Organization Of Medical Practice Research Articles

Once Bitten: Mosquito-Borne Malariotherapy and the Emergence of Ecological Malariology Within and Beyond Imperial Britain.

This article explores the extent to which the emergence of networked conceptions of etiology and network-oriented approaches to the organization of medical practice were historically congruent. Focusing on interwar malariology, it contextualizes the development of ecological approaches to infection management and control in terms of mosquito-borne malariotherapeutic practice. In Britain, mosquito breeding programs directed toward the therapeutic infection of mental hospital patients prompted malariologists to modify and refine existing environmental approaches to malaria. Breeding mosquitoes, attending to patients, and maintaining sources of malarial blood modified malariologists' etiological presumptions, contributing to a wider breakdown of associations between race, place, and disease. Simultaneously, the emergence of an international network of malariotherapy-devoted institutions helped transform malariological practice. Examination of a collaboration between British and Romanian malariologists shows one way in which this network contributed to the transformation of malariology from a formal League of Nations-focused endeavor to one distributed along common lines of research and prevention.

Activities of Provincial Medical Inspectors in Western Siberia in the Late XIX - Early XX Centuries

The article is devoted to the study of medical practice in Western Siberia of the late XIX - early XX centuries. Attention is paid to the organization of medical practice in the Tobolsk province. The quantitative and official composition of medical personnel is described. The relevance of the study is due to the fact that on the basis of a wide body of diverse material for the first time the experience of the activities and biographies of medical inspectors: N. A. Stroganov, F. K. Zembitsky, V. I. Nikitenko, M. V. Miloslavsky, G. N. Egorov is considered. Their role in the development of medical practice in the Tobolsk province of 1895-1917 is described. It is shown that these inspectors had a high level of education and extensive experience in medical work. It is pointed out that, despite all the efforts and significant success in the development of medical practice, there were objective difficulties in this field of activity, among which there was a shortage of personnel, funding, long distances between settlements, the Russian-Japanese War and World War I, etc. The authors use a representative base of both published sources and unpublished materials from the collections of the State Archives of Tobolsk.

Healthcare at the Crossroads: The Need to Shape an Organizational Culture of Humanistic Teaching and Practice

ABSTRACTBackgroundChanges in the organization of medical practice have impeded humanistic practice and resulted in widespread physician burnout and dissatisfaction.ObjectiveTo identify organizational factors that promote or inhibit humanistic practice of medicine by faculty physicians.DesignFrom January 1, 2015, through December 31, 2016, faculty from eight US medical schools were asked to write reflectively on two open-ended questions regarding institutional-level motivators and impediments to humanistic practice and teaching within their organizations.ParticipantsSixty eight of the 92 (74%) study participants who received the survey provided written responses. All subjects who were sent the survey had participated in a year-long small-group faculty development program to enhance humanistic practice and teaching. As humanistic leaders, subjects should have insights into motivating and inhibiting factors.ApproachParticipants’ responses were analyzed using the constant comparative method.Key ResultsMotivators included an organizational culture that enhances humanism, which we judged to be the overarching theme. Related themes included leadership supportive of humanistic practice, responsibility to role model humanism, organized activities that promote humanism, and practice structures that facilitate humanism. Impediments included top down organizational culture that inhibits humanism, along with related themes of non-supportive leadership, time and bureaucratic pressures, and non-facilitative practice structures.ConclusionsWhile healthcare has evolved rapidly, efforts to counteract the negative effects of changes in organizational and practice environments have largely focused on cultivating humanistic attributes in individuals. Our findings suggest that change at the organizational level is at least equally important. Physicians in our study described the characteristics of an organizational culture that supports and embraces humanism. We offer suggestions for organizational change that keep humanistic and compassionate patient care as its central focus.

Patient satisfaction with ambulatory care in Germany: effects of patient- and medical practice-related factors.

The study aimed to illustrate the effect of the patients' sex, age, self-rated health and medical practice specialization on patient satisfaction. Secondary analysis of patient survey data using multilevel analysis (generalized linear mixed model, medical practice as random effect) using a sequential modelling strategy. We examined the effects of the patients' sex, age, self-rated health and medical practice specialization on four patient satisfaction dimensions: medical practice organization, information, interaction, professional competence. The study was performed in 92 German medical practices providing ambulatory care in general medicine, internal medicine or gynaecology. In total, 9888 adult patients participated in a patient survey using the validated 'questionnaire on satisfaction with ambulatory care-quality from the patient perspective [ZAP]'. We calculated four models for each satisfaction dimension, revealing regression coefficients with 95% confidence intervals (CIs) for all independent variables, and using Wald Chi-Square statistic for each modelling step (model validity) and LR-Tests to compare the models of each step with the previous model. The patients' sex and age had a weak effect (maximum regression coefficient 1.09, CI 0.39; 1.80), and the patients' self-rated health had the strongest positive effect (maximum regression coefficient 7.66, CI 6.69; 8.63) on satisfaction ratings. The effect of medical practice specialization was heterogeneous. All factors studied, specifically the patients' self-rated health, affected patient satisfaction. Adjustment should always be considered because it improves the comparability of patient satisfaction in medical practices with atypically varying patient populations and increases the acceptance of comparisons.

Physician Quality Reporting System (PQRS) for Interventional Pain Management Practices: Challenges and Opportunities

Basing their rationale on multiple publications from Institute of Medicine (IOM), specifically Crossing the Quality Chasm, policy makers have focused on a broad range of issues, including assessment of the influence of medical practice organization structures on quality performance and development of quality measures. The 2006 Tax Relief and Health Care Act established the Physician Quality Reporting System (PQRS), to enable eligible professionals to report health care quality and health outcome information that cannot be obtained from standard Medicare claims. However, the Patient Protection and Affordable Care Act (ACA) of 2010 required the Centers for Medicare and Medicaid Services (CMS) to incorporate a combination of cost and quality into the payment systems for health care as a precursor to value-based payments. The final change to PQRS pending initiation after 2018, is based on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which has incorporated alternative payment models and merit-based payment systems. Recent publication of quality performance scores by CMS has been less than optimal. When voluntary participation began in July 2007, providers were paid a bonus for reporting quality measures from 2008 through 2014, ranging from 0.5% to 2% of the Medicare Part B allowed charges furnished during the reporting period. Starting in 2015, penalties started for nonparticipation. Eligible professionals and group practices that failed to satisfactorily report data on quality measures during 2014 are subject to a 2% reduction in Medicare fee-for-service amounts for services furnished by the eligible professional or group practice during 2016. The CMS proposed rule for 2016 physician payments contained a number of provisions with proposed updates to the PQRS and Physician Value-Based Payment Modifier among other changes. The proposed rule is the first release since MACRA repealed the sustainable growth rate formula. CMS proposed to continue many existing policies regarding PQRS from 2015 to 2016. In addition, 2016 will be the year that is utilized to determine the 2018 PQRS payment adjustment. However, after 2018 the PQRS payment adjustment will be transitioned to the Merit-Based Incentive Payment System (MIPS), as required by MACRA. Overall, there will be over 280 measures in the 2016 PQRS. Readers might be surprised to find out that despite the cost intensity including time requirements personnel, the negative payment adjustments, are only the tip of the iceberg of cost. Indeed, all of the above may only be one-third or one-fourth of the cost to completely implement the PQRS system. Thus far, data across all specialties shows participation to be around 50%. In addition, penalties for lack of reporting of PQRS measures stands to be controversial to the Supreme Court ruling that unfunded mandates must not be permitted and also lack of significant relationships with improvement in quality in the overall analysis in multiple publications. Key words: Value-based modifier, Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), alternative payment models (APMs), merit based payment systems, negative payments, bonuses

Quality markers in cardiology: measures of outcomes and clinical practice--a perspective of the Spanish Society of Cardiology and of Thoracic and Cardiovascular Surgery.

The complexity of the individual patient and organization of medical practice results in important institutional and country quality of care variability.1–17 Attempts to assess the quality of clinical practice have established rating systems that may yield completely different results and rating for the same hospital during the same period of time, adding confusion rather than help to prove their usefulness and, questioning whether existing measures can actually measure quality.18–35 Most important, benchmarking may be associated with progressive improvement both in performance and outcomes,18,26,28,36–38 highlighting the relevance of standardization of quality measures and the responsibility of scientific societies. The Spanish Society of Cardiology (SSC) and the Spanish Society of Thoracic and Cardiovascular Surgery (SSTCS) organized a task force to identify and define two sets of quality metrics in hospital cardiology practice: (i) outcome measures (metrics of the final quality of the practice of cardiology) and (ii) performance measures (metrics of clinical practice which are known to positively influence desirable outcomes). Beyond this objective, Scientific Societies and Health Care Authorities should be responsible for the implementation of programmes to measure quality, ensure the quality of the data, benchmarking, and certification/accreditation of cardiology services. All European Society of Cardiology (ESC)32 and American Heart Association/American College of Cardiology33 guidelines were reviewed and recommendations related to quality standards were included in the document. ### Grading of quality markers Three levels were established both for class recommendation and level of evidence considering (i) clinical and practical …

Measuring Changes in the Economics of Medical Practice.

For the latter third of the twentieth century, researchers have estimated production and cost functions for physician practices. Today, those attempting to measure the inputs and outputs of physician practice must account for many recent changes in models of care delivery. In this paper, we review practice inputs and outputs as typically described in research on the economics of medical practice, and consider the implications of the changing organization of medical practice and nature of physician work. This evolving environment has created conceptual challenges in what are the appropriate measures of output from physician work, as well as what inputs should be measured. Likewise, the increasing complexity of physician practice organizations has introduced challenges to finding the appropriate data sources for measuring these constructs. Both these conceptual and data challenges pose measurement issues that must be overcome to study the economics of modern medical practice. Despite these challenges, there are several promising initiatives involving data sharing at the organizational level that could provide a starting point for developing the needed new data sources and metrics for physician inputs and outputs. However, additional efforts will be required to establish data collection approaches and measurements applicable to smaller and single specialty practices. Overcoming these measurement and data challenges will be key to supporting policy-relevant research on the changing economics of medical practice.

Conflicts of interest and the future of medicine: the United States, France, and Japan

As most Americans know, conflicts of interest riddle the US health care system. They result from physicians practicing medicine as entrepreneurs, from physicians' ties to pharma, and from investor-owned firms and insurers' influence over physicians' medial choices. These conflicts raise questions about physicians' loyalty to their patients and their professional and economic independence. The consequences of such conflicts of interest are often devastating for the patients--and society--stuck in the middle. In Conflicts of Interest and the Future of Medicine, Marc Rodwin examines the development of these conflicts in the US, France, and Japan. He shows that national differences in the organization of medical practice and the interplay of organized medicine, the market, and the state give rise to variations in the type and prevalence of such conflicts. He then analyzes the strategies that each nation employs to cope with them. Unfortunately, many proposals to address physicians' conflicts of interest do not offer solutions that stick. But drawing on the experiences of these three nations, Rodwin demonstrates that we can mitigate these problems with carefully planned reform and regulation. He examines a range of measures that can be taken in the private and public sector to preserve medical professionalism--and concludes that there just might be more than one prescription to this seemingly incurable malady. Available in OSO: http://www.oxfordscholarship.com/oso/public/content/politicalscience/9780199755486/toc.html

Could Physicians Take the Lead in Health Reform?

PHYSICIANS HAVE A KEY ROLE IN REFORMING US MEDIcal care. The fundamental problem with the health care system is its high, uncontrollable cost, and that cost is largely determined by the elective decisions of physicians to use medical resources. Health policy experts increasingly suggest that controlling these physiciangenerated costs will require a change from fee-for-service to some type of global payment, and the formation of accountable care organizations (ACOs) in which integrated multispecialty groups of physicians will be able to share global payments with hospitals and other providers. In March 2010, Congress passed the Patient Protection and Affordable Care Act, which greatly extended public and private insurance coverage but did not replace fee-forservice payment or change the organization of medical practice. The act does provide support for trials of ACOs and for experiments with improving fee-for-service payments but most physicians are not organized or ready for ACOs, and Congress is unlikely to mandate the general use of global payments for government programs anytime soon. However, without waiting for new legislation, physicians could begin a transition to a major change in medical practice needed to save the imperiled US health care system. Before fee-for-service could be replaced nationally by some form of global payment and before ACOs could become a mainstream feature of US health care, there would have to be a reorganization of medical care delivery. All physicians would need to become part of medical groups that included most or all specialties. These groups could then receive global payments rather than fee-for-service reimbursement, and in collaboration with 1 or more hospitals could function as ACOs, capable of providing all services for a patient over a specified period or for a given episode of illness. That such reorganization of physicians may be starting to occur is suggested by the current experience of the American Medical Group Association (AMGA), which represents multispecialty group practices. According to the AMGA’s president and other association officials, the organization’s membership now consists of approximately 370 groups, the majority of which are owned and managed by physicians (D. W. Fisher, PhD, oral communications, October 2010). Membership is increasing at the rate of approximately 10% annually—much more rapidly than in past years. The median number of physicians in an AMGA group is 127 and the total number in all AMGA’s groups is approximately 109 000 full-time equivalents. Because many group physicians work less than full time, the total number of physicians working in AMGA groups is probably much larger, perhaps approaching 200 000. If this estimate is accurate, it would mean that nearly 25% of all practicing physicians in the United States may be practicing in multispecialty groups. Any existing multispecialty groups not currently members of the AMGA (estimated at approximately 50) would increase that estimate. The growth of multispecialty practice does not mean that physicians are on the verge of abandoning the fee-forservice model. Fee-for-service is still the predominant form of payment for the physicians in the AMGA multispecialty groups. However, most of these groups pay physicians a base salary, and there are well-known exceptions that rely solely or largely on salaries (eg, the Mayo Clinic, Geisinger, Scott and White, Kaiser Permanente, and the Cleveland Clinic). These groups also own or partner with 1 or more hospitals. Nearly half of the AMGA groups are legally organized as forprofit entities—another sign that many physicians practicing in multispecialty groups have not yet abandoned the business approach to medical care. Nevertheless, the growth of multispecialty group practices may represent a significant step toward the much-needed reform in the health care system. In addition to the growth of such physician-managed groups, the number of multispecialty physician groups owned by hospitals is also increasing. More physicians are now being recruited to salaried employment in hospitals that want to be positioned as ACOs qualified to accept global payments. However, most physicians probably would prefer to be employed by physician groups because relationships between hospital management and staff physicians are often strained. With the possible exception of teaching hospitals and certain not-for-profit community hospitals, ACOs managed by hospitals would probably have different incentives from those managed by not-for-profit physician groups. Many

Recruiting medical groups for research: relationships, reputation, requirements, rewards, reciprocity, resolution, and respect

BackgroundIn order to conduct good implementation science research, it will be necessary to recruit and obtain good cooperation and comprehensive information from complete medical practice organizations. The goal of this paper is to report an effective example of such a recruitment effort for a study of the organizational aspects of depression care quality.MethodsThere were 41 medical groups in the Minnesota region that were eligible for participation in the study because they had sufficient numbers of patients with depression. We documented the steps required to both recruit their participation in this study and obtain their completion of two questionnaire surveys and two telephone interviews.ResultsAll 41 medical groups agreed to participate and consented to our use of confidential data about their care quality. In addition, all 82 medical directors and quality improvement coordinators completed the necessary questionnaires and interviews. The key factors explaining this success can be summarized as the seven R's: Relationships, Reputation, Requirements, Rewards, Reciprocity, Resolution, and Respect.ConclusionWhile all studies will not have all of these factors in such good alignment, attention to them may be important to other efforts to add to our knowledge of implementation science.

Longitudinal analyses of four years of experience of a prepaid comprehensive medical care plan. 1958.

The spectacular contributions of science to medicine and the popularization of the results have greatly stimulated the demand on the part of the public for making modern medical benefits more readily accessible to a larger portion of the population. But the very advances which have stimulated this demand and which have focused attention on the preventive aspects of disease have also contributed greatly to the cost of medical care. On the one hand, this increased cost has led to an enormous growth in the application of the insurance principle to prepayment for medical and hospital care; on the other, it has led to new approaches in the organization of medical practice to provide this care. These changes in the methods of paying for and of providing medical care are comparative newcomers among American social institutions. Provision for prepayment of hospitalization began in 1933 with the establishment of Blue Cross plans. Prepayment of medical care is an even more recent phenomenon. Fewer than six persons per 1,000 held surgical and medical insurance in 1939. Today, according to the Health Information Foundation,2 almost 70 per cent of the population is protected or “covered” by some combination of hospital, surgical, or medical insurance. On the organizational side change has been less rapid, but there has been a steady growth in the number of group practice organizations. It has been estimated3 that while in 1932 there were 239 medical groups with 1,466 physicians in the United States, by 1951 there were 600 such groups with over 5,000 physicians. Growth in voluntary health insurance both in terms of people covered and in benefits offered will undoubtedly continue. New organizational patterns will continue to emerge. Unlike their predecessors, however, these new developments will be able to call upon a body of experience to guide them which was not available to most of the present voluntary prepayment plans for medical care at the time they were founded. The experience of one such plan—the Health Insurance Plan of Greater New York (HIP)—has been analyzed in the belief that it will be of value not only to HIP but also to administrators of other medical care plans, to welfare fund administrators, to public health officials, to community planners, to sociologists, and to the public in general, all of whom are interested in facts that bear on the problem of making the benefits of modern medical care available to the population. The HIP experience will be presented in three parts: Part I, the present paper, deals with enrollment experience and sets forth data on the extent to which enrollees of different classes remain in the Plan and factors influencing continuance of their enrollment; Part II will present information on the number and kinds of physicians’ services utilized by enrollees and how this utilization varies with length of coverage in the Plan; Part III will contain data on morbidity among enrollees of the Plan and will seek to develop measures of prevalence and incidence of various diagnoses as reflected in the operating records of HIP. These data represent the results of a “longitudinal” analysis of the first four years of operation in HIP—that is, they show the experience of the same group of individuals followed through four years of calendar time. They supplement material contained in a published report on the findings of a field survey inquiring into the health and medical care of HIP and New York City households4 which was essentially a cross-sectional study depicting the situation at a particular point in time.

Man versus machine: is technology a blessing or a barrier in screening for diabetic eye disease?

Man versus machine: is technology a blessing or a barrier in screening for diabetic eye disease?

Future practice risks: obstacles with opportunities.

The encouragement of a consumer-directed insurance market and the involvement of corporate America have led to a transformation of the healthcare system that will redefine patient expectations and the role of the physician. The expectation of a higher level of customer service, the role of electronic media, and an earnest regard for healthcare by the patient will impact the physician. Consumer-directed healthcare will call for a reprioritization, focusing on service, convenience, competency, quality, and low cost. Indifference to patient courtesies or failure to become involved in modern technology may cause the physician to be bypassed from this new healthcare system. As the business world integrates the business model into the medical profession, healthcare organizations will restructure themselves into well-organized business enterprises employing physicians. The singular physician may no longer be competitive with such business enterprises, leading to consolidation of organizations and a significant decision for the physician. The physician will have the unusual opportunity to either remain exclusively a medical professional or to also venture into the business world as an equity investor, participating in financial growth possibilities of those medical practice organizations that are for-profit. With the emergence of these new equity models of healthcare, the primary focus will be on profit, production, and service efficiencies. It is the responsibility of the physician to maintain professionalism and the commitment to quality and appropriateness of patient care. However, at the same time, the physician has the unique opportunity to participate in the distribution, economics, and subsequent financial profit of healthcare. The medical experience of the physician, coupled with business acumen, will be an unbeatable combination.

Nephrology in the 21st century: Revolutionary changes

The new millennium will be characterized by revolutionary changes in medical practice, including nephrology. These changes will occur as a result of the translation of fundamental discoveries or developments in molecular genetics, informatics, cyberbiology, and cyberpharmacology. The dialysis population may shrink as a consequence of new and effective therapies or preventive strategies in renal disease. The organization of medical practice will evolve into new, integrated systems of care. The disparity between the “haves” and the “have-nots” will widen. Profound challenges and opportunities await nephrology in the new millennium.

Health technology assessment in Belgium.

The Belgian healthcare system has a Bismarck-type compulsory health insurance, covering almost the entire population, combined with private provision of care. Providers are public health services, independent pharmacists, independent ambulatory care professionals, and hospitals and geriatric care facilities. Healthcare responsibilities are shared between the national Ministries of Public Health and Social Affairs, and the Dutch-, French-, and German-speaking Community Ministries of Health. The national ministries are responsible for sickness and disability insurance, financing, determination of accreditation criteria for hospitals and heavy medical care units, and construction of new hospitals. The six sickness and disability insurance funds are responsible for reimbursing health service benefits and paying disability benefits. The system's strength is that care is highly accessible and responsive to patients. However, the healthcare system's size remained relatively uncontrolled until recently, there is an excess supply of certain types of care, and there is a large number of small hospitals. The national government created a legal framework to modernize the insurance system to control budgetary deficits. Measures for reducing healthcare expenditures include regulating healthcare supply, healthcare evaluation, medical practice organization, and hospital budgets. The need to control healthcare facilities and quality of care in hospitals led to formal procedures for opening hospitals, acquiring expensive medical equipment, and developing highly specialized services. Reforms in payment and regulation are being considered. Health technology assessment (HTA) has played little part in the reforms so far. Belgium has no formal national program for HTA. The future of HTA in Belgium depends on a changing perception by providers and policy makers that health care needs a stronger scientific base.

The association between the organization of medical practice and primary care physician attitudes and practice orientations

This study was designed to identify the association between physicians' practice settings and their attitudes and practice orientations. The data for the study were obtained through a cross-sectional survey of 385 primary care physicians in the service area of the Kansas Primary Care Network (PCN), a joint federal-state funded program begun in 1984 to provide medical services for Medicaid consumers. Analysis of variance tests are used to analyze the differences between physicians in the different practice organizations. The results show that older physicians are more likely to join solo practice organizations. Solo practitioners are less supportive of group practice, and are more likely to locate in affluent and low physician population counties than group practitioners. More female physicians practice in institutional settings than their male colleagues. Graduates of schools of osteopathic medicine are more likely than graduates of schools of allopathic medicine to practice in solo and single-specialty organizations. Institutional physicians are more receptive to capitation-based reimbursement arrangements, government involvement in health care delivery and financing, and have larger Medicaid case-loads than the physicians in the other practice organizations examined in the study.

Health insurance and medical practice organization in Canada: findings from a literature review.

Health insurance and medical practice organization in Canada: findings from a literature review.

Preventive care in rural primary care practice.

Delivering preventive care in a primary care practice is often more difficult for rural than for urban practices. First, rural compared with urban patients tend to be older, poorer, and less well insured, all characteristics associated with lower levels of preventive care. Second, there are many more patients per physician in rural than urban settings. Third, the distance from sources of preventive care is much greater for rural than for urban people. Fourth, rural practices tend to be smaller, with fewer resources to perform high-quality preventive care. Long-term programs to increase recruitment and retention of primary care physicians and improve insurance coverage for rural people may eventually improve preventive care utilization. A more immediate approach is to change the organization of medical practice, including developing satellite clinics, redefining the roles of nurses and nurse practitioners, and using organized systems within practices to reach and follow-up underserved groups. Initial impressions from the North Carolina Prescribe for Health project indicate that an organized approach to preventive care within physicians' offices may improve utilization of carefully designed packages of preventive care. More information is needed to understand the differences among rural, urban, and suburban areas in delivering preventive care to primary care patients.

A task contingent model of medical practice organization.

The treatment of acute episodes of morbidities in hospitalized patients is a complex and uncertain task. To accomplish this task, physicians organize themselves into teams in an effort to overcome two constraints: the necessity to offer both complete care and continuous care. This study examines the extent to which the nature and size of medical teams is explained by task difficulty and task variability, which are two dimensions of task uncertainty. The results support globally the hypothesis that the organization of medical practice is contingent upon the nature of the task defined in terms of uncertainty. However, the results also suggest that the task contingent model should be adjusted to take into account the fact that formal organizational characteristics may have an a priori influence on team structure.

Preventive Practices of General Practitioners in Torino, Italy

Health care reforms introduced in Italy in the late 1970s triggered a profound rethinking of the role of general practitioners (GPs) in prevention. We interviewed 209 GPs registered in the Torino area to delineate their beliefs, attitudes, and practice patterns in relation to prevention. We examined an array of primary and secondary preventive interventions, including influenza vaccination of the elderly; counseling activities related to smoking, alcohol consumption, accidents, contraception, safety helmets, and seat belts; and early detection of hypertension and lung, cervical, and breast cancers. Improvement can still be made in the full implementation of preventive practices. We examine features of the organization of medical practices in Italy that impede the integration of preventive interventions in primary care.