Practices Of Primary Care Physicians Research Articles

Analysis of H. pylori prevalence in groups of dyspeptic patients

Introduction Aim of this study was to determine the practice of primary care physicians using rapid serological test and analyse data in two age groups of patients based on symptoms, anamnestic data and family history of GI malignancies.

Outreach and support in south London (OASIS): implementation of a clinical service for prodromal psychosis and the at risk mental state

Background. – While recent research points to the potential benefits of clinical intervention before the first episode of psychosis, the logistical feasibility of this is unclear. Aims. – To assess the feasibility of providing a clinical service for people with prodromal symptoms in an inner city area where engagement with mental health services is generally poor. Method. – Following a period of liaison with local agencies to promote the service, referrals were assessed and managed in a primary care setting. Activity of the service was audited over 30 months. Results. – People with prodromal symptoms were referred by a range of community agencies and seen at their local primary care physician practice. Over 30 months, 180 clients were referred; 58 (32.2%) met criteria for an at risk mental state, most of whom (67.2%) had attenuated psychotic symptoms. Almost 30% were excluded due to current or previous psychotic illness, of which two-thirds were in the first episode of psychosis. The socio-demographic composition of the 'at risk' group reflected that of the local population, with an over-representation of clients from an ethnic minority. Over 90% of suitable clients remained engaged with the service after 1 year. Conclusion. – It is feasible to provide a clinical service for people with prodromal symptoms in a deprived inner city area with a large ethnic minority population.

Current Colon Cancer Screening Practices of Primary Care Physicians for Patients at Various Risk for Colorectal Cancer

Current Colon Cancer Screening Practices of Primary Care Physicians for Patients at Various Risk for Colorectal Cancer

Self-reported hypertension treatment beliefs and practices of primary care physicians in a managed care organization

Blood pressure (BP) is controlled to recommended goal in less than one-third of people with hypertension. There has been little recent research on physician beliefs and practices with regard to the treatment of hypertension. In late 1999, we surveyed 104 primary care physicians in the 18 owned clinics of a large staff model, non-profit health maintenance organization. The survey included questions about demographics, BP treatment goals for patients with uncomplicated hypertension, and beliefs about hypertension. The reported systolic BP treatment goal was < or =140 mm Hg for 97% and the diastolic BP goal was < or =90 mm Hg for 100%. The systolic BP goal for patients with isolated systolic hypertension was < or =140 mm Hg for 82%, but 34% stated that they would treat to a different goal depending on the diastolic BP. The proportions of physicians who would intensify treatment for BP of 140/90 mm Hg, 150/95 mm Hg, 165/75 mm Hg, and 165/65 mm Hg were 64%, 97%, 89% and 77%, respectively. Although 93% believed that medication was necessary to control BP in most cases, a majority (55%) agreed with the statement that BP could be controlled in most patients with only one drug. Although 42% reported that they often had to change drugs because of side effects, only 16% believed that it was time-consuming to find a well-tolerated drug regimen. In this setting, primary care physicians' self-reported practices were in good agreement with national guidelines put forth in the late 1990s, and their beliefs were favorable to therapy. Our data point to a need for interventions to emphasize that combination drug therapy is frequently required to achieve BP control, and that more aggressive intervention is often warranted for isolated systolic hypertension.

Division of Labor and Coordination in Medical Office Practices

This paper examines the staffing, division of labor, and resulting profitability of primary care physician practices. We develop a theoretical model of how practice profit is determined by the number and mix of support staff and how tasks are delegated to support staff. A key element of the model is the way in which it incorporates coordination costs as an increase in labor time needed to process a patient visit when the number of staff and types of staff increase. We estimate model parameters using a survey of local physicians and, through numerical experiments with our theoretical model, find that in this setting, coordination costs can easily dominate productivity benefits from additional staff. The implication is that physicians who attempt to increase practice output by delegating a large fraction of the work to support staff gain little financially while spending less time with each patient. An empirical analysis of our survey data supports this conclusion.

Private Practice or Not: Economic Considerations for the Physician Assistant

The decision of the Physician Assistant whether to enter private practice or an alternate career path can be greatly aided by economic considerations. The potential income both now and in the future for each alternative needs to be assessed. Trends in operating costs and gross revenues for relevant private practices must be researched. Characteristics of the practices, such as, age, size, specialty and location have impact, as well. Issues of fee collection and reimbursements require investigation. The purpose of this article is to review the role that economics plays in the decision-making process for the Physician Assistant (PA) in terms of the type of practice to pursue. Critical to the decision of a new Mid-Level Professional whether or not to enter into employment in a private practice or hospital / clinical based assignment, is research into the long term economic consequences. A third practice model to add to the mix is the physician / physician assistant owned practice partnership. This entails consideration of the following: Potential salary presently available and its likely 1. growth in the future Any investment costs accounting for loss of future 2. interest Potential revenue, now and in the future from 3. private practice Operating costs attributable to private practice both 4. now and in the future Problems related to reimbursement and collection 5. of fees Type of practice e.g. size, age, specialty, or multi6. specialty Location of practice 7. Participation in managed care, HMO's, etc 8. Income disbursement from the practice or 9. organization In general, assessing potential salary and prospects for the future can be guided by Bureau of Labor Statistics publications that provide current salary ranges and employment prospects for the future. Among such publications are the Occupational Outlook Handbook and Occupational Outlook Online (http://www.occupationaloutlook-handbook.net). For physician assistants, median annual earnings in 2002 were $64,670 with the middle 50% earning between $49,640 and $77,280. These earnings are affected by factors such as specialty, practice setting, geographical location and years of experience. Physician assistants are expected to be in very high demand over the period extending to 2012, even more so than other professions. To the above data, one would need to make some estimates of the fringe benefits which would be in addition to salary. Perhaps a percentage estimate typical for these professions could be used. If a PA is entering a private practice as a partner, as many are beginning to do, one then would need to determine whether a capital investment would be required, and if so, what the amount would be. To this, one would needs to add an estimate of the lost interest earnings over time using a low risk long term interest rate. Next, an estimate of the revenues and costs associated with private practice must be made. While it may not be possible to obtain precise information related specifically to the PA, one can utilize private practice Private Practice or Not: Economic Considerations for the Physician Assistant 2 of 5 data to elicit trends in both revenues and costs that most likely would have effect on their practices and salaries. For the following analysis, we will primarily utilize data from office based private practices of primary care physicians. This is viewed as being the most akin to the PA profession. For ease of comparison, it has been determined that only data from various surveys conducted by Medical Economics over the past ten years related to office-based MD's and DO's in office-based private practice will be utilized in the following analysis. A limitation is that this may not be the most exact or best data available. In fact, professional organizations may possess more specific data necessary for the final decision making process. While there is no reason to believe the exact same population was sampled and responded to each of the surveys, the nature of the list gives some confidence that it is representative. It should be noted that the subsequent revenue and cost data is presented on a per physician basis. Tables 1 and 2 present data related to the revenue side of the picture. Median net earnings for 1995 and 1999 are presented in Table 1 and total compensation for 2002 and 2003 in Table 2 . While these are not strictly comparable, for eliciting a trend they serve the purpose. The data for 1995 and 1999 show either almost no growth or even a loss in year earnings when inflation is accounted for (consumer price index is utilized as a measure of inflation over the period). The total compensation picture for 2002 to 2003 is mixed across the various specialties but pretty much flat. Figure 1 Table 1: Median Net Earnings ($)

Prescription rates and diagnostic patterns are stable: A comparison of high-, medium- and low-prescribing primary care physicians treating community-acquired respiratory tract infections

The objective was to study prescription practices of primary care physicians in prescribing antibiotics for community-acquired respiratory tract infections. Design was time series analysis and cross-sectional survey. The setting was 30 community primary health care centres. A case report form was completed for 3478 patient consultations treated by 198 office-based primary care physicians. Main outcome measures were: classification of diagnoses of respiratory tract infections made by each physician; number of antibiotic prescriptions related to these diagnoses; each physician's mean weekly number of antibiotic prescriptions during 6 months before and after the survey. Patients' risk (odds ratio: OR) to receive an antibiotic prescription from the high and medium prescribers was 5.81 (95% confidence interval [CI] 4.85-6.96) and 2.41 (95% CI 2.04-2.86), compared to low prescribers. High and medium prescribers made more diagnoses of otitis media (OR 2.07, 95% CI 1.70-2.53 and 1.85, 95% CI 1.51-2.26, respectively) and fewer diagnoses of unspecified upper respiratory tract infection (OR 0.32, 95% CI 0.26-0.38 and 0.57, 95% CI 0.48-0.68, respectively) than low prescribers. The rank of the prescription rate of high, medium and low prescriber groups remained the same for all diagnoses except pneumonia. In addition, the annual rank between high, medium and low prescriber groups remained stable; high group prescribed more antibiotics during the year than medium group, which prescribed more than low prescriber group.

Physician Beliefs About Substance Misuse and Its Treatment: Findings from a U.S. Survey of Primary Care Practitioners

Primary care physicians are in a unique position to detect patients with substance use related problems and initiate treatment at an early stage when it may be more successful. To evaluate current knowledge, attitudes, and practices of primary care physicians in the United States regarding the detection of substance use related problems, a national telephone survey of practicing primary care physicians was conducted in 1999. A total of 648 randomly selected family and general practitioners, internists, pediatricians, and OB-GYNs were interviewed regarding their perceived preparation to diagnose selected health conditions, their perceived difficulty discussing selected health conditions with patients, and their perceptions of the effectiveness of available treatments for selected health conditions. Findings suggest that primary care physicians in the United States perceive themselves as being less prepared to diagnose substance “abuse” than other chronic conditions. They additionally find it more difficult to discuss this topic with their patients, and are more skeptical about the effectiveness of available treatments. Because the social, economic, and health consequences of untreated substance misuse negatively affect the quality of life for so many patients and their families, developing new approaches to improving the attitudes and screening behaviors of primary care providers vis-à-vis substance use disorders should continue to be an important priority.

Alzheimer's Disease in the Family Practice Setting: Assessment of a Screening Tool.

BACKGROUND: The prevalence of Alzheimer's disease (AD) is approximately 4.5 million people in the United States, and it is projected that by 2050, the prevalence could be as high as 16 million. As one step to minimize this health care burden, we investigated the practices of primary care physicians (PCPs) to determine barriers to and incentives in diagnosing AD and assessed the feasibility of utilizing a caregiver-based phone interview for dementia in the primary care setting. METHOD: This feasibility study was conducted in 2 phases. Phase I included PCP focus groups conducted to identify barriers and incentives to diagnosis of Alzheimer's disease, knowledge of available screening instruments, and current diagnostic procedures and patterns. A survey of a random sample of PCPs was also conducted to reassess the data obtained via the focus groups. Phase II assessed the feasibility of implementing a brief, caregiver-based dementia screening tool in the primary care setting. A participant's score on the screening tool was compared with the PCP's clinical impression using the kappa statistic. RESULTS: A general willingness exists among PCPs to improve the level of care for patients with AD; however, time constraints are a sizeable barrier in the PCP setting. The incorporation of a telephone-based (or caregiver-based) assessment is feasible. The agreement between the caregiver ratings and the PCPs' clinical impressions was kappa = 0.64 (95% CI = 0.19 to 1.0). CONCLUSION: The caregiver-based telephone assessment has indications of good agreement with the PCP's general assessment of dementia or possible AD. The limited number of patients with positive screens hinders generalization of this phase of the study, but the results confirm the potential value of caregiver-based assessment and the desirability of a larger study to address the scientific properties of a telephone-based screening instrument.

A STUDY OF KNOWLEDGE, ATTITUDE, AND PRACTICE OF CERVICAL SCREENING AMONG FEMALE PRIMARY CARE PHYSICIANS IN THE UNITED ARAB EMIRATES

Cancer is the third leading cause of death In the United Arab Emirates (UAE), which is situated in the Arabian Gulf. A national programme for cervical cancer screening is likely to be implemented in the future. In this study, we assessed the knowledge, attitude, and practice of UAE female primary care physicians of cervical screening through a self-administered questionnaire. Of the 98 physicians who participated in the study only 40% reported ever having performed a Pap smear. In the study, we identified various training needs, and a training programme on cervical screening currently is being developed based on the results of this study.

A national survey of primary care physicians' perceptions and practices related to Helicobacter pylori infection.

Our aim was to assess current perceptions and practices of primary care physicians in the United States concerning Helicobacter pylori infection. We mailed a structured questionnaire to approximately 2500 primary care physicians chosen at random from a national database. We asked about personal and practice demographics and practices relating to testing for and treating H. pylori infection. We received 424 responses from 2349 questionnaires (18%). Only 3% each had used either the C- or C-urea breath test; 5% had used the stool antigen test; 92% and 91% recommended testing-and 90% and 82% treatment-for H. pylori in patients with active duodenal and gastric ulcer, respectively. However, only 64% would test for and only 59% would treat H. pylori infection in a patient with past history of duodenal ulcer. Almost half would test patients with gastroesophageal reflux disease being started or maintained on a proton pump inhibitor. The most frequent treatment regimens used were combinations of a proton pump inhibitor, clarithromycin, and either amoxicillin or metronidazole. Most respondents had inaccurate information on antibiotic resistance rates for H. pylori. In the absence of symptoms, 26% would personally undergo testing for H. pylori; 30% would be treated if infected. Primary care physicians usually test for and treat H. pylori infection in patients with active ulcer, but fail to do so in patients with a prior history of ulcer. Some test for H. pylori in gastroesophageal reflux disease patients. Most use efficacious treatment regimens, but have inaccurate information on resistance rates.

Primary Care Physician (PCP) Attitudes Towards Unsedated Endoscopy (UE) and Screening Practices for Barrett's Esophagus (BE): A Survey Study

Background: Present screening strategies for BE, which rely on referral from PCPs to gastrointestinal specialists for sedated EGD, are inadequate. Unsedated endoscopy, performed either by PCPs or by gastrointestinal endoscopists, is a lower-cost screening alternative. Aims: To determine 1) PCP referral patterns for screening EGD; 2) Barriers to screening; 3) PCP interest in performing UE; and 4) The effect of availability of UE on PCP referral patterns. Methods: A one-page survey was initially administered to PCP practices within our institution. Questions on the survey that produced ambiguous answers were then modified. A random sample of 500 family practitioners and 500 internists was obtained from the American Academy of Family Physicians and American College of Physicians- American Society of Internal Medicine, respectively. The revised, validated, one-page survey was mailed, utilizing the Total-Design Approach, to this group of PCPs with a token financial incentive. A repeat mailing was sent to those who did not respond. Results: The overall response rate was 52.6% (73% men). Of the respondents, 49% are in group practice, 23% are solo practitioners, and 43% see 5 to 10 patients per week with GERD. The majority (71%) refer 10-75% of their GERD patients for EGD, however 28% refer patients for barium studies >10% of the time. More than 70% of PCPs cited alarm symptoms, refractory symptoms, chronicity and severity of symptoms as reason for referral for EGD. Gender, age, obesity and tobacco use were cited by less than 45% of PCPs. Cost of endoscopy was the most common reason cited for non-referral for EGD, the second most common reason being poor patient acceptance. A majority of PCPs (62%) indicated that the availability of UE would increase referral rates for the procedure. Overall, 52% would be willing to perform UE in their office, however newer PCPs (in practice <5) were more willing than older PCPs (in practice >20 years) (p=0.0005). PCPs with practices comprised of patients >50 years old had higher referral rates for EGD (p=0.009), although age was cited only 43% of the time as a reason for referral. Conclusions: Although symptomatic GERD was generally cited, other risk factors for BE, such as gender and age, were not cited as reasons to refer patients for EGD by a majority of PCPs. Cost of endoscopy is the greatest barrier to endoscopic screening. PCPs indicated referrals would increase with the availability of UE, which many would be willing to perform in their office.

A National Survey of Asthma Knowledge and Practices Among Specialists and Primary Care Physicians

Asthma is a chronic disorder that causes significant morbidity and mortality and requires ongoing chronic care. Approximately two‐thirds of people with asthma are receiving care from a primary care clinician, such as an internist, family practitioner, nurse practitioner, or pediatrician. The other one‐third of patients are obtaining treatment and ongoing care from specialists, including allergists or pulmonologists. The outcomes of asthma care are a subject of intense investigation. Many studies focus on pharmacotherapy, allergen control, and asthma education as interventions to reduce the morbidity and costs associated with asthma. Fewer studies have explored the differences in outcomes between asthmatic patients cared for by specialists compared with generalists. Even fewer have explored the practice differences between generalists and specialists that may relate to outcomes of care. With the advent of national asthma guidelines and the high prevalence of asthma seen in primary care settings, it is important to investigate the knowledge, attitudes, and practices of primary care physicians with regard to asthma.

How do primary care physicians identify young children with developmental delays? A national survey.

Little is known about the current practices of primary care physicians regarding developmental surveillance and screening during pediatric preventive care visits. We conducted a mailed survey of a random national sample of pediatricians and family physicians to describe their practices and identify factors that predict use of developmental screening tools, an efficacious way of identifying children with developmental delays. Most physicians reviewed developmental milestones and prompted parents for developmental concerns at preventive care visits. Approximately half of the physicians used a formal developmental screening instrument. Female physician gender predicted higher rates of use of screening tools for family physicians, but not for pediatricians. Most physicians seemed committed to the early diagnosis of developmental delays. Substantial variability in surveillance and screening practices, barriers of time and reimbursement, and under-reliance on parent-completed questionnaires underscore areas for improvement.

Inappropriate prescribing practices and implications for nurses.

This national chart audit of 7,019 patients with nonvalvular atrial fibrillation (AF) from 735 primary care physician practices sought to examine the management of Canadian patients with AF through an evidence-based, guideline-recommended approach. The appropriate use of oral anticoagulants (OACs) in this patient population and the potential factors guiding OAC choice were examined. Suboptimal dosing was seen. In patients on warfarin, 30.9% had not achieved a time in therapeutic range (TTR) in excess of 65% and, despite current Canadian guideline recommendations, were continued on warfarin rather than one of the novel OACs. In patients who received no antithrombotic therapy, 65.5% met criteria for treatment with an OAC. In addition, 62.8% of patients who were treated with acetylsalicylic acid monotherapy met guideline criteria for the use of an OAC. In those patients treated with an OAC, 24.8% were not on the recommended dose based on the product monograph or, if on warfarin, had a TTR <65%. Of the patients on novel OACs (NOACs), 7.4% of patients were underdosed, whereas overdosing was seen in 4.3%. Factors that may have contributed to dosing outside recommendations included underestimation of stroke risk, overestimation of bleed risk, compliance concerns, and lack of provincial reimbursement. In conclusion, significant correctable gaps remain in optimal treatment for stroke prevention in AF.

Explaining the de-prioritization of primary prevention: physicians' perceptions of their role in the delivery of primary care.

BackgroundWhile physicians are key to primary preventive care, their delivery rate is sub-optimal. Assessment of physician beliefs is integral to understanding current behavior and the conceptualization of strategies to increase delivery.MethodsA focus group with regional primary care physician (PCP) Opinion Leaders was conducted as a formative step towards regional assessment of attitudes and barriers regarding preventive care delivery in primary care. Following the PRECEDE-PROCEED model, the focus group aim was to identify conceptual themes that characterize PCP beliefs and practices regarding preventive care. Seven male and five female PCPs (family medicine, internal medicine) participated in the audiotaped discussion of their perceptions and behaviors in delivery of primary preventive care. The transcribed audiotape was qualitatively analyzed using grounded theory methodology.ResultsThe PCPs' own perceived role in daily practice was a significant barrier to primary preventive care. The prevailing PCP model was the "one-stop-shop" physician who could provide anything from primary to tertiary care, but whose provision was dominated by the delivery of immediate diagnoses and treatments, namely secondary care.ConclusionsThe secondary-tertiary prevention PCP model sustained the expectation of immediacy of corrective action, cure, and satisfaction sought by patients and physicians alike, and, thereby, de-prioritized primary prevention in practice. Multiple barriers beyond the immediate control of PCP must be surmounted for the full integration of primary prevention in primary care practice. However, independent of other barriers, physician cognitive value of primary prevention in practice, a base mediator of physician behavior, will need to be increased to frame the likelihood of such integration.

Primary care physicians perceptions and practices on the management of GERD: Results of a national survey

Primary care physicians perceptions and practices on the management of GERD: Results of a national survey

Something old, something new: recent developments in hospital-physician relationships.

To describe recent developments in hospital-physician relationships in 12 metropolitan areas. We analyze qualitative data from a third round of biannual site visit interviews conducted in 12 randomly selected metropolitan areas from 1996 to 2001. The study interviewed 895 respondents during the third round of site visits, conducted in 2000 and 2001. As HMO enrollment and capitation contracting has failed to grow in local markets, hospital executives have returned to a strategic focus on improving relationships with specialists in pursuit of fee-for-service revenue. Yet, 65 percent of hospitals interviewed in 2000 and 2001 continued to own primary care physician practices, with ownership more prevalent in highly concentrated hospital markets. A majority (55 percent) of hospitals have decreased the size of these practices in the past two years. Interest in forming integrated delivery systems has waned. The potential for quality improvement through these organizations systems--by emphasizing primary care and coordinating hospital and physician services--has not been realized. The new emphasis on hospital-specialist partnerships may improve the financial status of hospitals and participating specialists in local markets, and may improve quality of care in selected service areas, but it may also increase health care costs incurred by employers and consumers.

Prescribing practices of rural primary health care physicians in Uzbekistan.

Doctors prescribe medications for therapeutic indications and to meet patient expectations. Understanding the pattern of prescribing is a necessary precursor for any intervention and for improving prescribing practices. Using the WHO standard methodology, we investigated the prescribing practices of doctors in rural primary health care (PHC) clinics in the Ferghana region of Uzbekistan. Doctors in these clinics may have over-prescribed, prescribing 2.9 drugs per patient per encounter. Fifty-seven per cent of these were for injectable drugs, and 57% for antibiotics. Most prescriptions were for name brand (62%) rather than generic drugs.

Fiabilidad del diagnóstico de la EPOC en atención primaria y neumología en España. Factores predictivos

The aims of this study were to assess the methods used by primary care physicians and pneumologists to diagnose chronic obstructive pulmonary disease (COPD) in Spain, and to analyze the factors affecting correct diagnosis of the disease. This observational, descriptive, cross-sectional and multicenter study enrolled a stratified randomized sample from each Spanish region from the practices of primary care physicians and pneumologists. Five hundred sixty-eight (63.2%) of the 898 subjects enrolled had airway obstruction, 92 (10.3%) did not fulfill functional criteria for COPD and 238 (26.5%) did not perform spirometric tests to confirm the diagnosis and establish severity of disease. Primary care physicians classified 29.3% of the patients correctly, whereas pneumologists diagnosed 84.8% correctly. Clinical and/or radiologic criteria were the basis for correct diagnosis in 38.6% of the cases managed by primary care physicians and 10.2% of those treated by pneumologists. Spirometry was available to 49.1% of the primary care physicians and 97.8% of the pneumologists' cases (p < 0.001). Moreover, only 29.9% of the primary care settings had a technician in charge of performing the study, in comparison with 97.8% of the specialized pneumology settings (p < 0.001). The use of spirometry in diagnosing COPD was related to level of patient care (primary or specialized), availability of the test in the primary care setting, place of residence and a patient's situation of temporary absence from work due to COPD. Many COPD patients are incorrectly diagnosed, particularly in primary care. There are differences in diagnostic procedures at the different levels of patient care. The availability of spirometry is an important factor for correctly diagnosing COPD.