Office Policies Research Articles

Newborn Screening Expands: Recommendations for Pediatricians and Medical Homes—Implications for the System

Advances in newborn screening technology, coupled with recent advances in the diagnosis and treatment of rare but serious congenital conditions that affect newborn infants, provide increased opportunities for positively affecting the lives of children and their families. These advantages also pose new challenges to primary care pediatricians, both educationally and in response to the management of affected infants. Primary care pediatricians require immediate access to clinical and diagnostic information and guidance and have a proactive role to play in supporting the performance of the newborn screening system. Primary care pediatricians must develop office policies and procedures to ensure that newborn screening is conducted and that results are transmitted to them in a timely fashion; they must also develop strategies to use should these systems fail. In addition, collaboration with local, state, and national partners is essential for promoting actions and policies that will optimize the function of the newborn screening systems and ensure that families receive the full benefit of them.

Nuclear Factor I Coordinates Multiple Phases of Cerebellar Granule Cell Development via Regulation of Cell Adhesion Molecules

A central question is how various stages of neuronal development are integrated as a differentiation program. Here we show that the nuclear factor I (NFI) family of transcriptional regulators is expressed and functions throughout the postmitotic development of cerebellar granule neurons (CGNs). Expression of an NFI dominant repressor in CGN cultures blocked axon outgrowth and dendrite formation and decreased CGN migration. Inhibition of NFI transactivation also disrupted extension and fasciculation of parallel fibers as well as CGN migration to the internal granule cell layer in cerebellar slices. In postnatal day 17 Nfia-deficient mice, parallel fibers were greatly diminished and disoriented, CGN dendrite formation was dramatically impaired, and migration from the external germinal layer (EGL) was retarded. Axonal marker expression also was disrupted within the EGL of embryonic day 18 Nfib-null mice. NFI regulation of axon extension was observed under conditions of homotypic cell contact, implicating cell surface proteins as downstream mediators of its actions in CGNs. Consistent with this, the cell adhesion molecules ephrin B1 and N-cadherin were identified as NFI gene targets in CGNs using inhibitor and Nfi mutant analysis as well as chromatin immunoprecipitation. Functional inhibition of ephrin B1 or N-cadherin interfered with CGN axon extension and guidance, migration, and dendritogenesis in cell culture as well as in situ. These studies define NFI as a key regulator of postmitotic CGN development, in particular of axon formation, dendritogenesis, and migratory behavior. Furthermore, they reveal how a single transcription factor family can control and integrate multiple aspects of neuronal differentiation through the regulation of cell adhesion molecules.

Advanced practice nurse attitudes toward sex offender patients

To determine advanced practice nurses' (APNs') attitudes and behaviors toward patients in their practices who are registered sex offenders. An online survey of 300 APN members of a local APN organization asking respondents to identify the behavioral actions they were likely to agree or disagree with when faced with a scenario of realizing that a sex offender was a patient in their practice. Sixty-nine respondents submitted completed surveys. There was an ambiguity of behavioral responses and no consensus among APNs on how to respond to the issue of a sex offender patient in a healthcare practice. There was also a lack of awareness of whether sex offenders were patients in their practice. The modest number of respondents and their demographic homogeneity limit the ability to draw any conclusions or generalizations from this study. While awareness of a known sex offender in a practice is unlikely to alter direct patient care, it may have an impact on office policies and procedures and should be a consideration of all involved staff, including providers, ancillary team members, and administrative personnel.

The Black Box: The Reasons Behind Prosecutors' Declination Choices

This article explores some facets of internal regulation - efforts within the branch, and indeed within individual prosecutors' offices, to control and legitimize prosecutorial discretion. Our thesis is simple but profound. We believe that the office policies and practices of thoughtful chief prosecutors can produce the predictable and consistent choices, respectful of statutory and doctrinal constraints, that lawyers ordinarily expect from traditional legal regulation. Indeed, with regard to many legal and policy concerns, such as prosecutorial race and gender bias, we believe that internal regulation can deliver even more than advocates of external regulation could hope to achieve. We use more than a decade of detailed data from the New Orleans District Attorney's office (NODA) to explore this thesis. The database covers all cases handled by the NODA office between 1988 and 1999. It contains detailed information on around 430,000 charges and about 280,000 cases (involving 145,000 defendants), filed or adjudicated between 1988 and 1999. We find that declinations in New Orleans reveal an internal legal order at work. This legal order is practically hidden and virtually unknown to the scholarly and policy community; at the same time the values it incorporates are strangely familiar. This internal order responds not only to the policy priorities of the elected leaders of the office, but it also enforces and deepens the commands of the substantive criminal law and the adversarial criminal process. The inner workings of the NODA Office under Harry Connick suggest that while scholars and policy-makers have missed the importance of internal regulation, the best prosecutors have not. In this article we describe four distinct sources for the internal regulations visibly at work in New Orleans. Some internal regulations reflect procedural constraints, including constitutional criminal procedure, where prosecutors decline cases if they believe that the police violated the rules of search and seizure or other investigation constraints. This executive exclusion function can both predict the ultimate reaction of courts to these cases, and perhaps add to the procedural requirements that courts might impose. A second source of internal regulation comes from a most unexpected legal guest at the prosecutorial table, as prosecutors rely on doctrines in the substantive criminal law (particularly mens rea requirements) to sort cases. Third, some internal regulations derive from practical problems of proof and evidence, particularly when prosecutors account for the role and preferences of victims. Fourth, prosecutors account for various kinds of regularized policies, including the hostility to plea bargains examined in our earlier study. Together these four kinds of reasons have a surprisingly comfortable and familiar feel.

Improving Patient Retention After Botulinum Toxin Type A Treatment

Botulinum toxin treatments have been associated with consistently high patient satisfaction rates, but calculation of patient retention rates is not routinely performed. Retention measurements serve as critical indicators of clinical performance and can be optimized by evaluation of current office policies and implementation of strategies to improve patient retention. To investigate the reasons patients discontinue botulinum toxin treatments and to evaluate the effect of a single intervention intended to improve patient retention. A retrospective chart review was performed of all patients who received botulinum toxin injections in a private cosmetic dermatology practice over a 2-year time period to determine the patient retention rate. Patients who had discontinued botulinum toxin treatment after a single session were surveyed to discern their reasons for terminating treatment. A change in office policy was instituted wherein all patients who received their first botulinum toxin treatment were required to undergo a 2-week post-treatment evaluation to determine treatment effect and to receive touch-up treatment as necessary. Retention rates were calculated over the 1-year period immediately after initiation of the new policy. The initial patient retention rate was 55%. The most common reasons cited for discontinuance of botulinum toxin treatments were procedural cost, patient failure to re-schedule, perceived lack of product longevity, and clinical effect falling short of expectations. After initiation of the mandatory 2-week post-treatment office evaluation, a 67% patient retention rate was achieved. Managing patient expectations of botulinum toxin treatments and mandatory post-treatment appointments for evaluation of the initial procedure increase the patient retention rate.

Race, ethnicity and education under New Labour

From 1997 the New Labour government was eager to affirm a commitment to social justice and racial equality, and initially there were moves to address some long‐standing educational grievances. But a continuation of Conservative market policies of choice and diversity in schooling and a targeting of ‘failing’ schools exacerbated school segregation and racial inequalities. Policies intended to improve the achievement of minority groups have had some success, but the higher achievements of Indian and Chinese groups have led to facile comparisons which further pathologise young people of African‐Caribbean and Pakistani origin. Failure to develop a curriculum for a multiethnic society has contributed to an increase in xenophobia and racism, and there were no educational policies to deal with increased hostility towards young Muslims. Home Office policies targeting refugees and asylum seekers have encouraged racial hostility towards their children despite amended race relations legislation.

Primary care providers' willingness to see unaccompanied adolescents

Purpose To describe primary care practitioners' office policies and willingness to provide medical care for unaccompanied adolescents aged 11–17 years. Methods A unique 32-item survey was mailed in June and July, 2001 to 1979 office-based pediatricians and family practitioners randomly selected from the American Medical Association's physician database. The survey included questions regarding demographic information, number of adolescents seen in the practice, office policies regarding adolescents alone in the clinic, and 5-point Likert scales regarding their willingness to see patients in various situations, as well as to see patients in 12 brief clinical scenarios. Predictors of the willingness to see adolescents alone were identified and entered into binomial logistic regression models. Specific policies included on the surveys were coded into groups. Results Survey responses (n = 710) represented a 36% response rate. This sample included 288 family practitioners and 368 pediatricians; 43.3% of physicians reported having a specific policy regarding seeing adolescents without their parents present. Family practitioners were more likely than pediatricians to report having such a policy (51.3% vs. 38.2%, p = .001,), yet pediatricians reported a higher percentage of adolescents in their practices than family practitioners (22.6% vs. 12.4%, p < .0005). Not having a policy was an independent predictor of “often” or “always” seeing an adolescent alone for routine health maintenance (OR = 2.84, 95% CI 1.91–4.24) and urgent care visits (OR = 3.01, 95% CI 1.90–4.77). Specific policies varied, and many physicians assessed each case on an individual basis. Conclusions Specific policies are associated with a decreased willingness of physicians to see adolescents who are unaccompanied by a parent. Carefully developed clinic policies that are consistent with legal guidelines should be implemented in order to maximize adolescents' abilities to access care.

Consent by proxy for nonurgent pediatric care.

Minor-aged patients are often brought to the pediatrician for nonurgent acute medical care or health supervision visits by someone other than their custodial parent or guardian. These surrogates can be members of the child's extended family, such as a grandparent or aunt. In cases of divorce and remarriage, a noncustodial parent or stepparent may accompany the patient. Sometimes, children are brought for care by adults living in the home who are not biologically or legally related to the child. In some instances, a child care professional (eg, au pair, nanny) brings the pediatric patient for medical care. This report identifies common situations in which pediatricians may encounter "consent by proxy" for nonurgent medical care for minors and explains the potential for liability exposure associated with these circumstances. The report suggests practical steps that balance the need to minimize the physician's liability exposure with the patient's access to health care. Key issues to be considered when creating or updating office policies for obtaining and documenting consent by proxy are offered.

Patentability of life and ethics

Patent law has relied in part on ethical considerations since its inception in Europe. Such considerations have been introduced more recently in the United States. Whereas the EU Directive on the protection on the occasion of the Human Genome Project of biotechnological inventions was intended to foster economic development in Europe, its implementation is outweighted by controversy about patenting life and commercialization of science. The confusion created must be cleared at the international level through harmonization of patent office policies preventing abusive commercial practices in the absence of inventiveness. To cite this article: N. Lenoir, C. R. Biologies 326 (2003).

Deaf and hard of hearing Americans' instant messaging and e-mail use: a national survey.

An online survey of 884 deaf and hard of hearing adults asked about their current and past use of communication technologies, notably TTY, telecommunications relay services, e-mail, and instant messaging (IM). Results showed that respondents were using e-mail and IM far more than TTY and relay services. The study participants virtually all had e-mail and IM at home. In fact, about one quarter had a high-speed ("broadband") connection at home. While the vast majority also had and used e-mail at work, just 1 in 3 had IM at his or her place of employment. The findings have several implications. Most important for educators is that strong reading and writing skills are essential if adults who are deaf or hard of hearing are to take advantage of today's communications technologies. Another conclusion is that some workers who are deaf or hard of hearing appear to face discrimination in employment because office policies forbid the use of a highly effective reasonable accommodation, instant messaging.

Ambulatory surgery outcomes: a survey of office-based delivery.

Due to a few well-publicized stories about patient injury and death, office-based ambulatory surgery has recently been thrust upon the forefront of current discussions about clinical outcomes. This has stimulated interest among ambulatory surgery stakeholders, including physicians, patients, and elected officials. An analysis of medical office-based surgical facilities in Florida indicates that office-based surgeons tend to work independently, with limited peer oversight, although as a whole, they professionally subscribe to a high level of ethical standards and offer patients an expected high quality level of clinical expertise. The results did not definitively indicate a relationship between unaccredited medical offices and unacceptable surgical procedures. The paper concludes by offering fifteen medical office standards that can aid in developing office surgery oversight policies.

The mirage of available health care for the uninsured

The mirage of available health care for the uninsured

The Mirage of Available Health Care for the Uninsured

The Mirage of Available Health Care for the Uninsured

Primary care office policies regarding care of uninsured adult patients.

To describe primary care office policies regarding care of uninsured patients. Telephone survey of all adult primary care sites advertising in the area telephone directory. Sites were defined by ownership status, number of physicians, use of physician-extenders, and location. Policies assessed were whether the site was accepting new uninsured patients, billing policies, the availability of free or discounted care, and payment plans. Allegheny County, Pennsylvania. Of the 359 sites identified, 240 (66.9%) responded, representing 794 physicians. Survey respondents included receptionists (40.4%), office managers (36.2%), and physicians (22.9%). While the majority of all sites reported accepting new patients without health insurance (87.5%), policies regarding these patients varied significantly by ownership status and the number of physicians. Sites with 3 or fewer physicians were more likely to accept uninsured patients. Self-owned practices were more likely to require payment at the time of service, and provide discounted care, free care, and payment plans compared with hospital/health system practices or multisite group practices. Willingness to accept uninsured patients does not always equate to affordable or accessible care. Office policies have the potential to be substantial obstacles to primary care.

Primary Care Office Policies Regarding Care of Uninsured Adult Patients

Primary Care Office Policies Regarding Care of Uninsured Adult Patients

The Colonial Office and Natal's Annexation of Zululand

Colonial Office reaction to the sub-imperialism manifested by its south-east African colony showed neither consistent support nor implacable opposition. That much-neglected source, the original correspondence, provides a window on Victorian policy-making. Scrutiny of the official minutes reveals the factors involved in the evolution of Colonial Office policies, and impressions derived from the documents can be confirmed or corrected accordingly. Academic eavesdropping on the secretaries of state and their officials is a rewarding, and sometimes entertaining, experience.

St. Anthonyʼs Physician Office Policies and Procedures: Liability and Compliance for Personnel, OSHA, and Patient Care

St. Anthonyʼs Physician Office Policies and Procedures: Liability and Compliance for Personnel, OSHA, and Patient Care

Obstructive or promoting? British views on German unification 1989/90

Six years after unification German public opinion still regards Britain as the ‘No‐saying’ nation which not only holds up further European integration but also never really wanted German unity to happen. This article argues that British attitudes to the process of German unification in 1989/90 were more diverse and generally more positive than an undue concentration on the views of Margaret Thatcher and her advisers may suggest. An analysis of Foreign Office policies and an examination of public and published opinion as well as of the debates in both Houses of Parliament reveal a constructive British stance on German unity and a substantial and real contribution of British diplomats to the Two‐plus‐Four process. Whereas the Foreign Office and Downing Street agreed on the major effects German unity would have on Britain's international standing, they differed about the way Britain should respond to the new challenges.

Patient Satisfaction with Dental Care

The feedback studies illustrate the fact that it is possible for the individual practitioner or member of a group practice to take positive steps to enhance satisfaction among his or her patients. Simply knowing about the general components of patient satisfaction is not enough; one needs to know about the views of one's own patients so that effective steps can be taken to improve them. The steps may include changes in office policies or procedures, facilities or staff changes, or even changes in the dentist's interpersonal approach. In any case, the evidence suggests that efforts to improve will be rewarded by more satisfied patients who will be more likely to stay as clients and, perhaps, more readily accept treatment and more frequently refer friends to the practice. The consistent role of dentists' interpersonal skills suggests that dental schools could contribute to patient satisfaction by providing more interpersonal skills development in their curricula. This was a major recommendation of the 1984 Future of Dentistry Final Report. The evidence presented in this chapter firmly supports that recommendation.

Teaching in an Urban, Multiracial Physical Education Program: The Power of Context

The purpose of this study was to identify contextual factors affecting the conduct of a physical education program in an urban, multiracial junior high school. Using particiant observation, formal interviews, and informal discussion with teachers and students, the investigator spent 84 hours in the school observing class and nonclass interactions. Four contextual factors affecting the conduct of the physical education program were identified. (a) outdoor activity space, (b) central office policies, (c) schoolbased professional support for teaching, and (d) the unique qualities of urban, multiracial schools. The results are discussed in terms of the effects of contextual factors on the quality of curriculum and instruction possible in a particular school. Analysis of data from this field study underscores the importance of considering contextual factors in defining expectations for what physical educators can achieve. A primary conclusion is that in at least some instances, change in physical education mus...