Specialist Involvement Research Articles

Blood Transfusion Prescribing Patterns Across the Australian Capital Territory (ACT)

Aim To identify the medical officers responsible for blood transfusion therapy across the ACT. Method Medical records of patients having transfusions were audited in one tertiary referral hospital, one general hospital and one associated private hospital as part of a quality improvement project. The clinical status patients, reasons for transfusion and laboratory data were extracted and the appropriateness of transfusion was assessed independently by two of the authors. Differences were resolved by consensus. The prescriber was also identified where possible, defined as the most senior clinician recorded in the medical record involved in the decision to transfuse. Result The prescriber could be determined in 78% of transfusion episodes. In the majority of cases the decision to transfuse was attributed to specialist staff, in all hospitals. Registrars at the tertiary hospital prescribed significantly fewer inappropriate transfusions (12%) than specialists (18.1%, p < 0.05). This was not found at the smaller public hospital. After hours resident and registrar staff prescribed significantly fewer inappropriate transfusions (3%) than other prescribers across the Territory (18.7%, p < 0.005). Conclusion Medical practitioners with varying levels of experience make medical decisions in hospitals. Who is responsible for these decisions has not been well studied. Our findings demonstrate specialist involvement in the majority of transfusion decisions. The results favour a ‘top down’ approach to quality improvement in transfusion, rather than targeting junior medical officers. The findings also have significant implications in understanding the dynamics of clinical decision making in the hospital setting and for the targeting of other quality improvement strategies.

Association of specialist involvement and quality of care for Parkinson's disease

Because Parkinson's disease (PD) has multiple neurological symptoms and often complex treatments, the quality of PD care may be higher when a specialist is involved. We examined the medical records, from 1998 to 2004, of 401 Los Angeles veterans with Parkinson's disease to determine whether care met key indicators of PD care quality. All care following a visit to a movement-disorder specialist or general neurologist was classified as specialty care. We compared adherence to each indicator by level of specialist involvement through logistic regression models. Over the study period, 10 indicators of PD care quality were triggered 2,227 times. Overall, movement disorder specialist involvement (78%) was associated with higher adherence to indicators than did general neurologist involvement (70%, P = 0.006) and nonneurologist involvement (52%, P < 0.001). The differences between movement disorder specialist and nonneurologist involvement were especially large for four indicators: treatment of wearing-off, assessments of falls, depression, and hallucinations. There is significant room for improving aspects of PD care quality among patients who do not have the involvement of a specialist. Quality of care interventions should involve specialists in management of motor symptoms and incorporate methods for routine assessment of nonmotor PD symptoms.

Mapping speech and language therapy provision for school-aged children with receptive-expressive language impairment: Speech and language therapist opinion and practice

Children who experience receptive-expressive language impairment (R-E LI) have a significantly increased risk that their language disability will persist throughout their school years compared to children who experience expressive difficulties only. Effective speech and language therapy (SLT) intervention for these children is therefore of major concern to practitioners yet relatively little is know about current practice and little attention has been paid to SLT practitioner opinions on best provision. This paper reports the proportion of children with specific language impairments (SLI) on caseloads in one SLT service with R-E LI and the intervention offered to these children across the school years as well as SLT practitioner opinions on best practice. All paediatric SLTs across one Primary Care Trust completed an audit pro-forma on all children with language impairments on their caseloads during the month of October 2005. Eight SLTs, representing a range of experience, were then interviewed to gauge professional opinion on current practice and on what they felt was best practice for children with R-E LI. Two-hundred and sixty-four children on SLT caseloads had R-E LI and the majority of these children were of pre-school and key stage 1–2 age. Provision varied and included consultancy models of management as well as classroom based behavioural approaches to teaching language skills. At present, provision for children with R-E LI appears to focus on pre-school and primary school age children. Interview responses highlight the potentially greater perceived need for specialist (SLT) involvement in provision for children with R-E LI in the secondary school years.

Stroke prevention in patients with atrial fibrillation: The diagnosis and management of hypertension by specialists

Hypertension is common in patients with atrial fibrillation (AF) and is an important cause of stroke. To determine how effectively hypertension is managed among specialist-treated outpatients with AF. Investigators reviewed the charts of patients with a diagnosis of AF cared for by medical specialists to determine the change in blood pressure, patterns of antihypertensive drug use and the role of the specialist in the management of hypertension. Of 209 patients with AF, 118 had a history of hypertension or an office blood pressure greater than 140/90 mmHg. Blood pressure was measured at 73% of all visits. Hypertension was identified as an important problem in 57% of patients and antihypertensive therapy was either initiated or suggested in 77%. One year after the initial specialist visit, systolic blood pressure was significantly lower (140+/-20 mmHg at one year versus 148+/-23 mmHg initially; P=0.015); however, there was no change in diastolic blood pressure (80+/-12 mmHg at one year versus 81+/-16 mmHg initially; P=0.602) and only 50% of patients had a blood pressure less than 140/90 mmHg. In contrast, the percentage of patients receiving warfarin increased from 46% to 78% (P=0.0001). In patients treated by specialists for AF, systolic blood pressure is significantly reduced during follow-up; however, 50% of patients continue to have suboptimal blood pressure control. In many patients, hypertension is not identified as an important comorbid illness and antihypertensive therapy is neither recommended nor initiated by the specialist. Greater specialist involvement in the identification and treatment of hypertension in patients with AF could lead to an important, additional reduction in stroke.

Primary Care Physician Specialty Referral Decision Making: Patient, Physician, and Health Care System Determinants

To examine the effects of patient, physician, and health care system characteristics on primary care physicians' (PCPs') specialty referral decision making. Physicians (n=142) and their practices (n=83) located in 30 states completed background questionnaires and collected survey data for all patient visits (n=34,069) made during 15 consecutive workdays. The authors modeled the occurrence of any specialty referral, which occurred during 5.2% of visits, as a function of patient, physician, and health care system structural characteristics. A subanalysis was done to examine determinants of referrals made for discretionary indications (17% of referrals), operationalized as problems commonly managed by PCPs, high level of diagnostic and therapeutic certainty, low urgency for specialist involvement, and cognitive assistance only requested from the specialist. Patient characteristics had the largest effects in the any-referral model. Other variables associated with an increased risk of referral included PCPs with less tolerance of uncertainty, larger practice size, health plans with gate-keeping arrangements, and practices with high levels of managed care. The risk of a referral being made for discretionary reasons was increased by capitated primary care payment, internal medicine specialty of the PCP, high concentration of specialists in the community, and higher levels of managed care in the practice. PCPs' referral decisions are influenced by a complex mix of patient, physician, and health care system structural characteristics. Factors associated with more discretionary referrals may lower PCPs' thresholds for referring problems that could have been managed in their entirety within primary care settings.

GPs' perceptions of the management of ADHD in primary care: a study of Wandsworth GPs

Attention-deficit hyperactivity disorder (ADHD) is a growing diagnosis in child mental health in the UK and is increasingly being treated with methylphenidate (Ritalin, Equasym, Concerta). There are, however, clinical and public controversies over the diagnosis and ‘labelling’ of ADHD as a disorder, the use of drug treatments, and a relative paucity of guidance on the initial diagnosis and referral of the disorder. General practitioners (GPs) are involved in the assessment, diagnosis and treatment of children with ADHD and in liasing with the other parties involved, such as parents, teachers and specialists. Therefore their understanding of ADHD and its treatment is important. This study explores Wandsworth (South West London) GPs‘ understanding of ADHD as a disorder and their views of its management in order to provide more precise detail about the issues concerning the management of ADHD in primary care by GPs.Qualitative information was collected by semi-structured interviews (with 13 GPs) and quantitative information by means of questionnaires (93 completed by GPs) in Wandsworth.Whilst GPs had differing views of the aetiology of ADHD, there was a consensus view about the division of responsibility in the treatment of those diagnosed with ADHD. GPs felt uncomfortable initiating the prescribing of methylphenidate and stressed the importance of ongoing specialist involvement in the management of ADHD. There was also a feeling of inadequacy in terms of the training that GPs had received.It is suggested that guidance on the initial diagnosis of ADHD is drafted for GPs and that shared care protocols are agreed between primary care and secondary care so that the ongoing division of labour in the management of ADHD is made explicit, ensuring continuity of care.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders

Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines for the Treatment of Schizophrenia and Related Disorders

Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines for the Treatment of Schizophrenia and Related Disorders

Awareness of the side effects of possessed medications in a community setting.

To evaluate in a community setting the extent of and parameters related with awareness of side effects of medications by health consumers. We performed in-house interviews in an entire community. The population of the community of Chalki, Greece, was surveyed. Detailed information was recorded on all medications possessed by each individual. The main outcome measure was awareness of medication side effects. A total of 1079 medications were recorded among 279 subjects. Among 180 subjects for whom direct information was available, and who possessed at least one medication only 47 (26%) were aware of the side effects of at least one of their medications. Side effects awareness was more frequent in subjects who had experienced some adverse event themselves (76%), in those with completed university education (67%), ex-smokers (46%), housewives (45%), and never married adults (41%) and was less frequent in more permanent island residents (odds ratio 0.76 per 10% of lifetime spent in the island) and economic immigrants (0%). Side effects awareness existed for only 8% of the possessed medications and was more frequent when an adverse event had been experienced (54%), for medications not provided locally initially (28%), and for medications for joint and musculoskeletal problems (15%). Awareness rates were unrelated to availability of prescription, specialist involvement, or follow-up by a physician concerning the specific medication. Awareness of side effects was infrequent in this community setting and was determined mostly by live experiences of adverse events and social parameters. There is a need to improve the dissemination of adequate safety information among consumers in the ambulatory use of pharmaceuticals.

Cancer physicians’ attitudes toward colorectal cancer follow-up

The optimal follow-up strategy for colorectal cancer is unknown. We surveyed all Canadian radiation oncologists, medical oncologists and surgeons specializing in colorectal cancer to assess their recommendations for follow-up after potentially curative treatment, the beliefs and attitudes underlying these practices, and the cost implications of different follow-up strategies. One hundred and sixty practitioners (58%) returned completed surveys. Most recommended clinical assessments every 3-4 months in the first 2 years including carcino-embryonic antigen testing, gradually decreasing in frequency over 5 years. Ninety per cent recommend a surveillance colonoscopy in the first year. The majority felt that specialist involvement in follow-up was important because of the increased opportunities for patients to contribute to research (76%) and teaching (73%). About half felt that specialists were more efficient at providing follow-up than primary care physicians, but these same physicians recommended significantly longer and more expensive follow-up routines on average than others. Primary care physicians were felt to be important allies, especially in managing the psychosocial concerns of patients. Surveillance practices are generally in keeping with published recommendations. Most specialists feel that they should remain involved in follow-up, but this may result in increased resource utilization.

Specialty care for heart failure: Does it improve outcomes?

Am Heart J 2003;145:209-13.

Physicians' preferences for specialty involvement in the care of patients with neurological conditions.

Recent changes in the US health care system have produced questions about the appropriate roles and responsibilities of generalist and specialist physicians within a primary care-centered health care delivery system. To determine neurologists' and primary care physicians' preferences for specialist involvement in the management of common neurologic conditions and the factors influencing these preferences. A self-administered questionnaire was developed with the assistance of a multispecialty Advisory Board and sent to a stratified probability sample of 608 family physicians, 624 general internists, and 492 neurologists. The questionnaire contained three clinical scenarios, each followed by questions regarding respondent preferences for the primary care physician to manage alone, curbside, or refer to a specialist. The questionnaire also contained knowledge questions corresponding to each scenario and physician and practice characteristics questions. Response rate was 60%. For all three scenarios, primary care physicians' preferences to involve a specialist differed substantially from neurologists' preferences, with nearly all neurologists preferring involvement of a specialist. Primary care physicians with less knowledge were more likely to prefer assistance from a neurologist. Physician age and practice setting influenced the type of assistance preferred (curbside vs. referral). Utilization management techniques and financial incentives had little influence on physician preferences to involve a specialist. The extensive disagreement between primary care physicians' and specialists' preferences for specialty involvement represents cause for considerable concern, supporting further efforts to identify where inappropriate referral processes are occurring and to implement mechanisms for improving the coordination and quality of primary and specialty care.

Influence of physician specialty on adoption and relinquishment of calcium channel blockers and other treatments for myocardial infarction.

Recent reports have linked calcium channel blockers (CCBs) with an increased risk of acute myocardial infarction (AMI). We sought to determine to what extent physicians relinquished CCBs following these adverse reports and if there were differences in the use of CCBs and other AMI therapies across 3 levels of specialist involvement: generalist attendings, collaborative care (generalist with cardiologist consultation), and cardiologist attendings. We measured use of CCBs during hospitalization for AMI before (1992--1993) and after (1995--1996) the adverse CCB reports, controlling for hospital-, physician-, and patient-level variables. We also examined use of effective medications (aspirin, beta-blockers, thrombolytic therapy) and ineffective AMI treatments (lidocaine). Thirty-seven community-based hospitals in Minnesota. Population-based sample of 5,347 patients admitted with AMI. The primary outcome was prescription of a CCB at the time of discharge from hospital. Secondary outcomes included use of other effective and ineffective AMI therapies during hospitalization and at discharge. Compared with cardiologists, generalist attendings were less likely to use aspirin (37% vs 68%; adjusted odds ratio [OR], 0.58; 95% confidence interval [95% CI], 0.42 to 0.80) and thrombolytics (29% vs 64%; adjusted OR, 0.18; 95% CI, 0.13 to 0.25), but not beta-blockers (20% vs 46%; adjusted OR, 0.93; 95% CI, 0.66 to 1.31). From 1992--1993 to 1995--1996, the use of CCBs in patients with AMI decreased from 24% to 10%, the net result of physicians starting CCBs less often and discontinuing them more often. In multivariate models, the odds of CCB relinquishment after the adverse reports (adjusted OR, 0.33; 95% CI, 0.27 to 0.39) were independent of, and not modified by, the involvement of a cardiologist. Compared with cardiologists, generalist physicians were less likely to adopt some effective AMI therapies, particularly those associated with risk such as thrombolytic therapy. However, generalists were as likely as cardiologists to relinquish CCBs after the adverse reports. This pattern of practice may be the generalist physicians' response to an expanding, but increasingly risky and uncertain, pharmacopoeia.

The K.O.A.L.A.™ Continuous Professional Development Programme: An Integral Part of the Lifelong Learning Continuum

The quest for lifelong learning is shared by residents and practising physicians alike. They willingly participate in continuing medical education (CME) activities to update and maintain professional knowledge and skills. The ever-changing health care society and the wider and more rapid distribution of information over the Internet have forced physicians and medical societies to acknowledge the limitations of traditional ad hoc CME activities. The search for a method that recognizes the need for systematic documentation of competence, protects personal learning autonomy, allows for societal review and audit, encompasses elements of feedback and self-assessment and acknowledges the wider responsibility of physicians beyond the medical expert, led to the concept of continuous professional development (CPD). This new approach (CPD) embraces the multidimensional aspects of physician practice. Inherently, traditional CME is a subset of CPD.In response to these challenges, the Royal College of Physicians and Surgeons of Canada identified seven essential roles of specialist physicians, and accepted a 1997 recommendation that mandatory maintenance of certification be initiated within five years. The programme will provide standard documentation and encourage specialist involvement in a range of accredited educational activities demonstrating that these individuals are committed learners for life. The Society of Obstetricians and Gynaecologists of Canada (SOGC) will, during the 1999 calendar year, initiate a pilot project using the Computerized Obstetrics and Gynaecology Automated Learning Analysis (K.O.A.L.A.™) Continuous Professional Development (CPD) programme. In addition to the learning portfolio component of the original K.O.A.L.A.™ version, K.O.A.L.A.™ CPD includes a point system, peer and self-evaluation components, real-time graphical representation of progress over time and links to Web-based sites. The programme is merely a tool for systematic documentation that proves to all stakeholders the physician willingness to address their needs and goals while remaining relevant and competitive.

Right heart thrombus: the importance of early intervention.

A case report of mobile, right heart thrombus in the accident and emergency (A&E) department is presented. Though frequently associated with major pulmonary embolism, recognition is usually at postmortem examination....

The Influence of Human Factors and Specialist Involvement on Information Systems Success

Despite remarkable advances in information technology (IT), many computer-based information systems (IS) still fall short of performance expectations. A growing share of these implementation failures are due to nontechnical factors. This article considers the human factors and human resource (HR) management issues associated with IT assimilation. A taxonomy of specialist roles in the IS adoption process is proposed and illustrated in a series of brief case studies. The results from a field investigation are then reported. The relationships between different HR specialist roles and selected IS success measures were examined in more than 60 organizations across East and Southeast Asia. Proactive and supportive HR roles were found to be associated with greater user satisfaction, smoother organizational change and improved productivity, but did not significantly affect perceived output quality. The implications for management practice are discussed and specific areas for further research are identified.

Consultation between cardiologists and generalists in the management of acute myocardial infarction: implications for quality of care.

The rapid expansion of managed care in the United States has increased debate regarding the appropriate mix of generalist and specialist involvement in medical care. To compare the quality of medical care when generalists and cardiologists work separately or together in the management of patients with acute myocardial infarction (AMI). We reviewed the charts of 1716 patients with AMI treated at 22 Minnesota hospitals between 1992 and 1993. Patients eligible for thrombolytic aspirin, beta-blockers, and lidocaine therapy were identified using criteria from the 1991 American College of Cardiology guidelines for the management of AMI. We compared the use of these drugs among eligible patients whose attending physician was a generalist with no cardiologist input, a generalist with a cardiologist consultation, and a cardiologist alone. Patients cared for by a cardiologist alone were younger, presented earlier to the hospital, were more likely to be male, had less severe comorbidity, and were more likely to have an ST elevation of 1 mm or more than generalists' patients. Controlling for these differences, there was no variation in the use of effective agents between patients cared for by a cardiologist attending physician and a generalist with a consultation by a cardiologist. However, there was a consistent trend toward increased use of aspirin, thrombolytics, and beta-blockers in these patients compared with those with a generalist attending physician only (P<.05 for beta-blockers only). Differences between groups in the use of lidocaine were not statistically significant. The adjusted probabilities of use of thrombolytics for consultative care and cardiologist attending physicians were 0.73 for both. Corresponding probabilities were 0.86 and 0.85 for aspirin and 0.59 and 0.57 for beta-blockers, respectively. For patients with AMI, consultation between generalists and specialists may improve the quality of care. Recent policy debates that have focused solely on access to specialists have ignored the important issue of coordination of care between generalist and specialist physicians. In hospitals where cardiology services are available, generalists may be caring for patients with AMI who are older and more frail. Future research and policy analyses should examine whether this pattern of selective referral is true for other medical conditions.

Do Cardiologists Do It Better?

Pressure to lower the cost of health care delivery has fostered widespread efforts to limit patients’ access to specialists such as cardiologists. However, there is concern that diminished specialist involvement may lead to poorer patient outcomes for specific clinical conditions. As part of a state-sponsored effort to improve the quality of health care in Pennsylvania, the Pennsylvania Health Care Cost Containment Council gathered clinical and administrative data on all 40,684 hospital admissions for acute myocardial infarction (AMI) in that state in 1993. They prepared a detailed public report that included risk-adjusted in-hospital mortality and length of hospital stay by physician group, by hospital and by region. These data demonstrate that patients cared for by cardiologists, as a group, had a lower risk-adjusted mortality than patients cared for by either internists (risk ratio 1.26, 95% confidence interval 1.17 to 1.35) or family practitioners (risk ratio 1.29, 95% confidence interval 1.18 to 1.40). The patients of cardiologists also had a shorter length of stay than the other two groups. These data suggest that there is enhanced value in the care provided by cardiologists for patients with AMI and call into question the growing trend toward reliance on generalists instead of specialists.(J Am Coll Cardiol 1997;29:475–8)

Needs of families of critically ill patients: a literature review

More research is needed to assess and address all areas of concern to family members. Options such as family discussion groups, patient-family or psychiatric liaison nurses, or clinical nurse specialist involvement might be used to improve family care and coping. Family perceptions of important needs warrant further research, and nursing interventions such as orientation-education programs, descriptive visitor pamphlets, nurse-family interaction sessions, and open or flexible visiting policies need additional investigation. It is only through continued assessment, evaluation, and intervention that critical care nurses can achieve total care for the ICU patient and family.

Antimicrobial formulary management: meeting the challenge in the community hospital.

We established a casework approach to develop an antibiotic formulary for a large community hospital. The program consists of a combination of comprehensive clinical and administrative strategies designed to reduce antimicrobial expenditures and improve the quality of antibiotic prescribing. Strategies included a background document summarizing each pharmacologic group of antimicrobial drugs and formulary preferences, presentations to medical and surgical departments, development of drug use evaluation strategies that complement the development of the formulary, and a monitoring program for nonformulary antibiotic use. The development of a customized microbiologic/antibiotic susceptibility report card specific to the institution's inpatient and outpatient microflora was an integral part of the program. This tool also allowed for the continuous compilation of comparison data and development of prescribing tips. Predetermined criteria were established providing physicians with microorganism susceptibility reports and preferred treatment alternatives linked to pharmacoeconomic concerns. These strategies can be implemented with or without direct clinical pharmacotherapy specialist involvement at the individual patient care level.