Use Of Nonphysicians Research Articles

Alternative Care Pathways for Obstructive Sleep Apnea and the Impact on Positive Airway Pressure Adherence

The high burden of obstructive sleep apnea (OSA), combined with inadequate supply of sleep specialists and constraints on polysomnography resources, has prompted interest in alternative models of care to improve access and treatment effectiveness. In appropriately selected patients, ambulatory clinical pathways and use of nonphysicians or primary care providers to manage OSA can improve timely access and costs without compromising adherence or other clinical outcomes. Although initial studies show promising results, there are several potential barriers that must be considered before broad implementation, and further implementation research and economic evaluation studies are required.

Adherence to diabetes care processes at general practices in the National Capital Region-Delhi, India.

Aim:To assess the level of adherence to diabetes care processes, and associated clinic and patient factors at general practices in Delhi, India.Methods:We interviewed physicians (n = 23) and patients with diabetes (n = 406), and reviewed patient charts at general practices (government = 5; private = 18). We examined diabetes care processes, specifically measurement of weight, blood pressure (BP), glycated hemoglobin (HbA1c), lipids, electrocardiogram, dilated eye, and a foot examination in the last one year. We analyzed clinic and patient factors associated with a number of care processes achieved using multilevel Poisson regression model.Results:The average number of clinic visits per patient was 8.8/year (standard deviation = 5.7), and physicians had access to patient's previous records in only 19.7% of patients. Dilated eye exam, foot exam, and electrocardiogram were completed in 7.4%, 15.1%, and 29.1% of patients, respectively. An estimated 51.7%, 88.4%, and 28.1% had ≥1 measurement of HbA1c, BP, and lipids, respectively. Private clinics, physician access to patient's previous records, use of nonphysicians, patient education, and the presence of diabetes complication were positively associated with a number of care processes in the multivariable model.Conclusion:Adherence to diabetes care processes was suboptimal. Encouraging implementation of quality improvement strategies like Chronic Care Model elements at general practices may improve diabetes care.

The Use of Non-Physicians in Cosmetic Dermatology: Legal and Regulatory Standards

The demand for cosmetic medical procedures continues to rise. Dermatologists are increasingly employing non-physicians, and medical spas are hiring individuals without a medical license to meet this demand. This new frontier in medicine has opened the door to a number of legal and regulatory issues regarding scope of practice and appropriate physician supervision of these procedures. Further confounding the matter is state-by-state variation in laws and a lack of federal oversight. We discuss some of the most salient factors clinicians need to be cognizant of in this rapidly evolving field of cosmetic dermatology. Physicians must be aware of the pertinent legal issues they face when using non-physicians in their practice or when acting as the medical director of cosmetic procedures taking place in a non-medical setting. As a medical community, we should be aware of the risks and benefits of non-physicians performing cosmetic procedures on patients.

Commentaries on health services research

Commentaries on health services research

Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication

Most existing estimates of the shortage of primary care physicians are based on simple ratios, such as one physician for every 2,500 patients. These estimates do not consider the impact of such ratios on patients' ability to get timely access to care. They also do not quantify the impact of changing patient demographics on the demand side and alternative methods of delivering care on the supply side. We used simulation methods to provide estimates of the number of primary care physicians needed, based on a comprehensive analysis considering access, demographics, and changing practice patterns. We show that the implementation of some increasingly popular operational changes in the ways clinicians deliver care-including the use of teams or "pods," better information technology and sharing of data, and the use of nonphysicians-have the potential to offset completely the increase in demand for physician services while improving access to care, thereby averting a primary care physician shortage.

Classifying perinatal mortality using verbal autopsy: is there a role for nonphysicians?

BackgroundBecause of a physician shortage in many low-income countries, the use of nonphysicians to classify perinatal mortality (stillbirth and early neonatal death) using verbal autopsy could be useful.ObjectiveTo determine the extent to which underlying perinatal causes of deaths assigned by nonphysicians in Guatemala, Pakistan, Zambia, and the Democratic Republic of the Congo using a verbal autopsy method are concordant with underlying perinatal cause of death assigned by physician panels.MethodsUsing a train-the-trainer model, 13 physicians and 40 nonphysicians were trained to determine cause of death using a standardized verbal autopsy training program. Subsequently, panels of two physicians and individual nonphysicians from this trained cohort independently reviewed verbal autopsy data from a sample of 118 early neonatal deaths and 134 stillbirths. With the cause of death assigned by the physician panel as the reference standard, sensitivity, specificity, positive and negative predictive values, and cause-specific mortality fractions were calculated to assess nonphysicians' coding responses. Robustness criteria to assess how well nonphysicians performed were used.ResultsCauses of early neonatal death and stillbirth assigned by nonphysicians were concordant with physician-assigned causes 47% and 57% of the time, respectively. Tetanus filled robustness criteria for early neonatal death, and cord prolapse filled robustness criteria for stillbirth.ConclusionsThere are significant differences in underlying cause of death as determined by physicians and nonphysicians even when they receive similar training in cause of death determination. Currently, it does not appear that nonphysicians can be used reliably to assign underlying cause of perinatal death using verbal autopsy.

Diabetes care: Model for the future of primary care

ObjectiveTo review relevant trends threatening primary care and the evidence supporting use of nonphysicians in primary and chronic care of patients with diabetes. Data sourcesCurrent medical and pharmacy literature as selected by authors. SummaryThe care needed by patients with diabetes does not fit well into our current medical model for primary care, and an adequate supply of physicians is not likely to be available for primary care roles in coming years. Patients with diabetes who are placed on evidence-based regimens, are educated about their disease, are coached in ways that motivate them to lose weight and adopt other therapeutic lifestyle changes, and are adhering to and persisting with therapy will soon have improved clinical parameters. These quickly translate into fewer hospitalizations and emergency department visits. A growing body of literature supports the use of pharmacists and other nonphysicians in meeting the needs of patients with diabetes. Pharmacists should join nurse practitioners, specially trained nurses, and physician assistants as integral members of the health care team in providing care to patients with diabetes and, by logical extension, other chronic conditions. ConclusionDemand for primary care is likely to outstrip the available supply of generalist physicians in the coming years. In addition to nurse practitioners and physician assistants, pharmacists should be considered for key roles in future interdisciplinary teams that triage and provide direct care to patients, including those with diabetes and other chronic conditions.

The Neglect of the Global Surgical Workforce: Experience and Evidence from Uganda

I read the article by Ozgediz et al. entitled ‘‘The Neglect of the Global Surgical Workforce: Experience and Evidence from Uganda’’ [1]. I want to share my experience and contribute my thoughts on this serious problem facing rural populations in sub-Saharan Africa. I had conducted a similar health facility assessment and survey for the government of Cross River State (CRS) in Nigeria in 2000 (unpublished report). I have also worked in Mozambique and witnessed the surgical skill and volume of surgical services rendered by nonphysician surgical technicians called ‘‘tecnicos de cirurgia’’ in Portuguese. I have undergone surgical training as part of my residency training in General Practice/Family Medicine (GP/FM)-original Nigerian Model, and served in peripheral/rural hospitals in Nigeria and Mozambique at the level of Principal Medical Officer/Medical Director for more than 10 years before going into public health medicine. I am therefore not writing as a specialist surgeon but as someone who has served the rural population as a generalist physician with surgical and obstetric training and skills. My review had the same findings as Ozgediz et al. had in Uganda. There were two specialist surgeons for the 18 general hospitals (district hospitals) serving a population of more than 3 million people, 90% living in rural areas. The teaching hospital in the capital city is home to 95% of all the medical doctors in the State (province). This is because most of the doctors at the teaching hospital in the postgraduate residency in various surgical specialties (and other specialties) stay in training an average of 8 years (some stay up to 10 years). In their study in Mozambique Kruk et al. [2] have shown that training more midlevel health workers in surgery is a good investment and a way to respond to the shortage in the surgical workforce. In Nigeria, the surgical and obstetric and gynecologic training component in GP/FM residency (12 months), if maintained as the originally intended, is an equally good investment and way to increase surgical services in rural populations. It is obvious that one way of improving the surgical workforce in Africa is to promote short postgraduate (PG) training programs and intensive rural clerkship at the undergraduate level. A PG training program of 18 months in general surgery, 18 months in OG-GYN, and 18 months in anesthesia, all leading to government and medical council licentiates as specialists and designed for peripheral hospital career development, will go a long way to attract and retain trained specialists in rural and peripheral hospitals. One reason why the Mozambique program has worked is because of the recognition and respect given to these ‘‘tecnicos de cirurgia’’ by the government, medical council, and medical doctors (MD), both generalist physicians and specialists. In fact, the generalist MDs who spend two compulsory years in rural hospitals after graduation in Mozambique refer surgical cases to the ‘‘tecnicos’’ and some of the MDs even get surgical tutoring from the ‘‘tecnicos.’’ Finally, the above proposals of shortening surgical training for MDs or the use of nonphysicians are not substitutes for long surgical training and subspecialist programs. They are intended to produce more hands for basic and life-threatening surgical services until such a time when all the development indices have spread to engulf the rural population. The short training programs will then be adjusted accordingly. The UK recently E. Monjok (&) Institute of Community Health, University of Houston, Texas Medical Center, 1441 Moursund St. Suite 119, Houston, TX 77030, USA e-mail: emonjok@uh.edu

Screening for colorectal cancer with flexible sigmoidoscopy by nonphysician endoscopists

PURPOSE: Screening with sigmoidoscopy reduces the risk of death from colorectal cancer. Only 30% of eligible patients have undergone sigmoidoscopy, in part because of a limited supply of endoscopists. We evaluated the performance and safety of screening sigmoidoscopic examinations by trained nonphysician endoscopists in comparison with board-certified gastroenterologists. SUBJECTS AND METHODS: Asymptomatic patients 50 years or older without evidence of fecal occult blood and no personal history or family history of a first-degree relative with colorectal cancer under age 55 years were offered sigmoidoscopy. All examinations were performed either by a gastroenterologist or a trained nonphysician endoscopist at a staff model health maintenance organization. Outcomes included the depth of examination, number and histology of polyps, and complications. RESULTS: Nonphysicians performed 2,323 sigmoidoscopic examinations, and physicians performed 1,378 examinations. The mean (±SD) depth of sigmoidoscopy examinations performed by nonphysicians was 52 ± 10 cm compared with 55 ± 9 cm ( P <0.001) in physicians. Nonphysicians detected neoplastic polyps in a greater proportion of patients (7.8%) than physicians (5.8%), but this difference was not significant after adjusting for differences in the age, sex, and family history of the patients ( P = 0.35). No major complications occurred. The cost per examination, including the nonphysician training cost, was lower for nonphysicians ($186 per examination) than for physicians ($283 per examination). CONCLUSIONS: Appropriately trained nonphysicians may be capable of performing safe and effective screening for colorectal cancer with flexible sigmoidoscopy. An increased use of nonphysicians to perform sigmoidoscopy may increase the availability and reduce the cost of the procedure.

Evolution of echocardiography.

The evolution of echocardiography has been interesting and dramatic. The technology has grown and has become an integral part of the practice of cardiology. As with all technology, there are advantages and disadvantages. The principal disadvantage is the fact that education and training are imperative to provide high-quality examinations and proper interpretations. In addition, many of the diagnoses are still qualitative and subjective. The principal advantage is the amazing versatility of this technology. The wealth of information that can be provided both noninvasively with a transthoracic examination and invasively with either transesophageal or intravascular ultrasound is tremendous. The anatomic and physiological data provided frequently give definitive diagnoses. If performed properly and for the right reason, this test should be very cost effective and should be a major asset in the coming era of medical cost containment. There are many technological advances that should enhance this information. With technology such as digital recordings, it is hoped that the clinicians will have better access to these data and will be more comfortable in interacting with this important diagnostic tool.

The Medical Significance of the Narcotic SomsanitRDuring Disasters

Major disasters, during which large numbers of injured must be hospitalized, require specific medical measures. To obtain the most efficient results, the simplest means must be used at the site of the disaster to provide: the prevention of pain and shock; the maintenance of vital metabolic functions; the administration of local and general anesthesia; and the medical supervision of the transport of critically injured and the post-operative care of the patients. It must be taken into account that the use of non-physicians to help anesthesiologists may be necessary. These individuals work under the direction of the physician.Pain relief must be provided by sedatives and analgesics which cause minimal central respiratory depression, no increased stimulation to cardiac patients, and no increase in intracranial pressure in head injuries. An additional requirement is that no unwieldly apparatus is required. These criteria are met with the narcotic, sodium-4-hydroxybutyrate (SomsanitR).In 1950, Roberts and Frankel (1) investigated the effects of gamma-aminobutyric acid (GABA) on the regulating system for the sleep rhythm of the mammalian cerebrum. Two years later, Roberts and his co-workers (2-4) showed that GABA is reduced in the brain by a specific transaminase to a semial-dehyde of succinic acid (succinylsemialdehyde) and this, in turn, is reduced to a dehydrogenase, which is probably identical with lactate dehydrogenase, to gamma- or 4-hydroxybutyric acid. Since parenterally administered amino butyric acid is unable to pass through the blood-brain barrier, Laborit and his team (5,6) searched for derivatives which could reach the central nervous system via the cardiovascular system and found that 4-hydroxy-butyric acid has this property.

Pelvic examination instruction and the doctor-patient relationship.

Nonphysician women instructors from a women's health center taught the pelvic examination to second-year Harvard Medical School medical students. They demonstrated the procedure and acted as subjects for the students' examinations. In addition to teaching standard techniques, the instructors showed how the patient could be offered explanation of the procedure and information about her health during the performance of the examination. The exercises are described in terms of their implications for teaching the doctor-patient relationship during physical examination instruction. The following aspects are discussed: the use of nonphysicians as "practical instructors," improving attitudes toward women and promoting patient autonomy, and redefining aspects of the student-patient relationship in clinical training.

The Cost of Auditing Outpatient Records

When patient records are to be auditied in a program designed to assess the quality of medical care rendered, careful consideration must be given to the cost of the system implemented. Structured data collection and a defined treatment plan are advantageous in facilitating the use of nonphysicians for the majority of the audit. A system using checklists to ensure adequate recording of subjective and objective data and a defined treatment plan for a common symptom complex were implemented by physicians and physician's assistants with a patient load averaging more than 1,000 patient contacts per week in a general medical clinic at Duke University Medical Center. Audit was subsequently accomplished at a cost of 96 cents per record. To reduce this cost, more efficient methods of selecting records for audit should be developed.

Decision Modeling in Case Selection for Medical Utilization Review

A situation is described in which large amounts of physician time are being spent reviewing patient records. In order to promote efficient use of their time, careful selection of the cases they review is called for. A methodology is developed to elicit criteria from physicians for the use of nonphysicians in case selection. The methodology, called the direct approach to approximate decision models, involves the use of interviews and questionnaires asking the physician directly about the criteria he uses, rather than inferring his criteria by indirect means. He is asked to interpret these criteria in a way that will allow a nonphysician to use them for case selection so that the resulting model is an approximation to the physician's decision process.