess the clinical features, treatment strategies, and clinical outcome of patients with inclusion body myositis (IBM) and dysphagia. Design: Retrospective review. Setting: Multidisciplinary group practice. Participants: 26 consecutive patients (mean age, 72.2y) with IBM-associated dysphagia seen in 1997 to 2001. Interventions: Not applicable. Main Outcome Measures: Presence of dysphagia, and response to rehabilitation and interventional treatment. Results: Dysphagia in patients with IBM was more common in women (20:6). 11 patients (42.3%) presented with dysphagia as an initial presenting symptom. The common dysphagia-related symptoms included the sensation of food sticking, coughing while eating, and difficulty eating solid and dry foods. Cricopharyngeal muscle dysfunction was noted in all patients who had barium swallow studies. Swallowing compensation techniques and exercises were of unclear benefit, but the Mendelsohn maneuver as an exercise appears to help in maintaining oral intake. 18 (69%) patients underwent interventional procedures: 10, cricopharyngeal myotomy; 6, pharyngoesophageal dilation; 6, percutaneous endoscopic gastrostomy; and 2, botulinum injection. The mean follow-up duration was 55.5 months. Dysphagia tended to worsen with time, with improvement noted only in those who were treated interventionally: 5 with cricopharyngeal myotomy and 1 with pharyngoesophageal dilation. 13 (50%) patients died, with the mean age at death of 80.8 years and the mean interval of 110.4 months after the diagnosis of IBM. When the cause of death was identified in 7 patients, it was respiratory complications of aspiration in all 7. Conclusions: Dysphagia may precede weakness of the extremities and be a presenting symptom of IBM. Treatment involves both conservative and interventional measures. Despite interventional procedures in 69% of the patients, dysphagia in IBM was generally progressive. Selective patients may benefit from cricopharyngeal myotomy. Aspiration was the main cause of death in this population.

Key Process And Organization Indicators: In the Dietetic Management of Dyslipidemia in Canada

Diet interventions for dyslipidemia can produce clinically relevant changes in lipoprotein levels. To determine whether current nutrition counselling practices are consistent with such interventions, we studied aspects of Canadian dietitians' practice. Respondents to a self-administered mail survey (n=350) described practice for three groups of clients: those without and those with cardiovascular disease counselled through ambulatory care, and those with cardiovascular disease who were hospitalized. The process-of-care factors assessed were time spent in initial and follow-up sessions, diet, anthropometry, blood lipids, physical activity, and social and genetic factors. Organization factors assessed included availability of medical history and laboratory data, and perceived support for counselling services. Initial individual interview times averaged one hour, with 49% to 57% of respondents offering scheduled follow-up services versus passive or no follow-up services. Overall, counselling practices were consistent with efficacious interventions, but there was wide variation. This was particularly evident in ambulatory care, where higher percentages of clients received follow-up care when respondents reported multidisciplinary group practice; better access to the medical history, and more frequent assessment of measured body weight, client social support, and laboratory data during follow-up care (all p < 0.01). Health care effectiveness may be improved through changes in the process and organization of services.

The structure of psychiatrists' outpatient practice.

psychiatrists and their patients (2). Psychiatrists completing the NSPP were asked to indicate specifically the outpatient care setting where they worked the greatest number of outpatient hours—individual practice, psychiatric group practice, multidisciplinary mental health group practice, or multidisciplinary general medical and mental health group practice—or whether they did not work in an outpatient setting. A total of 889 psychiatrists responded to this question, of whom 847 (95 percent) reported working in an outpatient setting. This column summarizes the demographic and practice characteristics of psychiatrists providing outpatient care. Figure 1 shows the outpatient settings where psychiatrists spend the most hours. The percentage of psychiatrists in an individual practice was approximately equal to the percentage in group practice. Of the psychiatrists working in group practice, the majority were in a multidisciplinary mental health group practice. Female psychiatrists were more likely than male psychiatrists to spend the greatest number of their outpatient care hours in group practice. Psychiatrists age 39 years and younger were also more likely than those age 55 and older to spend the most hours in a group practice. As Figure 2 shows, psychiatrists in group practice treated more patients per week than those in individual practice and had almost twice the number of referrals per month. The larger number of patients treated by psychiatrists in group practice may reflect differences in practice styles between the two settings; for example, private solo office practitioners may treat patients