Medical Practice Study Research Articles

Receptivity to Change in a General Medical Practice

AbstractIn this paper, Pettigrew, Ferlie and McKee's concepts of receptive and non receptive contexts for change are examined using data from an evaluation study of a general medical practice implementing a Personal Medical Services Pilot between 1998 and 2001. Four questions concerning the applicability, associatedness, temporality and dynamism of the eight factors Pettigrew et al. identified as constitutive of receptivity are used in the analysis, which extends the original model through an operationalization yielding 21 ‘focal questions’. Although the process of change at the fieldwork site was stalled, the receptivity model is shown to have been a useful tool in identifying the factors blocking change. The analysis shows that when the eight factors are conceptualized in terms of the strength, direction and continuity of their influence, the receptivity metaphor provides a distinctive tool for the analysis of change. The paper concludes that further refinement of the model could provide a basis for the derivation of change management typologies.

Medical practices' sensitivity to patients' needs. Opportunities and practices for improvement.

This article presents the results of a national study of medical practices' patient satisfaction using data collected from January to December 2001 with Press Ganey Associates' Medical Practice Survey (n = 503,407). The question, "Our sensitivity to your needs" (r = 0.85), most highly correlated with overall patient satisfaction. Patients' age, sex, or first visit were not predictors of sensitivity to patients' needs. Responses highly correlated with sensitivity to patients' needs: (1) concern for patients' privacy, (2) cheerfulness of practice, (3) care received during visit, and (4) likelihood to recommend practice. Patient perception and satisfaction with medical practices' sensitivity to patient needs and recommended practices for improvement are discussed.

The traffic in Victorian bodies: Medicine, literature, and history.

Have we lost the connections between literary studies of Victorian bodies, studies of medicine and literature, and historical studies of medical ideas and practices? The boundary police of academic disciplines might be pardoned for thinking so; indeed, for believing that these projects have always been on different continents drifting in different directions. Certainly, the "body languages" of the former and the latter are often wide apart—the heavily theorized "pathology poetics" of the one being a far cry from the empirical realist narratives of the other. Much recent literary scholarship has gone into rewriting the Victorians in terms of the body's discursive fabrications, the body being taken as the culturally embedded text (often the text) for imaginative and contested readings of the self and others. As testified through the work of Mary Poovey, Catherine Gallagher, Helena [End Page 513] Michie, and Linda Shires among others, a major part of the literary turn in cultural studies has been its somatic turn. While accounts of the medical epistemology of the modern social body remain relatively obscure (and contested), 1 few historians, and even fewer cultural analysts, now doubt that the history of the body forms an important part of the conceptual history of modernity. Whether as a means of contemplating the human condition, or merely pursuing language practices and literary strategies, corporeality and pathology have become obligatory points of passage in the study of Victorian society and culture.

Infection control - a problem for patient safety.

Nosocomial, or hospital-acquired, infections (more appropriately called health care–associated infections) are today by far the most common complications affecting hospitalized patients. Indeed, the Harvard Medical Practice Study II found that a single type of nosocomial infection — surgical-wound infection — constituted the second-largest category of adverse events.1 Long considered the greatest risk that the hospital environment poses to patients,2 nosocomial infections abruptly became the province of public health officers at the time of a nationwide epidemic of hospital-based staphylococcal infections, in 1957 and 1958.3 Since then, the study and control of nosocomial infections have been profoundly shaped by the discipline . . .

Medication errors: causes, prevention and reduction.

Medication errors: causes, prevention and reduction.

Five-year Mortality for Stable Angina in a Medical Practice Study and a Randomized Trial

Objective : Evolution of revascularization and medical therapy has increased the probability of improved survival in patients with stable angina. The present investigation tests the hypothesis that medical practice will generate lower mortality than randomly assigned bypass surgery in the European Coronary Surgery Study (ECSS) two decades earlier. Method : Using eligibility criteria of ECSS, a clinical decision strategy (CDS) cohort of 362 patients was selected from a nationwide study of medical practice in Sweden. Access to the individual data allowed common protocol design to compare 5-year mortality between CDS and surgical strategy of ECSS. Results and interpretation : CDS advised bypass surgery (BS) or percutaneous transluminal coronary angioplasty (PTCA) in 93% and medical treatment alone in 7%, while 94% of 394 patients randomized to surgery (Euro-S) in ECSS obtained BS. Operative mortality was 3.2% for Euro-S while no operative deaths occurred in CDS reflecting medical progress during two decades. However, the 5-year mortality for CDS decreased first when the risk ratio was adjusted for age, diabetes mellitus and hypertension (RR = 0.49 with 95% CI 0.26-0.93) p = 0.03 suggesting a need for improved comprehensive medical care.

Research as a visiting doctor in Afghanistan and Cambodia.

This paper describes research I conducted into health care and its difficulties while working as a visiting doctor in two developing countries. The research was conducted in the Departments of Medicine, University Hospital, Jalalabad, Afghanistan, in 1994 and 1995, and Calmette Hospital, Phnom Penh, Cambodia, in 1997 and 1998. In Afghanistan I did an observational study of medical practice and case studies at the Department of Medicine, and a survey of drugs sold in pharmacies in Jalalabad. In Cambodia I surveyed hemoglobin concentrations of medical patients, and did an observational study of medical practice and case studies at Calmette Hospital. I surveyed the body weight of medical patients in relation to drug doses, and used a questionnaire to survey prescribing practices of physicians. Each project was conducted by me alone and was completed within 1-3 months. The support by the hospital was good and there where no ethics committees that had to approve the projects. Only verbal consent from the patients had to be obtained and no national laws or regulations affected the research. Small clinical research projects in developing countries are relatively easy to perform, if conducted by one researcher working in a hospital and not relying on special equipment such as a computer.

Estimating the kappa-coefficient from a Selected Sample

Cohen's K-coefficient (1960) is often used as a measure of agreement between exchangeable pairs of binary ratings on a subject. The coefficient depends on the marginal probability of a positive rating. Suppose that the probability of a positive rating in the observed sample is not applicable to the group of interest. We estimate the (2 x 2)-table of probabilities for a pair of raters from the observed sample. Assuming that the odds ratios in the observed sample and the group of interest are the same, we use iterative proportional fitting to rescale the (2 x 2)-table to have marginal probabilities equal to those from the group of interest. Finally, we re-estimate the K-coefficient from this rescaled table. Our example is from the Harvard medical practice study In which the 'rating' is a physician's view of whether an 'adverse event' occurred in the hospital; an adverse event is an unintended injury caused by medical workers in a hospital rather than the disease process. The group of interest Is the whole population of hospital patients, but the observed sample consists of patients who are at high risk for an adverse event.

The electronic medical record and everyday medical work

The deployment of the electronic medical record (EMR) is widely seen by healthcare policy makers and service managers as a key step in the achievement of more efficient and integrated healthcare services. However, our studies of medical work practices reveal important discrepancies between the presumptions of EMR and the ways in which healthcare professionals actually use and communicate information. These lead us to conclude it may be some time before technologies like the EMR can deliver promised benefits, and will do so only if they are allowed to evolve via user-led design and development processes.

Medication Errors and Adverse Drug Events in Nursing Homes: Problems, Causes, Regulations, and Proposed Solutions

The Institute of Medicine (IOM) report To Err is Human: Building a Safer Health System has focused national attention on quality of care and the prevalence of medical errors in the healthcare system. According to the report, medical errors are responsible for a large number of deaths and additional morbidity in healthcare facilities and increased cost to the healthcare system. 1 Kohn LT Corrigan JM Donaldson MS To Err is Human: Building a Safer Health System. The Institute of Medicine National Academy Press, Washington, DC1999 Google Scholar A large proportion of medical errors are medication-related. 2 Leape LL Brennan TA Laird N et al. The nature of adverse events in hospitalized patients: Results of the Harvard medical practice study II. N Engl J Med. 1991; 324: 377-384 Crossref PubMed Scopus (2855) Google Scholar Medication-related errors and other adverse drug reactions are known collectively as adverse drug events (ADEs), defined as “any injury resulting from the medical use of a drug.” 3 Bates DW Spell N Cullen DJ et al. The costs of adverse drug events in hospitalized patients. JAMA. 1997; 277: 307-311 Crossref PubMed Google Scholar , 4 Gurwitz JH Field TS Avorn J et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med. 2000; 109: 87-94 Abstract Full Text Full Text PDF PubMed Scopus (526) Google Scholar ADEs occur across the entire healthcare delivery system and are most common in older people, particularly those in hospitals and nursing homes. 5 Rothschild JN Bates DW Leape LL Preventable medical injuries in older patients. Arch Intern Med. 2000; 160: 2717-2728 Crossref PubMed Scopus (220) Google Scholar , 6 Gurwitz JH Sanchez-Cross T Eckler MA Matulis J The epidemiology of adverse and unexpected events in the long-term care setting. J Am Geriatr Soc. 1994; 42: 33-38 Crossref PubMed Scopus (74) Google Scholar ADEs are the adverse events most common in hospitalized patients 2 Leape LL Brennan TA Laird N et al. The nature of adverse events in hospitalized patients: Results of the Harvard medical practice study II. N Engl J Med. 1991; 324: 377-384 Crossref PubMed Scopus (2855) Google Scholar and the second most common adverse event in nursing home residents. 6 Gurwitz JH Sanchez-Cross T Eckler MA Matulis J The epidemiology of adverse and unexpected events in the long-term care setting. J Am Geriatr Soc. 1994; 42: 33-38 Crossref PubMed Scopus (74) Google Scholar In a report to Congress published in January 2000, 7 United States General Accounting Office. Adverse drug events. The magnitude of health risk is uncertain because of limited incidence data. Report to congressional requesters. GAO/HEHS-00–21. Washington, DC, January 2000. Google Scholar the United States General Accounting Office (GAO) reviewed available studies and concluded that the magnitude of health risk, as well as the cost, is uncertain because of limited incidence data and the difficulty inherent in recognition and identification of ADEs. However, studies reviewed in the report showed a rate of 0.56 ADEs per 100 patients admitted to hospitals in Colorado and Utah and 0.72 in New York. 8 Brennan TA Leape LL Laird NM et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard medical practice study I. New Engl J Med. 1991; 324: 370-376 Crossref PubMed Scopus (3435) Google Scholar , 9 Thomas EJ Studdert DM Burstin HR et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000; 38: 261-271 Crossref PubMed Scopus (1241) Google Scholar In nursing homes, two studies reported an incidence of 0.44 to 0.71 per patient month. 10 Gerety MB Cornell JE Plichta DT Eimer M Adverse events related to drugs and drug withdrawal in nursing home residents. J Am Geriatr Soc. 1993; 41: 1326-1332 Crossref PubMed Scopus (84) Google Scholar , 11 Cooper JW Drug-related problems in a geriatric long term care facility. J Am Geriatr Soc. 1986; 37: 323-326 Google Scholar Another study in 332 nursing home residents showed an incidence of 134 ADEs per 100 admissions. 12 Cooper JW Probable adverse drug reactions in rural geriatric nursing home population: A four year study. J Am Geriatr Soc. 1996; 44: 194-197 PubMed Google Scholar A recently published study conducted in 18 Massachusetts nursing homes 4 Gurwitz JH Field TS Avorn J et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med. 2000; 109: 87-94 Abstract Full Text Full Text PDF PubMed Scopus (526) Google Scholar found an incidence of 1.89 ADEs per 100 resident/months and potential ADEs in an additional 0.65 per 100 resident/months.

Error in Medicine

Letters20 February 2001Error in MedicineDavid W. Bates, MD, MSc and Atul A. Gawande, MD, MPHDavid W. Bates, MD, MScBrigham and Women's Hospital; Boston, MA 02115 (Bates, Gawande)Search for more papers by this author and Atul A. Gawande, MD, MPHBrigham and Women's Hospital; Boston, MA 02115 (Bates, Gawande)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-134-4-200102200-00022 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:Dr. Dunn brings up the controversy over the annual number of deaths related to iatrogenic injuries in the United States. The figure we cited—180 000 iatrogenic deaths—comes from the Medical Practice Study (1) and refers to the total number of deaths due to injury. Just over half of these deaths were deemed preventable, resulting in the Institute of Medicine's upper end figure of 98 000. We believe that given the importance of the problem, too few relevant data are available, and that whatever the actual point estimate is, it is too high. Furthermore, the problem of injuries associated ...

Prevention of adverse drug events: a decade of progress in patient safety

Anesthesiology has led the medical profession’s involvement in the study of human error in clinical practice. Seminal studies by Cooper et al., Gaba et al., and the many initiatives of the Anesthesia Patient Safety Foundation resulted in technological advances and application of patient safety principles to anesthesia and, thus, contributed to the delivery of safe anesthesia care. Studies of anesthesia mortality, anesthesia morbidity, anesthesia closed claims, the development of standards of care,14–15 monitoring of pulse oximetry and end-tidal CO2, 20 have increased awareness about the importance of safe anesthetic care as a primary focus of research and clinical attention. However, until the initial Harvard Medical Practice Study provided data that indicated a serious problem existed in other areas of medicine and surgery across a broad spectrum of hospitals and patient care settings, little was being done to address the more generalized problems of human error in medicine. Recent studies examining the root causes of human error in medicine have extended the Harvard Medical Practice Study into its next phase, the Adverse Drug Event Prevention Study. The latter helped to galvanize a nationwide patient safety movement, culminating in the establishment of the National Patient Safety Foundation. More recently, a report from the Institute of Medicine emphasized the serious problem of human error in medicine and demanded improvements in patient safety throughout the scope of medical practice. In 1994, Leape characterized the medical model of error analysis as one that focuses on incidents and individuals using a problem-solving approach to identify the immediate cause of the error and then correct it. He noted that root causes of error, that is, the underlying systems failures, are rarely identified and

Preventable medical injuries in older patients.

Injuries associated with hospitalization are more common in older (>/=65 years) than in younger patients (<65 years), and they may be more severe and more often preventable. The increasing age of the population magnifies the importance of this problem. In this review, we first consider medical injuries in general and then review the literature for 6 categories: adverse drug events, falls, nosocomial infections, pressure sores, delirium, and surgical and perioperative complications. For each of these categories, older patients appear to be at higher risk, ranging from a 2.2-fold increase for perioperative complications to a 10-fold increase for falling, based on Harvard Medical Practice Study rates. The main cause of these increased risks appears to be the diminished physiological reserve of elderly patients; however, age alone is a less important predictor of adverse events than comorbidities and functional status. Furthermore, many of these complications appear to be preventable, although the proportion preventable varies by type of complication. While some prevention strategies are specifically beneficial in older patients, many apply to all age groups. Geriatric care units and consultation systems have improved outcomes in some instances, although the data are mixed. The success of intervention varies by type of complications. For medications, various interventions have been successful, and fall prevention programs have been demonstrated to be effective in the nursing home and home.

Beyond Dead Reckoning: Measures of Medical Injury Burden, Malpractice Litigation, and Alternative Compensation Models from Utah and Colorado

From 1995 to 1998, we conducted an empirical research project in Utah and Colorado that was designed to estimate the burden of medical injury and the performance of the medical malpractice systems in those states. Our aim was to test the results of a similar project, the Harvard Medical Practice Study, conducted a decade earlier in New York. Part I of this Article recaps the intellectual and methodological heritage of the Utah-Colorado Medical Practice Study (UCMPS). Part II describes important changes in the health care system and peculiarities of the New York study that made repetition of a large-scale study of iatrogenic injury worthwhile. Part III describes the origins of the UCMPS itself. Part IV outlines methods and results from each of the four main areas of analysis that comprised the study: (1) incidence of medical injury; (2) malpractice claiming behavior; (3) the economic consequences of medical injury; and (4) the feasibility of alternative approaches to compensation. In conclusion, we discuss implications of the findings for health care policy.

Incidence and types of adverse events and negligent care in Utah and Colorado.

The ongoing debate on the incidence and types of iatrogenic injuries in American hospitals has been informed primarily by the Harvard Medical Practice Study, which analyzed hospitalizations in New York in 1984. The generalizability of these findings is unknown and has been questioned by other studies. We used methods similar to the Harvard Medical Practice Study to estimate the incidence and types of adverse events and negligent adverse events in Utah and Colorado in 1992. We selected a representative sample of hospitals from Utah and Colorado and then randomly sampled 15,000 nonpsychiatric 1992 discharges. Each record was screened by a trained nurse-reviewer for 1 of 18 criteria associated with adverse events. If > or =1 criteria were present, the record was reviewed by a trained physician to determine whether an adverse event or negligent adverse event occurred and to classify the type of adverse event. The measures were adverse events and negligent adverse events. Adverse events occurred in 2.9+/-0.2% (mean+/-SD) of hospitalizations in each state. In Utah, 32.6+/-4% of adverse events were due to negligence; in Colorado, 27.4+/-2.4%. Death occurred in 6.6+/-1.2% of adverse events and 8.8+/-2.5% of negligent adverse events. Operative adverse events comprised 44.9% of all adverse events; 16.9% were negligent, and 16.6% resulted in permanent disability. Adverse drug events were the leading cause of nonoperative adverse events (19.3% of all adverse events; 35.1% were negligent, and 9.7% caused permanent disability). Most adverse events were attributed to surgeons (46.1%, 22.3% negligent) and internists (23.2%, 44.9% negligent). The incidence and types of adverse events in Utah and Colorado in 1992 were similar to those in New York State in 1984. Iatrogenic injury continues to be a significant public health problem. Improving systems of surgical care and drug delivery could substantially reduce the burden of iatrogenic injury.

Erratum

This article has been withdrawn as it was published elsewhere and accidentally duplicated. The original article can be seen here: 10.1108/02689239710195251. When citing the article, please cite: Jane Wren, Barrie Craven, (1997) “A cost-effectiveness study of changing medical practice in early pregnancy”, Journal of Management in Medicine, Vol. 11 Iss: 6, pp. 372 - 381.

Gender and Science

While there are several different approaches to the study of gender and science, this paper focuses on the consequences of the introduction of the concept of gender on studies of scientific and medical practices. It is limited, in the main, to historical studies of twentieth‐century biomedicine, which allows an examination of the validity of scientific assumptions underlying our understanding of the natural world, the genesis and the present status of scientific definitions of masculinity and femininity, and the ideological basis of science‐based technological interventions in the domain of sexuality and reproduction.

Variations in the management of primary care: effect on cost in an HMO network.

To determine the relation to cost of different aspects of the management of primary care among group practices within a health maintenance organization network. A cross-sectional survey study of medical practices conducted with Blue Cross Blue Shield of Minnesota, St Paul. The subjects were group practices accepting financial and administrative responsibility for primary care services in the managed care plans of Blue Cross Blue Shield of Minnesota. One hundred twelve primary care practices and 153397 enrollees were included in this analysis. The principal resource use measure in this study was nonhospital cost per member per year estimated from payments to providers plus subscriber-eligible liability. The medical directors' responses revealed considerable variability in the management of primary care in these 112 practices. Group practice characteristics consistently associated with lower nonhospital cost were patient identification of a primary care physician, cost of care profiling, more frequent physician profiling, more patients per hour in the clinic, a higher proportion of primary care physicians in the specialty of family or general practice, and a greater number of physicians in the group practice. Results of this study demonstrate substantial variation in the management of primary care among group practices participating in a health maintenance organization network. These differences are associated with significant variation in the nonhospital cost of care for enrollees.

A cost-effectiveness study of changing medical practice in early pregnancy.

Until recent years women with symptoms consistent with miscarriage either referred themselves or were referred by their doctors to the local Accident and Emergency (A&E) department. This generally resulted in admission to a gynaecological ward and delayed treatment. Examines the costs and benefits of an Early Pregnancy Assessment Clinic (EPAC), at a teaching hospital in North East England, to deal with the complications in the first trimester. The data show clear benefits together with cost savings. There is an unambiguous policy recommendation to implement the proposed clinic. Examines the delivery of service provision and the impact on referral patterns to the A&E department. Raises the issue of care provision at the margin. Finally, shows the results of an evaluative survey of the clinic from returns of a questionnaire sent to and completed by local general practitioners.

Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995.

In 1991 a new procedure for reporting physician-assisted deaths was introduced in the Netherlands that led to a tripling in the number of reported cases. In 1995, as part of an evaluation of this procedure, a nationwide study of euthanasia and other medical practices concerning the end of life was begun that was identical to a study conducted in 1990. We conducted two studies, the first involving interviews with 405 physicians (general practitioners, nursing home physicians, and clinical specialists) and the second involving questionnaires mailed to the physicians attending 6060 deaths that were identified from death certificates. The response rates were 89 percent and 77 percent, respectively. Among the deaths studied, 2.3 percent of those in the interview study and 2.4 percent of those in the death-certificate study were estimated to have resulted from euthanasia, and 0.4 percent and 0.2 percent, respectively, resulted from physician-assisted suicide. In 0.7 percent of cases, life was ended without the explicit, concurrent request of the patient. Pain and symptoms were alleviated with doses of opioids that may have shortened life in 14.7 to 19.1 percent of cases, and decisions to withhold or withdraw life-prolonging treatment were made in 20.2 percent. Euthanasia seems to have increased in incidence since 1990, and ending of life without the patient's explicit request to have decreased slightly. For each type of medical decision except those in which life-prolonging treatment was withheld or withdrawn, cancer was the most frequently reported diagnosis. Since the notification procedure was introduced, end-of-life decision making in the Netherlands has changed only slightly, in an anticipated direction. Close monitoring of such decisions is possible, and we found no signs of an unacceptable increase in the number of decisions or of less careful decision making.