Effects of Peer-Review Groups on Physicians’ Practice

Background: Peer-review groups are often considered to be an effective means of improving routine practice at the primary health care level. In contrast, little evidence has been published proving the efficacy of peer-review groups in controlled studies.

Objectives: This study evaluates the effects of peer-review groups of primary-care physicians on process quality of diabetes care, especially the screening of retinopathy, nephropathy and peripheral neuropathy.

Methods: Prospective controlled study, assessment of office-based documentation of diabetes-related data in a random sample of 25 patients per practice initially and after one year in the intervention and the control group.

Intervention: Primary-care physicians from ten practices participated in five sessions of a structured peer-review group on the subject of diabetes. Control: Seven primary-care physicians met once to discuss the results of the first assessment of office-based documentation of diabetes-related data.

Results: Records of 239 patients in the intervention group and 164 patients in the control group could be evaluated. Initially, in the patients’ charts results of screening for diabetic foot complications could hardly be detected: In the intervention group a result of pallaesthesia screening with a tuning fork was documented in 0.4% of diabetic patients and in 4.9% in the control group. Results of screening for retinopathy were documented in 8.4 resp. 5.5%, results of screening for microalbuminuria in 1.2 vs. 8.5% per year. After intervention, relevant improvements were observed in the intervention group: Documentation of screening for pallaesthesia increased up to 35.1% (+34.7% absolute), documentation of screening for retinopathy up to 32.2% (+23.8% absolute), whereas the results in the control group remained unchanged.

Conclusion: Structured peer-review groups following the described methodology are a means of changing physicians’ behaviour concerning the quality of office-based documentation. Further relevant improvements in process quality would be desirable. Other means (e.g. remuneration combined with control of process quality) should be evaluated.     

Factors Associated with Physicians’ Choice of Working Sector

Objective

To analyse factors affecting physicians’ choice to work in either the public or the private sector.

Method

We undertook a longitudinal data analysis in the years 1988, 1993, 1998 and 2003 (n = 12 909) using a multilevel modelling technique. Factors related to economic factors, physician identity, appreciation as well as demographic factors were hypothesised to influence sector choice.

Results

Physicians seem to make their career choices prior to graduation, at least to some extent. Wage levels, the physician’s personal characteristics and whether or not the physician knew his or her place of work before graduation were the key factors affecting the decision-making process in the years 1988, 1993, 1998 and 2003. Physicians for whom wages were important were less likely to choose the public sector. Also, physicians who regarded themselves as entrepreneurial preferred to work in the private sector. If a physician had worked in the public sector during his or her medical training before graduation, the probability of applying for a vacancy in the public sector was higher.

Conclusion

It is not only economic factors, such as salary, that are involved in the physician’s decision to choose the working sector.     

When Physicians Intervene in Their Relatives’ Health Care

Physicians often struggle with ethical issues surrounding intervention in their relatives' health care. Many editorials, letters, and surveys have been written on this topic, but there is no systematic review of its prevalence. An Ovid Medline search was conducted for articles in English, written between January 1950 and December 2010, using the key words family member, relatives, treatment, prescribing, physician, and ethics. The search identified 41 articles (editorials, letters, and surveys). Surveys were reviewed to explore demographics of these treating physicians and reasons for and against intervention. Physicians often intervene directly or indirectly in the health care of relatives. The most common reasons were convenience, cost savings, and the perception of having greater knowledge or concern than colleagues. Lost objectivity, fear of misdiagnosis, and inability to provide complete care were the main considerations against intervention. The characteristics of treating doctors were nonspecific. Most surveys recommend against this practice except for emergencies or minor ailments. This review included only a few surveys with small sample size and only assessed scientific literature written in English after 1950. Survey data may be biased by physicians' self-reporting. In conclusion, most doctors occasionally intervene in their relatives' care. The decision to do so is determined by multiple factors. Physicians should treat only short-term or minor illnesses within their scope of practice. Future research should evaluate doctors' attitudes toward their relatives, medical student feelings about treating family, and intervention frequencies of medical and nonmedical professionals.     

Insurers’ Influences on Attending Physicians of Workers Sick-listed for Common Mental Disorders: What Are the Impacts on Physicians’ Practices?

Purpose In many jurisdictions, general practitioners (GPs) play an important role in the sick-leave and return-to-work (RTW) process of individuals with common mental disorders (CMD). Since it is insurers that decide on workers’ eligibility for disability benefits, they can influence physicians’ ability to act. The nature of these influences remains little documented to date. The aim of this study was therefore to describe these influences and their impacts from the GPs’ perspective. Methods Semi-structured interviews were conducted with GPs having a diversified clientele (n?=?13). The interviews were audio-recorded, transcribed verbatim and analyzed according to thematic analysis principles. Results The results indicated that the GPs recognized insurers as influencing their practices with patients on sick leave for CMDs. The documented influences were generally seen as constraints, but sometimes as enablers. The impacts of these influences on the GPs’ practices depended on the organizational characteristics of their work context (such as limited consultation time) and other characteristics of their practice setting (such as lack of timely access to consultations with specialists). Conclusion The results brought three major issues to light: the quality of the information sent to insurers by GPs, the respect shown (or not) for workers’ care preferences, and the relevance of the specialized services offered to support workers’ RTW. These issues in turn reveal potential risks for workers, risks that need to be identified and recognized by all parties concerned if we are to come up with possible solutions.     

Female Farmworkers’ Perceptions of Heat-Related Illness and Pregnancy Health

ABSTRACT

Although agricultural workers have elevated risks of heat-related illnesses (HRI), pregnant farmworkers exposed to extreme heat face additional health risk, including poor pregnancy health and birth outcomes. Qualitative data from five focus groups with 35 female Hispanic and Haitian nursery and fernery workers provide details about the women's perceptions of HRI and pregnancy. Participants believe that heat exposure can adversely affect general, pregnancy, and fetal health, yet feel they lack control over workplace conditions and that they lack training about these specific risks. These data are being used to develop culturally appropriate educational materials emphasizing health promoting and protective behaviors during pregnancy.     

Physicians’ decision processes about the HPV vaccine: A qualitative study

BackgroundThe contemporary crisis of trust in vaccines has severely impaired acceptance of the HPV vaccine, especially in France, where its uptake culminated at 23.7% in 2018 (complete course at age 16). Physicians’ recommendations strongly influence its acceptance/refusal. Our study sought to understand the decision processes leading physicians to recommend this vaccine (or not).MethodsQualitative interviews of French physicians (general practitioners, gynecologists, and pediatricians). We first randomly selected doctors in a national register of medical professionals and then resorted to snowballing to build a convenience sample. We coded the interviews in a thematic analysis built both inductively and deductively from our research questions and data.ResultsTwo thirds of the participants (19/28) were favorable to HPV vaccination, some (4) opposed it, while the others were hesitant about recommending it. In explaining their opinions, most participants mentioned that they trusted the stakeholders within the vaccination system: the less trust they had, the more critical they were of the vaccine and the more importance they attributed to patients’ opinions. We identified three different ways they interacted with patients on this topic: informing and convincing; adapting to patients’ opinions; refusing compromise about vaccination. Crossing these various themes, we found 5 types of physicians: dissidents (mistrustful of the healthcare system and HPV vaccine), hesitant (finding it difficult to make up their minds about this vaccination), laissez-faire (letting patients decide by themselves, but very favorable to HPV vaccination), educator (very favorable), and uncompromising vaccinators (refusing debate). Pediatricians were overrepresented among the latter two types.ConclusionsPhysicians’ judgment was influenced by their trust in the stakeholders involved in designing and implementing the HPV vaccination strategy. In this sense, doctors did not differ substantially from laypeople. They were, nonetheless, strongly influenced by their professional style and ethos.     

Factors Influencing Family Physicians’ Contribution to the Child Health Care Workforce

PURPOSE

We wanted to explore demographic and geographic factors associated with family physicians’ provision of care to children.

METHODS

We analyzed the proportion of family physicians providing care to children using survey data collected by the American Board of Family Medicine from 2006 to 2009. Using a cross-sectional study design and logistic regression analysis, we examined the association of various physician demographic and geographic factors and providing care of children.

RESULTS

Younger age, female sex, and rural location are positive predictors of family physicians providing care to children: odds ratio (OR) = 0.97 (95% CI, 0.97–0.98), 1.19 (1.12–1.25), and 1.50 (1.39–1.62), respectively. Family physicians practicing in a partnership are more likely to provide care to children than those in group practice: OR = 1.53 (95% CI, 1.40–1.68). Family physicians practicing in areas with higher density of children are more likely to provide care to children: OR = 1.04 (95% CI, 1.03–1.05), while those in high-poverty areas are less likely 0.10 (95% CI, 0.10–0.10). Family physicians located in areas with no pediatricians are more likely to provide care to children than those in areas with higher pediatrician density: OR = 1.80 (95% CI, 1.59–2.01).

CONCLUSIONS

Various demographic and geographic factors influence the likelihood of family physicians providing care to children, findings that have important implications to policy efforts aimed at ensuring access to care for children.     

Physicians’ current use and preferences for male HPV vaccine-related patient education materials

Understanding physician preferences for educational materials to support male HPV vaccination is critical to improving vaccine uptake. Pediatric (Peds) and Family Medicine (FM) physicians in Florida completed a survey from May-August 2014 assessing current use of male-specific HPV vaccination patient education materials, and preferences for materials to increase HPV vaccination uptake. Peds and FM responses were compared with chi-squared or nonparametric tests. Most participants were FM (53.2%), White (66.6%), non-Hispanic (74.1%), and provided male patients/parents with HPV educational materials (59.1%). More than half (55.5%) provided a CDC factsheet for parents. Peds were more likely to indicate they provide educational materials (p < 0.0001) than FM. The preferred source was the CDC (77.8%). Peds preferred using a factsheet as the medium of information more often than FM (85.6% vs. 68.0%; p < 0.0001). When asked about preferences for targeted materials, 74.8% of providers indicated they would prefer materials targeted towards patients, 63.2% preferred information targeted towards parents, and 20.7% indicated they prefer non-targeted materials. Future research should focus on the development and testing of new HPV vaccine-specific materials and communication strategies for Peds and FM physicians.     

Predictors of Primary Care Physicians’ Self-reported Intention to Conduct Suicide Risk Assessments

Primary care physicians play a significant role in depression care, suicide assessment, and suicide prevention. However, little is known about what factors relate to and predict quality of depression care (assessment, diagnosis, and treatment), including suicide assessment. The authors explored the extent to which select patient and physician factors increase the probability of one element of quality of care: namely, intention to conduct suicide assessment. Data were collected from 404 randomly selected primary care physicians after their interaction with CD-ROM vignettes of actors portraying major depression with moderate levels of severity. The authors examined which patient factors and physician factors increase the likelihood of physicians’ intention to conduct a suicide assessment. Data from the study revealed that physician-participants inquired about suicide 36% of the time. A random effects logistic model indicated that several factors were predictive of physicians’ intention to conduct a suicide assessment: patient’s comorbidity status (odds ratio (OR) = 0.61; 95% confidence interval (CI) = 0.37–1.00), physicians’ age (OR = 0.67; 95% CI = 0.49–0.92), physicians’ race (OR = 1.84; 95% CI = 1.08–3.13), and how depressed the physician perceived the virtual patient to be (OR = 0.58; 95% CI = 0.39–0.87). A substantial number of primary care physicians in this study indicated they would not assess for suicide, even though most physicians perceived the virtual patient to be depressed or very depressed. Further study is needed to establish factors that may be modified and targeted to increase the likelihood of physicians’ providing one element of quality of care—suicide assessment—for depressed patients.     

Who uses multivitamins? A cross-sectional study in the Physicians’ Health Study

Purpose

The aim of this study was to examine the prevalence of self-reported multivitamin use in the Physicians’ Health Study (PHS) cohort and its association with various lifestyle, clinical, and dietary factors to improve our understanding of who tends to use multivitamins.

Methods

Among 18,040 middle-aged and older men, information on lifestyle and clinical factors was collected from a baseline enrollment questionnaire, and supplement use and dietary factors were assessed through a food-frequency questionnaire. Four categories of multivitamin use were considered: (1) no supplement use, (2) use of multivitamins only, (3) use of multivitamins with other individual vitamin/mineral supplements, and (4) use of other supplements only. We used logistic regression to calculate multivariate odds ratios and 95 % confidence intervals of taking multivitamin supplements for various lifestyle, clinical and dietary factors.

Results

Overall, 36 % of men reported current multivitamin use. Men who were older, current smokers, and currently using aspirin were 143, 43, and 74 % more likely to use multivitamins only. Men having a history of hypercholesterolemia were 16 % more likely to use multivitamins only. A 14, 24, and 26 % greater likelihood of using multivitamins was also observed among men consuming more fruits and vegetables, whole grains, and tea, respectively. Similar associations were observed for the likelihood of using multivitamins with other supplements; however, men with higher physical activity, history of cancer, hypertension, higher consumption of nuts, and lower consumption of red meat and coffee were also more likely to use multivitamins with other supplements (all P < 0.05).

Conclusion

Self-reported multivitamin use associated with lifestyle, clinical and dietary factors may be an indicator of healthy behaviors. These results provide important information for the interpretation of the recent findings from the PHS II trial and consideration of results from observational studies of multivitamin use and chronic disease.     

Reducing Communication Apprehension for New Patients Through Information Found Within Physicians’ Biographies

This study investigated whether state communication apprehension (CA) with physicians, for high CA patients, can be reduced before consultations by manipulating information found within physicians’ online biographies. Participants were presented with three experimentally manipulated physician biographies and asked to choose which physician they would want to visit to get a hypothetical ailment checked out. Guided by uncertainty reduction theory, results support a path model where increases in perceived similarities between a patient and doctor led to greater uncertainty reduction, greater liking, and subsequent reductions in CA with the physician for high CA participants. In addition, the majority of participants decided to visit the physician with whom they perceived the greatest similarity. The importance of reducing CA in the medical context is discussed, as well as theoretical implications for communication researchers. The results also provide practical guidance for health care systems to help improve their current physician biographical offerings available to prospective patients.     

New York City Physicians’ Views of Providing Long-Acting Reversible Contraception to Adolescents

PURPOSE

Although the US adolescent pregnancy rate is high, use of the most effective reversible contraceptives—intrauterine devices (IUDs) and implantable contraception—is low. Increasing use of long-acting reversible contraception (LARC) could decrease adolescent pregnancy rates. We explored New York City primary care physicians’ experiences, attitudes, and beliefs about counseling and provision of LARC to adolescents.

METHODS

We conducted in-depth telephone interviews with 28 family physicians, pediatricians, and obstetrician-gynecologists using an interview guide based on an implementation science theoretical framework. After an iterative coding and analytic process, findings were interpreted using the capability (knowledge and skills), opportunity (environmental factors), and motivation (attitudes and beliefs) conceptual model of behavior change.

RESULTS

Enablers to IUD counseling and provision include knowledge that nulliparous adolescents are appropriate IUD candidates (capability) and opportunity factors, such as (1) a clinical environment supportive of adolescent contraception, (2) IUD availability in clinic, and (3) the ability to insert IUDs or easy access to an someone who can. Factors enabling motivation include belief in the overall positive consequences of IUD use; this is particularly influenced by a physicians’ perception of adolescents’ risk of pregnancy and sexually transmitted disease. Physicians rarely counsel about implantable contraception because of knowledge gaps (capability) and limited access to the device (opportunity).

CONCLUSION

Knowledge, skills, clinical environment, and physician attitudes, all influence the likelihood a physician will counsel or insert LARC for adolescents. Interventions to increase adolescents’ access to LARC in primary care must be tailored to individual clinical practice sites and practicing physicians, the methods must be made more affordable, and residency programs should offer up-to-date, evidence-based teaching.Key words: intrauterine devices, contraceptive IUD, qualitative research, contraceptive devices, contraception, physicians, primary care, adolescent, delivery of health care, health services accessibility     

Female sex workers’ empowerment strategies amid HIV-related socioeconomic vulnerabilities in Cameroon

Abstract

Research has consistently demonstrated that female sex workers use a variety of empowerment strategies to protect one another and their families. This study examines the strategies Cameroonian sex workers employ to do so. In-depth interviews and focus-group discussions were conducted with 100 sex workers. Coded texts were analysed for recurring themes. Sex workers reported being concerned with physical violence and sexual assault and demands from authorities for bribes to avoid fines and/or imprisonment. Women described strategies such as ‘looking out for’ each other when faced with security threats. Many reported staying in sex work to provide for their children through education and other circumstances to allow them to lead a better life. Sex worker mothers reported not using condoms when clients offered higher pay, or with intimate partners, even when they understood the risk of HIV transmission to themselves. Concern for their children’s quality of life took precedence over HIV-related risks, even when sex workers were the children’s primary carers. A sex worker empowerment programme with a focus on family-oriented services could offer an effective and novel approach to increasing coverage of HIV prevention, treatment and care in Cameroon.     

Eye Fixations Indicate Men’s Preference for Female Breasts or Buttocks

Evolutionary psychologists have been interested in male preferences for particular female traits that are thought to signal health and reproductive potential. While the majority of studies have focused on what makes specific body traits attractive—such as the waist-to-hip ratio, the body mass index, and breasts shape and size—there is little empirical research that has examined individual differences in male preferences for specific traits (e.g., favoring breasts over buttocks). The current study begins to fill this empirical gap. In the first experiment (Study 1), 184 male participants were asked to report their preference between breasts and buttocks on a continuous scale. We found that (1) the distribution of preference was bimodal, indicating that Argentinean males tended to define themselves as favoring breasts or buttocks but rarely thinking that these traits contributed equally to their choice and (2) the distribution was biased towards buttocks. In a second experiment (Study 2), 19 male participants were asked to rate pictures of female breasts and buttocks. This study was necessary to generate three categories of pictures with statistically different ratings (high, medium, and low). In a third experiment (Study 3), we recorded eye-movements of 25 male participants while they chose the more attractive between two women, only seeing their breasts and buttock. We found that the first and last fixations were systematically directed towards the self-reported preferred trait.