Optimizing the response to epidemics of meningococcal meningitis: report of a workshop of experts at CERMES (Niamey, Niger, 12th to 14th January 1998)

The effect of the addition of emergency medicine residency on the use of ancillary testing in a teaching hospital's emergency department (ED) staffed previously by emergency medicine board-certified physicians was studied. Prospectively, the utilization of three common ancillary tests (electrolyte levels, X-ray, or electrocardiogram) for four common chief complaints of patients eventually discharged from the ED was evaluated. A 12-month period before and a 15-month period after introduction of an emergency medicine residency program were compared. The mean number of ancillary tests utilized by the ED attending physicians working with residents was compared with the mean number of tests generated by the same physicians (all emergency medicine board-certified) for the same complaints in the year before the residents' arrival. There was no significant difference in test use before and after introduction of the residency (P = .66). Faculty use of tests was also unaffected by the concurrent presence of residents (P = .068). These results show that the use of testing for a sample of common ED complaints was not affected by the introduction of emergency medicine residents to a previously emergency medicine board-certified staff in one community teaching hospital.     

The clinical utility of the Safe Times Questionnaire

PURPOSE: To evaluate a valid, reliable self-report health behavior screening instrument, the Safe Times Questionnaire (STQ), in a clinical setting. METHODS: One hundred and fifty-two patients at a primary care health center completed the STQ and were randomized into two groups; physicians in the "STQ group" (79 patients) used the STQ while physicians in the "interview group" (73 patients) were blinded to the STQ. Physicians rated each patient on their need for intervention in nine topic areas. Patients then had a psychological interview and were rated on the same topic areas. RESULTS: The total time of the patient visit was significantly longer in the interview group than in the STQ group. Physicians in the STQ group had significantly higher accuracy in identification of subjects at risk for depression and family conflict. CONCLUSIONS: The Safe Times Questionnaire is a potentially useful instrument to efficiently screen adolescents.     

Benchmarking surgeon satisfaction at academic health centers: a nationwide comparative survey

BACKGROUND: Forty-six academic health centers (AHCs) belonging to the University HealthSystem consortium joined forces to compare the efficiency of their surgical services and to identify best practices. In addition to measures of operational performance, surgeon satisfaction with the surgical services provided was measured by using a standardized questionnaire. METHODS: From hospital records, indicators of the efficiency of surgical services were collected in three main areas: scheduling, preoperative testing and assessment, and the intraoperative process. Responding to a mail questionnaire, a sample of surgeons rated their satisfaction with key aspects of surgical services including scheduling, operating room staff, and equipment/supplies. On the basis of a review of the operational measures and the survey results, high performers were identified. Site visits were made to several of these high performers to uncover the critical factors responsible for their success. RESULTS: The survey revealed distinct variations in surgeon satisfaction across the participating institutions. Numerical benchmarks were obtained for surgeon satisfaction with each key component of surgical services. Scheduling was the most important component of overall surgeon satisfaction, explaining 71% of the variance in the rating of overall satisfaction with surgical services. High operational efficiency and high surgeon satisfaction were not incompatible. Several of the participating institutions were able to achieve both. These results were disseminated to all of the participants at a national meeting as well as in written form. CONCLUSIONS: The surgeon satisfaction survey allowed the participants to establish benchmarks for surgeon satisfaction for each key component of the surgical services they receive. The site visits revealed several common characteristics of highly efficient surgical services. Taken by themselves, the participating institutions might have been reluctant to consider adopting these best practices for fear of alienating the surgical staff. The availability of data on surgeon satisfaction showed the participants that these best practices can coexist with high levels of surgeon satisfaction. This has helped to promote their adoption by the other participating institutions.     

A prospective study to assess the effect of ambulatory teaching on patient satisfaction

PURPOSE: To assess the effect of ambulatory teaching on patients' satisfaction. METHOD: In 1996, 103 adult patients presenting to the Walter Reed General Medicine Walk-in Clinic completed a patient-satisfaction questionnaire immediately following their visits, during which they were initially seen by a trainee (third-year medical student or intern) and then seen by a faculty preceptor. The questionnaire included five items from the validated Medical Outcomes Study (MOS)-9 questionnaire as well as two open-ended questions. Fourteen staff physicians, 13 students (49% of the visits), and 11 interns (51% of the visits) participated in the study. Satisfaction was analyzed by level of training, and the responses from the study patients were compared with the responses from 372 usual-care (i.e., non-teaching) patients from the same clinic, using the chi-squared test. RESULTS: The study patients were typically pleased with their encounters, rating their overall satisfaction as excellent (61%), very good (29%), or good (9%). Nearly two thirds of the patients rated their satisfaction with waiting time to be very good or excellent. Compared with the usual-care patients, the study patients reported equal or greater satisfaction for all five MOS-9 items. Ninety-five percent of the study patients said they would be willing to be seen by a trainee-staff team on future visits. There was no difference in patient satisfaction by trainee level. The study patients cited enhanced interaction (45%), enhanced education (34%), and improved care (26%) as benefits of trainee-involved care, and increased waiting time (18%) and worse care (5%) as drawbacks. CONCLUSION: The results of this study suggest that ambulatory teaching does not adversely affect patient satisfaction, regardless of trainee level, and that patients who have been seen by trainee-staff teams are willing to experience such encounters again.     

Wellness Promotion in Persons With Disabilities: Physicians' Personal Behaviors, Attitudes, and Practices.

Objective: To examine physicians' attitudes, personal wellness behaviors, and wellness promotion practices with their patients who were living with a disability. Design and Participants: A 20-item survey was mailed to 1,200 physicians from a national stratified random sample. Responses were received from 417 physicians (34.8% response rate). Results: Physicians who reported engaging in high levels of wellness promotion with their patients with disabilities rated wellness promotion as more important and reported feeling more competent and responsible. Several barriers and incentives to wellness promotion were reported. Conclusions: Physicians' attitudes and perceived competencies may influence their wellness promotion activities with their patients with disabilities. Medical training modules and other methods may increase physicians' wellness promotion activities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

General satisfaction and satisfaction with nursing communication on an adult psychiatric ward

A client satisfaction survey was undertaken on an adult psychiatric admission ward in Sheffield, England, being sent to all clients discharged from the ward over 12 months. The questionnaire consisted of a general satisfaction element, and two questions asking about satisfaction with nursing communication. The response rate was 81 from 199 forms sent. General satisfaction levels were lower than for a sample of 3120 mainly out-patient psychiatric clients in the USA. Satisfaction with nursing communication was significantly correlated with general satisfaction. The survey allowed the number of dissatisfied clients to be identified, and their views highlighted. One aspect often reported by dissatisfied clients was a perceived lack of time from staff. The importance of nursing communication with respect to client satisfaction is highlighted by the study.     

Boron neutron capture therapy: re-irradiation response of the rat spinal cord

PURPOSE: To examine factors that influenced, positively or negatively, the specialty career choices of physicians trained at Yale-New Haven Hospital (YNHH) from 1929 to 1994. METHOD: The authors sent questionnaires to 4,888 physicians who had trained or were training in YNHH-sponsored residency programs. The physicians rated 36 factors posited to be influenced in career choice on a seven-point Likert scale from very negative to very positive. The authors compared the means of each factor's ratings by decade of medical school graduation. RESULTS: The most positively rated influences were similar in each decade from the 1920s to the 1990s. These influences shared characteristics of intellectual curiosity ("intellectual content of the specialty" and "challenging diagnostic problems"), altruism ("interest in helping people" and "opportunity to make differences in people's lives"), and personal identity ("consistent with personality" and "possess the required skill or ability"). Negative factors, such as "demands on time and effort," "stress in the field," and "malpractice costs," were also consistently rated throughout the decades. CONCLUSION: The reasons that physicians choose certain specialty careers have not changed significantly over the past 65 years despite all the changes that have occurred in medicine. Physicians continue to seek professional opportunities that are viewed as intellectually challenging and of benefit to others.     

Is gatekeeping better than traditional care? A survey of physicians' attitudes

CONTEXT: Nearly all managed care plans rely on a physician "gatekeeper" to control use of specialty, hospital, and other expensive services. Gatekeeping is intended to reduce costs while maintaining or improving quality of care by increasing coordination and prevention and reducing duplicative or inappropriate care. Whether gatekeeping achieves these goals remains largely unproven. OBJECTIVE: To assess physicians' attitudes about the effects of gatekeeping compared with traditional care on administrative work, quality of patient care, appropriateness of resource use, and cost. DESIGN: Cross-sectional survey of primary care physicians SETTING: Outpatient facilities in metropolitan Boston, Mass. PARTICIPANTS: All physicians who served as both primary care gatekeepers and traditional Blue Cross/Blue Shield providers for the employees of Massachusetts General Hospital, Boston. Of the 330 physicians surveyed, 202 (61%) responded. OUTCOMES MEASURES: Physician ratings of the effects of gatekeeping on 21 aspects of care, including administrative work, physician-patient interactions, decision making, appropriateness of resource use, cost, and quality of care. RESULTS: Physicians reported that gatekeeping (compared with traditional care) had a positive effect on control of costs, frequency, and appropriateness of preventive services and knowledge of a patient's overall care (P<.001). They also felt that gatekeeping increased paperwork and telephone calls and negatively affected the overall quality of care, access to specialists, ability to order expensive tests and procedures, freedom in clinical decisions, time spent with patients, physician-patient relationships, and appropriate use of hospitalizations and laboratory tests (P<.001). Overall, 32% of physicians rated gatekeeping as better than traditional care, 40% the same, 21% gatekeeping as worse, and 7% were of mixed opinion. Positive ratings of gatekeeping were associated with fewer years in clinical practice, generalist training, and experience with gatekeeping and health maintenance organization plans. CONCLUSIONS: Physicians identified both positive and negative effects of gate-keeping. Overall, 72% of physicians thought gatekeeping was better than or comparable to traditional care arrangements.     

Skills that Iowa family physicians desire in a new physician partner

BACKGROUND AND OBJECTIVES: The importance of specific skills in primary care continues to be debated. As a result, there is not consensus on which skills need to be stressed during residency training. Our project asked community-based family physicians to rate the importance of specific skills in a new family physician partner. METHODS: Data were collected through a cross-sectional survey of all active members of the Iowa Academy of Family Physicians. Participants were surveyed by mail, using a list of 83 skills pertinent to primary care. Physicians were asked to rate the importance of a new member of their practice having the individual skills on this list. RESULTS: A total of 546 family physicians (67%) completed questionnaires. Fourteen skills (seven cognitive and seven psychomotor) were reported to be "essential" or "very important" by at least 80% of the physicians. A total of 43 skills were rated as "essential" or "very important" by at least 50% of responding family physicians. Many of the hospital-based procedural skills, particularly those used in an intensive care setting, were rated as less important. The importance ratings of many skills were associated with the physicians' ages, size of their primary hospitals, and availability of other medical specialties. CONCLUSIONS: Family physicians tended to rate office-based procedural skills, counseling skills, and management skills as "essential or very important" to their practices. These rating might be used to guide residency training in family practice.     

Effects of supervision in the training of nonprofessional crisis-intervention counselors.

Evaluated 3 major models currently used by crisis intervention centers to train and supervise nonprofessional counselors. Training groups included preservice training only (PSO), preservice training and delayed supervision (PSD), and preservice training and immediate supervision (PSI). The 4 nonprofessional counselors in each group saw actual clients of a walk-in clinic and were compared on (a) pattern and timing of interventions, (b) self-evaluations of their interview performance, and (c) client evaluations of treatment received. Except for explicit empathy, the groups did not differ in frequencies of counselor statements. Across time periods, only PSI counselors' response patterns began to approximate those of experienced crisis counselors. PSI patterns began to approximate those of experienced crisis counselors. PSI counselors rated their interview performances most positively, followed by PSD and then PSO counselors. Clients reported greatest satisfaction with treatment received from PSI counselors. Findings indicate that most of the learning by nonprofessionals occurs during ongoing supervision. The practice of relying on pretraining may promote harmful outcomes for volunteers and may account for the common problem of high staff attrition. (17 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Measuring the quality and quantity of information-giving to in-patients

Community health councils (CHCs) were set up in the United Kingdom in 1974 as part of the reorganization of health care delivery. They were intended to have a 'watch dog' function, monitoring the quality of health care in their own district and acting as a link between the providers of care and the public, who are the health care consumers. This paper describes a year-long survey undertaken by one CHC to monitor the quality of information-giving in acute hospital care. A large sample of 1500 discharged patients were sent questionnaires relating to satisfaction with information-giving, and a good response rate was achieved. Results indicate a generally high level of satisfaction, particularly relating to information about surgical and other technical procedures. Information was less satisfactory about non-technical aspects of care and about administrative procedures.     

The influence of the concentration of volatile anesthetics on the stapedius reflex determined intraoperatively during cochlear implantation in children

STUDY OBJECTIVE: To evaluate the impact of a protocol on partner abuse (PA) at increasing identification and improving acute management of abused women by emergency department (ED) staff. METHODS: A community intervention trial compared two public hospital EDs at baseline and following implementation of a PA intervention. The intervention involved training staff at one ED in a protocol for the identification and acute management of abused women. Outcomes were assessed by reviewing a random sample of women's medical records. Identification of PA was assessed for each record on a yes/no basis. Identified cases were classified as 'confirmed' or 'suspected' PA. Acute management was assessed by ascertaining staff documentation of abuse and use of interventions. RESULTS: Approximately equal numbers of records were reviewed at each ED, pre and post implementation (total n = 8,051). Eighty-nine per cent of ED staff were trained. No difference in the overall identification of PA was found (chi 2 = 0.13, p = 0.72), but logistic regression analyses showed other significant changes. At the intervention site, there was an increase in confirmed cases of PA (chi 2 = 7.6, p = 0.006), a trend towards increased documentation (chi 2 = 3.5, p = 0.06) and a significant increase in interventions offered (chi 2 = 13.8, p = 0.002). Changes at the comparison site failed to reach significance. CONCLUSION: Implementation of this protocol resulted in a moderate increase in confirmed cases of abuse and improved the acute management offered to identified victims. The findings reinforce recommendations for widespread implementation of training and protocols to address partner abuse.     

Subordinate participation and reactions to the appraisal interview.

Conducted 2 studies which examined relationships of subordinate participation in an appraisal interview to reactions to the appraisal and subordinate satisfaction. In Study 1, 25 managers rated their last appraisal on (a) helpfulness and (b) the Wexley et al measure of psychological participation, and then rated their overall satisfaction with supervision. The lack of significant intercorrelations among the psychological participation items indicated that different concepts of participation were represented. Items representing participation in interaction correlated significantly with appraisal helpfulness and satisfaction, while control of goal setting did not correlate significantly. In a 2nd field study, 56 hourly employees and 1st-level managers in a bank rated (a) their appraisal on certain characteristics, (b) their satisfaction with the appraisal, and (c) their job satisfaction. The invitation to participate was most predictive of appraisal satisfaction. The occurrence of goal setting correlated significantly with both appraisal and job satisfaction. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Senior house officer training: are overseas graduates treated differently?

In a survey of senior house officers' (SHOs') satisfaction with training, overseas graduates rated their posts at least as highly as British graduates. Overseas graduates were older, more experienced and more likely to be training in district general hospitals.     

Nonverbal behaviors of "good" and "poor" counselors.

Determined whether skills involved in decoding of nonverbal behaviors are related to the clinical skills of the beginning counselor. Two groups of master's level counselor-trainees (N?=?24) served as Ss. One group was judged by the practicum supervisor as "good" (top 20%) and the other was judged as "poor" (bottom 20%) in interviewing skills. Each counselor conducted a 21-min videotaped interview with a client. The counselor's nonverbal behaviors were rated by the client (using the Behavior Rating Form) and were analyzed by 2 training judges on 4 dimensions of nonverbal behaviors. Decoding skills, as measured by a film test (the Profile of Nonverbal Sensitivity), were compared between good and poor groups. Also, client- and judge-rated counselor nonverbal behaviors were compared with decoding skills. Results show no significant difference between good and poor counselors in nonverbal decoding abilities. Counselor nonverbal behaviors, as rated by judges, showed no significant correlations with decoding skills; however, client ratings were inversely related to nonverbal decoding skills. (7 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Influence of separate interviews on clinicians' evaluative perceptions in family therapy.

The parents and identified patients of 68 families in both conjoint and separate assessment interviews were rated by 48 clinical staff and students according to the semantic differential technique. Each evaluating clinician saw the entire family in a conjoint interview and either the parents or the child identified as the patient during a separate interview. As predicted, clinicians who had separately interviewed identified patients rated them more favorably than did clinicians who had instead conducted separate interviews of parents. Ratings of parents, however, were unaffected by the separate interview variable. (4 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The use of empiric clinical data in the evaluation of practice guidelines for unstable angina

OBJECTIVE: To determine the applicability to emergency department (ED) clinical practice of a nationally disseminated practice guideline on the disposition of patients with a diagnosis of unstable angina, and to determine the potential impact of the guideline on hospital admissions and demand for intensive care beds. DESIGN: Application of guideline criteria for ED disposition decisions to a validation sample derived from a prospective clinical trial. SETTING: Five hospitals, including 2 urban general teaching hospitals, 2 urban tertiary care university hospitals, and 1 suburban university-affiliated community hospital. PATIENTS: A consecutive sample of 457 patients who presented with symptoms suggestive of acute cardiac ischemia and who had "unstable angina" or "rule out unstable angina" diagnosed by ED physicians. Greater than 90% of eligible patients were enrolled in the clinical trial; follow-up data sufficient for assignment of a definitive diagnosis were obtained for 99% of subjects. MAIN OUTCOME MEASURES: Acute myocardial infarction and unstable angina, based on blind review of initial and follow-up clinical data, including cardiac enzyme levels and electrocardiograms. After completion of the trial, without knowledge of final diagnosis or outcome, the investigators classified patients into risk groups specified by the unstable angina guideline. RESULTS: Of subjects with an ED diagnosis of unstable angina, only 6% (n=28) met the guideline's criteria corresponding to low risk for adverse events and were therefore suitable for discharge directly to home. Fifty-four percent (n=247) met the intermediate-risk criteria; 40% (n=182) met the high-risk criteria and were identified as requiring admission to an intensive care unit. Actual ED disposition differed from guideline recommendations in 2 major areas: only 4% (1/28) of low-risk patients were discharged to home with outpatient follow-up, and only 40% (72/182) of high-risk patients were admitted to an intensive care unit. CONCLUSIONS: Although the guideline was intended to reduce hospitalization by identifying a low-risk group, the small size of this group among ED patients suggests that little reduction in hospitalization can be expected. Indeed, the guideline may increase demand for the limited number of intensive care beds to accommodate patients with unstable angina considered high-risk but currently placed elsewhere. These results emphasize the need to use empiric data from target clinical settings to assess the likely actual impact of guidelines on clinical care prior to national dissemination.     

Postoperative nausea and vomiting. A retrospective analysis in patients undergoing elective craniotomy

CONTEXT: Managed care and capitation have placed new responsibilities on primary care physicians, including formally acting as "gatekeepers" for specialty services and tests. Previous studies have not examined whether primary care physicians who provide services to patients under many coverage arrangements feel differently about caring for patients covered under capitation vs those covered through more traditional forms of insurance. An understanding of whether California primary care physicians feel that they deliver a different level of quality to capitated patients could help signal whether variations in care for patients with different coverage forms are evolving. OBJECTIVE: To evaluate whether primary care physicians in California capitated groups report different satisfaction levels with quality of care for patients in their overall practice than for patients covered by capitated contracts and to examine whether physicians' satisfaction with capitated care quality is influenced by the characteristics of the practice setting. DESIGN: Cross-sectional questionnaire. SETTING: A total of 89 California physician groups with capitated contracts. PARTICIPANTS: A total of 910 primary care physicians (80% response rate). MAIN OUTCOME MEASURE: Satisfaction with 4 aspects of quality of care provided to patients covered by capitated contracts vs patients overall. RESULTS: Physicians reported lower satisfaction with all 4 aspects of care for patients covered by capitated contracts than for patients in their overall practice: 71% were very or somewhat satisfied with relationships with capitated patients (compared with 88% for overall practice), 64% were very or somewhat satisfied with the quality of care they provided to capitated patients (compared with 88% for overall practice), 51% were very or somewhat satisfied with their ability to treat capitated patients according to their own best judgment (compared with 79% for overall practice), and 50% were very or somewhat satisfied with their ability to obtain specialty referrals (compared with 59% for overall practice) (P< or =.001 for all comparisons). Being in a medical group practice (vs an independent practice association) and having a larger percentage of capitated patients were independently associated by multivariate analysis with higher levels of satisfaction with capitated quality of care (P< or =.005). CONCLUSION: These California primary care physicians were less satisfied with the quality of care they deliver to patients covered by capitated contracts than with the quality of care they deliver to patients covered by other payment sources. However, those in medical group practices and with a higher percentage of capitated patients were more satisfied with capitated care. National expansion of capitation should be accompanied by efforts to ensure that the satisfaction of practicing physicians with the care they deliver does not decline.     

Androgen receptor gene mutations in prostate cancer. Implications for disease progression and therapy

Increasing numbers of cancer survivors and the tradition of long-term follow-up in the outpatient clinic has resulted in overcrowded oncology clinics and long waiting times. Little is known about patients' perceptions of their clinic attendance. This survey of 252 oncology patients investigated patients' satisfaction with the clinic, anxiety associated with clinic attendance and the strengths and weaknesses of the oncology service. Results demonstrated high levels of satisfaction. Far from being perceived as anxiety-provoking, the clinic was looked upon as a valuable source of reassurance, 92% of patients reporting they were 'always' or 'usually' reassured as a consequence of their visit. Qualitative data showed that clinic staff were the most important source of satisfaction. Waiting was overwhelmingly the worst aspect of the clinic, described by 27% of patients as 'excessively long'. One-fifth of the total sample had attended the clinic for 10 years or more and over a third of this group reported they would be worried at the prospect of being discharged to the care of their general practitioners. Despite disadvantages associated with long waits, the clinic was perceived as providing a valuable source of reassurance which a proportion of patients were clearly reluctant to be without.     

Who applies to regional review boards and what are the outcomes?

OBJECTIVES: Obtaining accurate and representative patient-centered data may be difficult among poor, inner-city patients because of changing addresses, variable access to telephones, and a higher prevalence of illiteracy than in the populations in which many survey instruments were developed and tested. Assumptions about the usefulness of mailed surveys versus telephone interviews may not hold for the urban poor. Therefore, identifying the most efficient mode of survey administration in this population becomes an important methodological question. METHODS: We conducted a randomized trial of patients discharged from the inpatient medicine service of an urban teaching hospital to compare telephone interview with mailed self-administration of a detailed instrument for measuring patients' experiences with hospital care. Our primary outcomes were response rate, missing data, and data collection costs. Patients were excluded if they were not discharged to home or were mentally or physically unable to complete mailed or telephone interviews. The research assistant contacted eligible patients while hospitalized, informed them of the postdischarge survey, and obtained current phone numbers and addresses. Patients then were randomized to receive a 116-item satisfaction survey via one of two survey methods: mail-first (mailed surveys with follow-up on nonrespondents by telephone) or telephone-first (telephone interviews with follow-up of nonrespondents by mail). RESULTS: Of the 252 patients enrolled, 130 were randomized to the mail-first and 122 to the telephone-first method. Response rates were higher with the telephone-first (73%) compared with the mail-first method (50%; P < 0.0001). Surveys obtained by the telephone-first method had fewer missing data (0.7 +/- 2.39) for those items not involved in skip patterns compared with the mail-first method (7.1 +/- 12.3; P < 0.001) and were 42% less expensive per completed survey ($26.32 versus $37.35; P < 0.0001). CONCLUSIONS: In this survey of patients served by an urban teaching hospital, a strategy of telephone interviews with mail follow-up proved less expensive and yielded a higher response rate with more complete data than using a method where mailed surveys were followed by back-up telephone interviews. In addition, we believe that the improved response rate for telephone interviews compared with those reported in the literature for similar populations is the result of informing inpatients of the survey and obtaining telephone numbers and addresses in the hospital.