Practices Of Primary Care Physicians Research Articles

Hospital-Based Employment of Orthopaedic Surgeons—Passing Trend or New Paradigm?

Hospital employment of physicians in the United States has passed through periods of intense activity and decline over the past several decades. In the early 1990s, many hospitals sought to acquire primary-care physician practices, with the goal of increasing market share by controlling referrals of patients enrolled in managed-care plans and increasing negotiating leverage with managed-care organizations. In general, these employment relationships were hastily developed, with very little foresight and planning regarding the goals and responsibilities of each party. Furthermore, the importance of physician leadership, accountability, and cultural differences between hospitals and physician practices were grossly underestimated. As a result, most of these relationships resulted in financial losses and were divested by the end of the decade1-3. Since the year 2000, there has been an increasing trend toward the acquisition and employment of specialist physicians by hospitals. According to a recent survey of members of the American Academy of Orthopaedic Surgeons (AAOS), more than three times as many orthopaedic surgeons are employed by hospitals today as compared with when they entered into practice4. Physician recruiting agencies note that hospitals are among their fastest-growing clients and now comprise the largest percentage of their physician recruiting activity. Specialist physicians, including orthopaedic surgeons, are among the most common hospital-based physician recruitments5. Multiple factors are driving this trend. Hospitals are seeking increased alignment of their interests and goals with those of specialist physicians for many reasons, including the desire to gain and/or preserve market share in a particular specialty area, such as orthopaedics; to neutralize competition from physician owners of imaging and physical therapy facilities, ambulatory surgery centers, and specialty hospitals; to stabilize their medical staff; and to meet urgent clinical needs, including emergency call and indigent care. Furthermore, alignment with specialist physicians may allow hospitals …

Tobacco Intervention Practices of Primary Care Physicians Treating Lower Socioeconomic Status Patients

Tobacco use greatly contributes to overall socioeconomic health disparities, and physicians are a major source of information about effective methods for tobacco cessation. This study examined the tobacco intervention practices of primary care physicians in Arkansas who treat a high proportion of lower socioeconomic status patients. More than 70% of respondents’ patients were covered by Medicaid and/ or Medicare or paid for primary care services without health insurance. Although physicians were highly motivated and considered cessation to be very important, 74% had no training of any kind in the treatment of tobacco dependence and familiarity with the free treatment services in Arkansas was low. Younger and nonwhite physicians and physicians with any type of training in treating tobacco dependence reported more positive attitudes, more frequent intervention behaviors and more familiarity with treatment services. More frequently seeing the effects of tobacco use on the health of patients as well as increased knowledge, preparedness, and perceived effectiveness of treatments were related to a higher frequency of providing cessation assistance. More frequently seeing the effects of tobacco use on patients, as well as increased familiarity with treatment services were related to a higher frequency of referring patients to treatment services. These findings suggest that training experiences that increase physician awareness of the multiplicity of consequences of tobacco use as well as increase knowledge, preparedness, perceived effectiveness of treatments and familiarity with treatment services will increase the frequency with which physicians assist and refer this important patient population.

Screening colonoscopy in the US: attitudes and practices of primary care physicians.

Rising colorectal cancer (CRC) screening rates in the last decade are attributable almost entirely to increased colonoscopy use. Little is known about factors driving the increase, but primary care physicians (PCPs) play a central role in CRC screening delivery. Explore PCP attitudes toward screening colonoscopy and their associations with CRC screening practice patterns. Cross-sectional analysis of data from a nationally representative survey conducted in 2006-2007. 1,266 family physicians, general practitioners, general internists, and obstetrician-gynecologists. Physician-reported changes in the volume of screening tests ordered, performed or supervised in the past 3 years, attitudes toward colonoscopy, the influence of evidence and perceived norms on their recommendations, challenges to screening, and practice characteristics. The cooperation rate (excludes physicians without valid contact information) was 75%; 28% reported their volume of FOBT ordering had increased substantially or somewhat, and the majority (53%) reported their sigmoidoscopy volume decreased either substantially or somewhat. A majority (73%) reported that colonoscopy volume increased somewhat or substantially. The majority (86%) strongly agreed that colonoscopy was the best of the available CRC screening tests; 69% thought it was readily available for their patients; 59% strongly or somewhat agreed that they might be sued if they did not offer colonoscopy to their patients. All three attitudes were significantly related to substantial increases in colonoscopy ordering. PCPs report greatly increased colonoscopy recommendation relative to other screening tests, and highly favorable attitudes about colonoscopy. Greater emphasis is needed on informed decision-making with patients about preferences for test options.

Practices, Perceptions, and Concerns of Primary Care Physicians About Opioid Dependence Associated with the Treatment of Chronic Pain

ABSTRACT When prescribing opioids to treat chronic pain, physicians face the dilemma of balancing effective pain management while avoiding iatrogenic opioid addiction. Through mailed surveys, the current study assessed concerns, perceptions, and practices of primary care physicians related to this dilemma. Of the 35 (43%) physicians that replied, 32 (91.4%) reported to prescribe opioids for pain. Twenty-six (81.3%) physicians mentioned that “legitimate pain” was the main reason why most patients who are opioid dependent begin using opioids. Most physicians (71.5%) rated their knowledge/comfort of treatment/management of opioid dependence as being low. Although these physicians believed training is essential to learning about the risks involved with chronic pain and opioid dependence, many of these physicians evaluated their own medical training in these areas as unsatisfactory. Training programs may better equip primary care physicians when addressing the treatment of chronic pain and addiction to opioids.

Use of a Standardized Patient Paradigm to Enhance Proficiency in Risk Assessment for Adolescent Depression and Suicide

Although routine adolescent depression and suicide risk assessment (ADSRA) is recommended, primary care physician (PCP) ADSRA training is needed for successful ADSRA implementation. This study examined the effect of an intervention using standardized patients (SPs) on PCP ADSRA confidence, knowledge, and practices. The intervention consisted of a 60-minute seminar followed by a 60-minute SP session to practice ADSRA skills in simulated clinical situations. PCPs (n = 46) completed pre- and postintervention assessments. Untrained PCPs interested in the intervention (n = 58) also completed assessments. Assessments evaluated ADSRA self-reported confidence and practices and objectively assessed knowledge. The main outcomes were (1) changes in pre-/postintervention PCP ADSRA confidence and knowledge, and (2) ADSRA practices in untrained versus postintervention PCPs. Compared with untrained PCPs, PCPs 5-10 months postintervention were more likely to screen most adolescents for depression (40% vs. 22%, p = .05), to use a depression screening tool (50% vs. 19%, p = .001), to have diagnosed at least one adolescent with depression in the past 3 months (96% vs. 78%, p = .013), and to have screened depressed adolescents for suicide risk factors, including access to weapons (51% vs. 25%; p = .007) or an impulsive violence history (27% vs. 11%; p = .037). PCP confidence and knowledge about depression assessment and treatment also significantly improved postintervention. This study supports the use of an SP intervention to improve PCP ADSRA confidence, knowledge, and practices. Widespread implementation of similar educational efforts has the potential to dramatically improve adolescent morbidity and mortality.

The use of theory in research on nutrition guidance practices by primary care physicians from 1995 to October 2008: a review

Theory-based interventions on nutrition guidance practices of primary care physicians (PCPs) are thought to be more effective than those that do not use theory. To assess how often and which theoretical models of behaviour change are used in research on nutrition guidance practices of PCPs. A review of articles published from 1995 to October 2008 (n = 111). It was found that 45% of the articles in this review included theories or theoretical models of behaviour change. No difference in proportion of model use was found with time. Model use differed between type of study. In 29% of the articles, the Transtheoretical Model was used. Little was found on authors' views on theoretical model applicability. Forty-five per cent of the articles on nutrition guidance practices of PCPs published from 1995 to October 2008 included theories or theoretical models of behaviour change. It would be beneficial for nutrition behaviour change research if more researchers use theoretical models and report on applicability of the selected theory, to increase effectiveness of nutrition guidance by PCPs.

Lung cancer screening practices of primary care physicians: results from a national survey.

Although current practice guidelines do not recommend screening asymptomatic patients for lung cancer, physicians may still order lung cancer screening tests. No recent national survey of health care professionals has focused on lung cancer screening. In this study, we examined the lung cancer screening practices of US primary care physicians and characteristics of those who order lung cancer screening tests. We conducted a nationally representative survey of practicing primary care physicians in 2006-2007. Mailed questionnaires assessed the physicians' knowledge of lung cancer screening guidelines, beliefs about the effectiveness of screening tests, and ordering of screening chest radiograph, low-dose spiral computed tomography, or sputum cytology in the past 12 months. Clinical vignettes were used to assess the physicians' intentions to screen asymptomatic 50-year-old patients with varying smoking histories for lung cancer. A total of 962 family physicians, general practitioners, and general internists completed questionnaires (cooperation rate = 76.8%). Overall, 38% had ordered no lung cancer screening tests; 55% had ordered chest radiograph, 22% low-dose spiral computed tomography, and less than 5% sputum cytology. In multivariate modeling, physicians were more likely to have ordered lung cancer screening tests if they believed that expert groups recommend lung cancer screening or that screening tests are effective; if they would recommend screening for asymptomatic patients, including patients without substantial smoking exposure; and if their patients had asked them about screening. Primary care physicians in the United States frequently order lung cancer screening tests for asymptomatic patients, even though expert groups do not recommend it. Primary care physicians and patients need more information about lung cancer screening's evidence base, guidelines, potential harms, and costs to avert inappropriate ordering.

Development of a primary care pharmacist practice-based research network

A practice-based research network (PBRN) has traditionally been composed of a group of primary care physician practices focused on improving the quality of care through research. PBRN development in a college/school of pharmacy may overcome pharmacy practice faculty barriers to research. Pharmacy student and resident involvement in rigorous research may assist with development of the next generation of practice-based researchers. The University of Tennessee Pharmacist Practice-Based Research Network (UT Pharm Net) was developed using key strategies developed by pharmacy practice–based research stakeholders. These strategies include (1) establishing relationships with key stakeholders, (2) developing a rigorous and robust research program that studies and improves patient care, (3) empowering and educating pharmacists to participate, and (4) engaging patients in practice-based research. This manuscript describes steps taken by UT Pharm Net, using the framework of key strategies and drivers, to successfully develop a PBRN across several interdisciplinary primary care practice sites.

Sustained Impact of Anticoagulant Control Achieved in an Anticoagulation Management Service After Transfer of Management to the Primary Care Physician

To determine whether the impact of anticoagulant control achieved in an Anticoagulation Management Service (AMS) is sustained after transfer of anticoagulation management to the primary care physician (PCP), and to assess patient satisfaction with their anticoagulation management by both the AMS and PCP. Prospective, randomized trial. Pharmacist-directed ambulatory AMS located in a tertiary medical care facility and PCP practices in Canada. Sixty-two adults who had received at least 6months of warfarin therapy managed by the AMS. Patients were randomly assigned to remain with AMS care (32 patients) or to transfer their anticoagulation management care to their PCP (30 patients). After 4.5months of care, patients in both groups completed a validated survey instrument assessing their satisfaction with the management of their warfarin therapy. Of 295 patients screened, most were excluded from the study for denying consent or for having previous bleeding or clotting complications while taking warfarin. Patients in the AMS and PCP groups who completed the study were similar in age (median 70 and 76yrs, respectively), and most had atrial fibrillation as an indication for warfarin (75% and 83%, respectively). The primary outcome measure-mean percentage of time within the desired international normalized ratio (INR) range after 6months-was compared between the two groups, using both the actual range (INR 2.5±0.5) and an expanded range (INR 2.5±0.7). No significant difference was noted in this outcome between the groups (73.5±19.1% vs 76.9±24.5% for the AMS vs PCP groups, p=0.54). Other outcome measures were rates of thrombotic and hemorrhagic events resulting in emergency department visits or hospitalizations, patients' overall satisfaction with warfarin therapy, and patients' preferred anticoagulation management strategy. Two hemorrhagic events and one thrombotic event occurred in each group. Patients were more satisfied with their anticoagulant management by the AMS relative to PCP care (p=0.01), and given the choice, patients preferred AMS care (p=0.001). During this 6-month trial, anticoagulation control did not significantly differ between patients who continued to receive anticoagulation management by the AMS and those who transferred to their PCP for anticoagulation management, indicating that the effects of AMS care were sustained. Although patients were more satisfied and preferred to stay with AMS care, this study shows that select patients could have their anticoagulation care transferred to their PCP without compromising anticoagulation control.

Reference programme: Diagnosis and treatment of headache disorders and facial pain. Danish Headache Society, 2nd Edition, 2012

Headache and facial pain are among the most common, disabling and costly disorders in Europe. Correct diagnosis and treatment is important for achieving a high quality of care. As a national organisation whose role is to educate and advocate for the needs of patients with primary headaches, the Danish Headache Society has set up a task force to develop a set of guidelines for the diagnosis, organisation and treatment of the most common types of headaches and for trigeminal neuralgia in Denmark. The guideline was published in Danish in 2010 and has been a great success. The Danish Headache Society decided to translate and publish our guideline in English to stimulate the discussion on optimal organisation and treatment of headache disorders and to encourage other national headache authorities to produce their own guidelines. The recommendations regarding the most common primary headaches and trigeminal neuralgia are largely in accordance with the European guidelines produced by the European Federation of Neurological Societies. The guideline provides a practical tool for use in daily clinical practice for primary care physicians, neurologists with a common interest in headache, as well as other health-care professionals treating headache patients. The guideline first describes how to examine and diagnose the headache patient and how headache treatment is organised in Denmark. This description is followed by individual sections on the characteristics, diagnosis, differential diagnosis and treatment of each of the major headache disorders and trigeminal neuralgia. The guideline includes many tables to facilitate a quick overview. Finally, the particular problems regarding headache in children and headache in relation to female hormones and pregnancy are described.

Knowledge, attitudes, and practices of primary care physicians about irritable bowel syndrome in Northern Saudi Arabia

Background/Aim:Primary health care (PHC) physicians manage most patients with irritable bowel syndrome (IBS). In Saudi Arabia, there are limited data on their knowledge, attitudes, and practices about this disorder. This study aimed to assess knowledge, attitudes, and practices of primary care physicians about IBS.Patients and Methods:A cross-sectional survey of 70 practitioners aged 36 ± 10.25 years was carried out in primary care centers in AlJouf Province of Saudi Arabia. The physicians were asked to fill a valid questionnaire containing their sociodemographic data, and well-modified questions regarding their knowledge, attitudes, and practices about IBS. Data was processed and analyzed using SPSS (version 15) program, and the level of significance was set at P<0.05.Results:A response rate of 92.9% yielded 65 questionnaires for analysis. Majority of physicians surveyed (83.1%) considered IBS as a common health problem in Saudi Arabia, and (55.4%) believed it is underestimated. There was a significant association between physicians’ qualifications and using diagnostic tools to facilitate IBS diagnosis (14.3% vs 35.5%; P<0.05), while utilization of “Rome or Manning criteria” was more frequent by physicians with master's degree (35.5%) compared to residents (14.3%). Also, 35.4% of physicians (15 males and 8 females) were not sure how to diagnose IBS.Conclusions:This study suggested that PHC physicians had a suitable attitude toward IBS, but they lacked knowledge, and their practices toward this condition were inappropriate.

Screening Colonoscopy in the US: Attitudes and Practices of Primary Care Physicians

Screening Colonoscopy in the US: Attitudes and Practices of Primary Care Physicians

Knowledge, attitude, and practice of primary health care physicians in the management of osteoarthritis in Al-Jouf province, Saudi Arabia

Background:Primary health care (PHC) physicians manage most patients with osteoarthritis (OA). In Saudi Arabia, very little is known about the management of OA by PHC physicians. This study aims to assess knowledge, attitude, and practice of PHC physicians in the management of OA.Materials and Methods:During October 2011, a cross-sectional survey was conducted on physicians who were practicing at the primary care centers in AlJouf province of Saudi Arabia. The physicians were asked to fill a valid questionnaire comprised of 35 closed ended questions, 6 items about their socio-demographic characters, and a very well modified 29 questions about their knowledge, attitude, and practice in the management of OA. Data was processed and analysed using SPSS (version 16) program, the level of significance was set as Chi-square test was applied for analysis of categorical data.Results:Response rate (77/90=85.6% yielded 77 questionnaires for analysis. The mean ± SD age of respondents was 38 (12.3) years. Majority of the physicians surveyed, 58 (75.3%) considered OA as a common health problem in Saudi Arabia. Only 28 (36.4%) physicians surveyed will achieve continuity of care for OA, whereas more than half (n=44; 57.1%) will refer OA immediately or later to the specialists. The proportion of continuity of care for OA among physicians with diplomas was more than that found among general practitioner (57.1% vs 34.1%; <.05). Only 30 (39%) of physicians appeared to know the radiographic changes associated with OA. 21 (27.3%) of physicians manage an average of 5-10 patients with OA per week. Almost 3/4 th of the physicians (n=57; 74%) prescribe NSAIDs, and only (n=14; 18.2%) prescribe acetaminophen for OA. Less than 1/5 th of the physicians surveyed (n=12; 15.6%) prescribe herbal medicine for OA. Almost all physicians subscribe to regular training programs about OA.Conclusions:Appropriate attitude with lack of knowledge was found, and practice of our physicians with regards to this disorder appeared inappropriate. More education focusing on the disorder is recommended.

2011 Recommendations for the Diagnosis and Management of Gout and Hyperuricemia

Gout is a major health problem in the United States; it affects 8.3 million people, which is approximately 4% of the adult population. Gout is most often diagnosed and managed in primary care physician practices. Primary care physicians have a significant opportunity to diagnose and manage patients with gout and improve patient outcomes. Following publication of the 2006 European League Against Rheumatism (EULAR) gout guidelines, significant evidence on gout has accumulated and new treatments for patients with gout have become available. It is the objective of these 2011 recommendations for the diagnosis and management of gout and hyperuricemia to update the 2006 EULAR guidelines, paying special attention to the needs of primary care physicians, who manage most patients with gout. The revised 2011 recommendations are based on the Grading of Recommendations Assessment, Development, and Evaluation approach as an evidence–based strategy for rating quality of evidence and grading strength of recommendation in clinical practice. A total of 26 key recommendations for diagnosis (n = 10) and management (n = 16) were evaluated. Presence of tophus (proven or suspected) and response to colchicine had the highest clinical diagnostic value (likelihood ratio [LR], 15.56 [95% CI, 2.11–114.71] and LR, 4.33 [95% CI, 1.16–16.16], respectively). The key aspect of effective management of an acute gout attack is initiation of treatment within hours of onset of first symptoms. Low–dose colchicine is better tolerated than and is as effective as high–dose colchicine (number needed to treat [NNT], 5 [95% CI, 3–13] and NNT, 6 [95% CI, 3–72], respectively). For urate–lowering therapy, allopurinol in combination with probenecid was shown to be more effective than either agent alone (effect size [ES], 5.51 for combination; ES, 4.46 for probenecid; and ES, 2.80 for allopurinol). Febuxostat, also a xanthine oxidase inhibitor, has a slightly different mechanism of action and can be prescribed at unchanged doses for patients with mild–to–moderate renal or hepatic impairment. Febuxostat 40 mg versus 80 mg (NNT, 6 [95% CI, 4–11]) and 120 mg (NNT, 6 [95% CI, 3–26]) both demonstrated long–term efficacy. The target of urate–lowering therapy should be a serum uric acid level of # 6 mg∕dL. For patients with refractory and tophaceous gout, intravenous pegloticase is a new treatment option.

Review of Current Guidelines on the Care of Postherpetic Neuralgia

An unfortunate minority of patients with acute herpes zoster (AHZ) experience pain beyond the typical 4-week duration, and roughly 10% develop the distressing complication of postherpetic neuralgia (PHN), often defined as pain persisting for > 4 months after the onset of the rash. Elderly patients are at increased risk of PHN. The pathophysiology of PHN is complex, likely involving both peripheral and central processes. This complexity may create opportunities for pharmacologic interventions with multiple differing mechanisms of action. Consequently, complementary combinations of pharmacologic agents are frequently more effective than any monotherapy. Current US and international guidelines on the care of patients with PHN are reviewed and interpreted here to facilitate their effective incorporation into the practice of primary care physicians, acknowledging the contrasts that often exist between the clinical trial populations analyzed to craft so-called evidence-based medicine and the individual patients seen in daily practice, many of whom may not have been candidates for those clinical trials. First-line treatments for PHN include tricyclic antidepressants, gabapentin and pregabalin, and the topical lidocaine 5% patch. Opioids, tramadol, capsaicin cream, and the capsaicin 8% patch are recommended as either second- or third-line therapies in different guidelines. Therapies that have demonstrated effectiveness for other types of neuropathic pain are discussed, such as serotonin-norepinephrine reuptake inhibitors, the anticonvulsants carbamazepine and valproic acid, and botulinum toxin. Invasive procedures such as sympathetic blockade, intrathecal steroids, and implantable spinal cord stimulators have been studied for relief of PHN, mainly in patients refractory to noninvasive pharmacologic interventions. The main guidelines considered here are those issued by the American Academy of Neurology for the treatment of postherpetic neuralgia (2004) and general guidelines for the treatment of neuropathic pain issued by the Special Interest Group on Neuropathic Pain of the International Association for the Study of Pain (2007) and the European Federation of Neurological Societies (2010).

Primary Care Physician Attitudes and Practice Patterns in the Management of Obese Adults: Results from a National Survey

Purpose: Obesity remains a serious public health problem. The purpose of this study was to identify the current attitudes and practices of primary care physicians (PCPs) with respect to obesity. Methods: A survey was systematically developed and administered electronically to PCPs, who received a small honorarium for their time. Results were analyzed to identify specific attitudes and practices and their associations with each other and with demographic and other variables. Results: Physicians expressed little confidence in their ability to manage obesity. In general, however, they believed that obesity could be successfully managed. Lifestyle changes were perceived to be the most effective available method for patients to lose weight, and respondents were more likely to recommend this approach over pharmacotherapy or bariatric surgery. Respondents perceive the greatest barrier to managing obese patients to be a lack of patient motivation. Physicians were significantly more likely to initiate discussions with obese patients about their weight if they believed they had positive attitudes about and knowledge of weight management, and adequate resources to manage the problem. Conclusions: Physicians report a lack of confidence in managing obesity. Lack of patient motivation is perceived to be the greatest barrier. Physicians with greater knowledge, more positive attitudes toward obesity management, and access to more resources are more likely to provide weight management in primary care settings.

Attitudes and practices of primary care physicians in Ankara about food allergy and anaphylaxis

Results Median of the age of the participants and duration of theri practice were 42.4±6.5 and17.0±6.4 years. The 72.4% of participants pointed out that lower than 5% of their pediatric patients had food allergy. The 36.6% of the participants thought that FA could be completely cured with therapy, the 36.9% stated that they didn’t refer the patients suspected for FA.The 73.4% defined asthma as a significant risk factor of A for the patient with FA. Egg white was the most common food allergen (85.8%) defined by PCP and teh second common food allergen was cow’s milk (67.5%). The 4.3% of the participants had ever given a prescription of epinephrine otoinjector, 83% of them defined they know poorly about the use of epinephrine otoinjector. The 50% of PCP defined epinephrine as the first drug in a case with anaphylaxis, 60% of this group pointed out to give subcutaneously. Fifty two percent of PCP indicated that the education for FA and A in medical school was deficient. Conclusions PCP have some information about FA, but they heve to be educated about practical applications about the diagnosis and management of FA and A. Otherwise we could neither know the real extent end burden of FA and A nor form right practice.

Challenges in Recruiting Minority-Serving Private Practice Primary Care Physicians to a Quality Improvement Project

The objectives of this study were the following: (1) describe one organization's experience with recruiting minority-serving private practice primary care physicians to an ambulatory quality improvement (QI) project; (2) compare and contrast physicians who agreed to participate with those who declined; and (3) list incentives and barriers to participation. The authors identified eligible physicians by analyzing Medicare Part B claims data, a publicly available physician database, and office staff responses to telephone inquiries. The recruitment team had difficulty identifying, contacting, and recruiting eligible physicians. Solo practitioners and physicians who had lower scores on certain quality measures were more likely to participate. Barriers to participation were similar in all practices and included concerns about extra work, difficulty of change, and impact on office work flow. Commonly used incentives were offered but were not universally embraced. Additional work is required to refine the process of physician recruitment and to find more compelling incentives for QI.

Role of Patent Foramen Ovale in Migraine Etiology and Treatment: A Review

An increased prevalence between patent formen ovale (PFOs) and migraine exists but there is conflicting data regarding causal relationship between these two conditions. It is controversial whether cardiac screening and intervention like PFO closure provides any benefit in this population and so this area still remains under intense investigation. The management of migraine lies at the intersection between the practice of primary care physicians, neurologists, and cardiologists. There is no consensus as to what is the best practice for the evaluation of these patients with difficult to control migraine given the millions of dollars spent on physician visits and pharmacotherapy. This review seeks to summarize the current literature on this association and studies that have investigated PFO closure in this population.

The relationship between office system tools and evidence-based care in primary care physician practice

A number of office system tools have been developed to improve the rates of preventive services and enhance the quality of medical care in practice settings. New approaches to measuring physician adherence to evidence-based standards of treatment, offer a unique opportunity to examine the link between the use of office system tools and evidence-based practices in primary care. Using episode-based profiling measures of adherence as the criterion, results from this investigation suggest that the application of simple physician reminders can be an effective technique for promoting evidence-based treatment. The data also reveal that the influence of health information technology (HIT) resources on adherence was not exclusively positive. Specifically, adherence to evidence-based standards was higher for primary care practices that employed HIT resources judiciously. In contrast, extensive use of personal digital assistants was negatively associated with adherence. Despite concerns directed towards the new generation of episode-based profiling measures, results from this research indicate that the measures behave similarly to traditional measures of quality.