德国家庭医生执业路径及服务模式

德国“家庭医生”包含全科医生、家庭内科医生和儿科医生三类医师。除门诊开业外,家庭医生执业场所可延伸至医院,医院通过加强私人诊所与医院之间的良好互动从而发展整合医疗。家庭医师协会作为家庭医生职业群体代理,在福利报酬等方面与政府医保支付机构进行谈判。“家庭医生服务模式”下,疾病保险基金通过改进与家庭医生的服务购买协议,从而达到激励患者和服务提供方主动依从“守门人”制度的效果。     

Physician practice size and variations in treatments and outcomes: evidence from Medicare patients with AMI

Little is known about the relationships between physician practice size and patient treatments or outcomes. We examined whether the practice size of attending physicians was related to within-hospital differences in care for Medicare patients with acute myocardial infarction (AMI). We found that patients treated by solo physicians were less likely to receive cardiac catheterization and angioplasty within a day of admission and more likely to die than other patients in the same hospital, even after a number of patient and physician characteristics were taken into account. These differences suggest that solo practitioners are less likely to follow guidelines calling for quick use of angioplasty.     

Attitudes of Washington State primary care physicians toward capitation-based insurance plans

Recent years have brought many changes in health care financing, including health care insurance plans based on capitation allowances to physicians. This study describes a survey examining physician attitudes toward such plans. The survey was distributed to a random sample of 30% of the family physicians, general practitioners, general internists, and general pediatricians in the Washington State Medical Association in 1986. Responses from 322 physicians (71%) indicated that most primary care physicians had a negative attitude toward such plans. Participants in capitation-based plans (48% of total respondents) had a nearly neutral attitude, which was significantly different from the attitude of nonparticipants. Respondents identified the main disadvantages of such plans as confusion about benefits, increased administrative demands, liability risks, altered professional relationships, and loss of autonomy. The main advantages perceived were increased physician awareness of cost, increased importance of the primary care role, and reduction of unnecessary health care utilization. Attitudes were significantly more negative among solo practitioners and physicians with more years in practice. Respondents rated selection of consultants, favorable economic arrangements, and benefits information as the features most likely to influence them to participate in capitation-based plans.     

Use of nonphysician health care providers for skin cancer screening in the primary care setting

BACKGROUND: Nonphysician health care providers are in an optimal position to provide cancer prevention and screening services. METHODS: We conducted a survey of primary care physicians to determine physician use and amenability to use of nonphysician health care providers to perform skin cancer screening in comparison with other cancer screening examinations. RESULTS: A total of 1,363 eligible physicians completed the survey. Of these, 631 physicians (46%) reported a nurse practitioner or physician assistant performing at least one type of cancer screening examination on their patients. Twenty-nine and 22% of all physicians reported nurse practitioners or physician assistants performing skin cancer screening, respectively. Family physicians were more likely to use nurse practitioners and physician assistants to perform these cancer screening examinations than internists (chi(2) test, P = 0.001 for each examination). Skin examinations were performed less frequently by nurse practitioners and physician assistants than all other cancer screening examinations. A total of 73-79% of family physicians and 60-70% of internists were amenable to having a nonphysician health care provider perform one or more of these examinations. CONCLUSIONS: Primary care physicians are currently utilizing nonphysician health care providers to perform cancer screening examinations and the majority of those surveyed are amenable to the use of these providers for such examinations. This suggests that one possible strategy for increasing skin cancer screening is through an expanded role of nonphysician health care providers.     

Barriers to screening sexually active adolescent women for chlamydia: a survey of primary care physicians.

PURPOSE: To determine the proportion of primary care physicians who screen sexually active teenage women for chlamydia and to determine demographic factors, practice characteristics, and attitudes associated with chlamydia screening. METHODS: We obtained a random sample of 1600 Pennsylvania physicians from the American Medical Association masterfile, stratified to include at least 40% women and equal numbers of family physicians, internists, obstetricians/gynecologists, and pediatricians. In January 1998, physicians received mailed questionnaires; nonrespondents received two follow-up mailings. Physician characteristics associated with chlamydia screening were determined using bivariate and logistic regression analyses. RESULTS: Only one-third of physicians responded that they would screen asymptomatic, sexually active teenage women for chlamydia during a routine gynecologic examination. In multivariate analysis, physicians were significantly (p <.05) more likely to screen if they were female (43% vs. 24%), worked in a clinic versus solo practice (60% vs. 18%), worked in a metropolitan location (46% vs. 26%), or had a patient population > or = 20% African-American (54% vs. 25%). Attitudes associated with screening included the belief that most 18-year-old women in their practice were sexually active (36% vs. 12%), feeling responsible for providing information about the prevention of sexually transmitted diseases to their patients (42% vs. 21%), or knowing that screening for chlamydia prevents pelvic inflammatory disease (37% vs. 13%). Physicians were less likely to screen if they believed that the prevalence of chlamydia was low (10% vs. 41%). CONCLUSIONS: A majority of physicians do not adhere to recommended chlamydia screening practices for teenage women. Interventions to improve chlamydia screening might target physicians who are male, in private practice, or who practice in rural areas, and should focus on increasing awareness of the prevalence of chlamydia and benefits of screening.     

The diagnostic process in primary care: a comparison of general internists and family physicians

This investigation examined the formulation of diagnostic hypotheses by general internists and family physicians in response to three patient cases (dyspnea, abdominal pain and syncope). The investigation was conducted in the United States. Physician responses to sequentially presented written clinical information were audiotaped. Each transcribed protocol was scored to enumerate and characterize the hypotheses considered by physicians in each specialty. Results of the analyses of variance of hypothesis measures revealed that internists generated more hypotheses than family physicians and that the internist's hypotheses were more specific and were less likely to be generated by other physicians. In addition, internists tended to consider hypotheses more closely related to the final diagnosis sooner in the case presentation than did family physicians. The findings of increased number, specificity, and uniqueness of hypothesis considered by internists are consistent with previously demonstrated differences in the amount and nature of diagnostic information collected by family physicians and internists.     

Health care system and insurer support for smoking cessation guideline implementation

Physician use of clinical practice guidelines (CPGs) is disappointingly low in the United States. Much emphasis historically has been placed on the individual clinician to implement use of guidelines in practice. Recently, the Public Health Service issued an updated set of smoking cessation guidelines that include recommendations not only for patients and physicians, but also for health care administrators, insurers, and purchasers. A random sample of Missouri family physicians and general internists was used to determine, for the first time empirically, whether physicians receiving external support for guideline implementation were more likely to adopt and adhere to guidelines in practice. Fewer than 20 percent of physicians receive system support consistent with the updated guideline for smoking cessation. Only 32 percent of physicians who are unaware of the guidelines receive any of the recommended external support, while nearly 60 percent of physicians who adhere to the guidelines in practice are receiving some form of external support. Thus, the fundamental issue that requires national attention is that successful guideline implementation is highly dependent on administrative supports from health care organizations and insurers.     

MGB1 Poor Adherence to Hypertension Treatment Guidelines: An Analysis of Therapeutic Choices

The recent Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) reiterated long-standing recommendations that Stage 1 hypertension (BP ≥ 140/90 mm Hg) without comorbidity should be treated initially with diuretics (DI) or beta blockers (BB). Yet market research suggests that many physicians prefer to use other drug classes, such as calcium channel blockers and ACE inhibitors.
OBJECTIVES: To explore the determinants of therapeutic choice in hypertension.
METHODS: We surveyed by mail a stratified random sample of 10,000 U.S. cardiologists, internists, and family/general practitioners. Physicians were queried about their practice environment and their knowledge, attitudes, and practices regarding antihypertensive therapy, including their choice of drugs to treat patients with specified clinical profiles. The probability that physicians would follow JNC guidelines Stage 1 hypertension was analyzed using multiple logistic regression with stepwise backward elimination to select variable with p < 0.001.
RESULTS: Completed surveys were received from 1,023 physicians. 86.7% prescribe drug therapy for Stage 1 hypertension, and 19.5% (22.5% of drug prescribers) limit their choices to DI and BB. Guideline conformity was higher among physicians who: practice in academic medical centrers; are older; are general practitioners (versus general internists); have smaller caseloads; have fewer hypertensive patients; have higher proportions of HMO, Medicaid, and uninsured patients; and experience more formulary restrictions. Cardiologists and family practitioners were less likely than internists to follow guidelines.
CONCLUSION: JNC guidelines are better accepted by academic physicians, older physicians who have more expenence using DI and BB, physicians with smaller caseloads and hence more time for follow-up and therapy adjustment, and physicians who face drug reimbursement constraints.     

Family physicians and general internists: do they treat hypertensive patients differently?

This study compared 51 San Francisco Bay Area family physicians and 47 general internists in their treatment of hypertensive patients. Charts from 2254 patients of these physicians were reviewed. The average age and percentage of board certification of both groups of physicians are similar. Patients of general internists were slightly older than the family practice patients (average age 61 vs 59 years). The general internists saw significantly fewer patients per hour (3.0) than the family physicians (3.6). Family physicians were more likely to employ a registered nurse (33%) than were general internists (17%), and family physicians were twice as likely to delegate patient education to office staff than were the general internists. The mean number and kinds of antihypertensive medications prescribed were similar. Internists did more laboratory testing, but the difference was not statistically significant. General internists were more likely to change medication when their patients' blood pressure was uncontrolled than were family physicians (in 60% vs 40% of patients, P = .02), and they were also more likely to recall uncontrolled patients within 3 months than were family physicians (50% vs 35% of patients, P = .05). There was no significant difference in mean diastolic blood pressure or in hypertension-related behaviors, such as medication adherence, aerobic exercise, alcohol consumption, or amount of dietary salt, between the two patient groups; however, over 35% of patients of both groups had elevated blood pressure readings despite taking medications. Overall, there were more similarities than differences in the care physicians provided. Efforts to change physician performance in the treatment of hypertensive patients are still warranted and equally applicable to both groups.     

Physician behavior under the medicare assignment option

Using a national sample of general practitioners, internists, and general surgeons, we analyzed the willingness of physicians to accept Medicare patients on assignment. Assignment rates were found to be very sensitive to reimbursement and administrative practices under Medicare. A ten percent increase in the prevailing charge, for example, raised assignment by 14.7 percent. The assigned and non-assigned components of the Medicare program were found to compete with each other; assignment rates were lower where the demand for non-assigned services was stronger. As for the kinds of physicians who take assignment, they were disproportionately general surgeons and foreign medical graduates.     

The impact of managed care and practice size on primary care physicians' perceived ability to refer

OBJECTIVES: To identify the determinants of primary care physicians' perceived ability to refer patients, to compare perceived ability to refer between solo/two-physician practices and group practices, and to determine the impact of managed care on perceived ability to refer. METHODS: Multivariate analysis using a dataset derived from the Community Tracking Study Physician Survey, 1996-1997. The variables used to explain physicians' perceived ability to refer included physician and practice characteristics as well as aspects of the financial arrangements of managed care. The sample was stratified by practice size. A likelihood ratio test was performed to determine whether there were differences in practice characteristics and managed care financial arrangements that could explain variations in perceived ability to refer between physicians in solo/two-physician and group practices. RESULTS: Perceived ability to refer did not vary much between physicians in solo/two-physician practices and those in group practices. However, the determinants of perceived ability to refer did vary by practice size. The effects of physicians' characteristics were more pronounced among physicians in group practice, whereas the effects of financial arrangements were significant for physicians in solo/two-physician practices. The most significant determinant of perceived ability to refer was primary care physicians' satisfaction in their communication with specialists. CONCLUSION: Group practices are more immune than solo/two-physician practices to external financial arrangements from managed care contracts, possibly through their ability to take advantage of economies of scale and to diversify their sources of funds.     

Physician knowledge levels and barriers to coronary risk prevention in women: survey results from the Women and Heart Disease Physician Education Initiative.

BACKGROUND: Few studies have examined whether physician knowledge, attitudes, or practice patterns might contribute to gender disparities in the primary prevention of coronary heart disease (CHD), including among physicians caring for the largest number of reproductive-age women, obstetricians and gynecologists (OB/GYNs). We sought to identify barriers affecting the provision of recommended coronary risk factor therapies in women. METHODS: We surveyed internists and OB/GYNs who attended Grand Rounds presentations developed for the New York State Women and Heart Disease Physician Education Initiative. This program was designed to improve screening and management of coronary risk factors in women. Attendees were asked to complete a 7-minute questionnaire. RESULTS: The mean age of the 529 respondents was 40.3 years (standard deviation = 12.3), 75.1% were internists (n=378), and 42.7% (n=226) were women. Physicians correctly responded to 71.5% of the 13 questions assessing knowledge of coronary risk prevention (range, 4-13). Almost one third of internists and half of the OB/GYNs did not know that tobacco use was the leading cause of myocardial infarction in young women. For patients who smoked tobacco, only two thirds of internists and 55.4% of OB/GYNs reported suggesting a quit date (p=.007). After controlling for covariates, physicians who did not perceive time as a barrier were more likely to discuss smoking cessation (odds ratio=1.7 [1.1-2.7]). CONCLUSIONS: Among the internists and OB/GYNs surveyed, time was perceived as a barrier to implementing risk prevention. These physicians also underestimated the impact of tobacco use as a risk factor for CHD in young women. To lessen gender disparities in CHD prevention, both specialties need time-efficient educational programs that reflect specialty differences.     

Use of Interpreters by Physicians Treating Limited English Proficient Women with Breast Cancer: Results from the Provider Survey of the Los Angeles Women's Health Study

Objective. Little is known about how cancer physicians communicate with limited English proficient (LEP) patients. We studied physician-reported use and availability of interpreters.
Data Sources. A 2004 survey was fielded among physicians identified by a population-based sample of breast cancer patients. Three hundred and forty-eight physicians completed mailed surveys (response rate: 77 percent) regarding the structure and organization of care.
Study Design and Settings. We used logistic regression to analyze use and availability of interpreters.
Principal Findings. Most physicians reported treating LEP patients. Among physicians using interpreters within the last 12 months, 42 percent reported using trained medical interpreters, 21 percent telephone interpreter services, and 75 percent reported using untrained interpreters to communicate with LEP patients. Only one-third of physicians reported good availability of trained medical interpreters or telephone interpreter services when needed. Compared with HMO physicians, physicians in solo practice and single-specialty medical groups were less likely to report using trained medical interpreters or telephone interpreter services, and they were less likely to report good availability of these services.
Conclusions. There were important practice setting differences predicting use and availability of trained medical interpreters and telephone interpretation services. These findings may have troubling implications for effective physician–patient communication critically needed during cancer treatment.     

Physician extenders, the law, and the future

The process of Physician Extender authorization through general delegatory and regulatory-authority model legislation in the various states is examined in this paper. In light of past legislative and professional developments, the likelihood of independent practice patterns emerging among both nurse practitioners and physicians's assistants is assessed. It is concluded that current trends in physician manpower supply and distribution make the establishment of a physician extender group serving in competition with primary care physicians unlikely at this time. Rather, it is more likely that a clearly defined role may be established either in the employer/employee setting or through a position quite distinct from that of the primary care physician. Physician extenders functioning in this more independent role could contract with primary care and other physicians for their services without engendering economic competition for patient services.     

A systems model of clinical preventive care: the case of breast cancer screening among older women. For the NCI Breast Cancer Screening Consortium

BACKGROUND: In older women covered by Medicare, relationships among physician recommendation, mammography in the past 2 years, and clinical breast examination (CBE) in the past year were systematically explored with a variety of predisposing, enabling, and situational factors identified in the Systems Model of Clinical Preventive Care. METHODS: A population-based survey of women age 65 years and older was conducted in five National Cancer Institute's Breast Cancer Screening Consortium geographic areas. Analyses focused on women with a regular physician and site of care (n = 5318). RESULTS: Physician recommendation and mammography use declined with women's increasing age and increased with income, education, and insurance. CBE and mammography increased with number of physicians and breast cancer family history; mammography use decreased with worsening health status. Recommendations were higher among physicians who were younger, female, and internists. Family practitioners were older and male; women who saw family practitioners reported characteristics associated with decreased screening-lower income, education, and insurance-and seeing only one physician. CONCLUSIONS: Public policy and health system changes that create a uniform system of finance and service performance expectations may reduce the persistent discrepancy in physician recommendation and mammography use due to sociodemographics and physician specialty.     

Solo and Small Practices: A Vital,Diverse Part of Primary Care

PURPOSE

Solo and small practices are facing growing pressure to consolidate. Our objectives were to determine (1) the percentage of family physicians in solo and small practices, and (2) the characteristics of and services provided by these practices.

METHODS

A total of 10,888 family physicians seeking certification through the American Board of Family Medicine in 2013 completed a demographic survey. Their practices were split into categories by size: solo, small (2 to 5 providers), medium (6 to 20 providers), and large (more than 20 providers). We also determined the rurality of the county where the physicians practiced. We developed 2 logistic regression models: one assessed predictors of practicing in a solo or small practice, while the other was restricted to solo and small practices and assessed predictors of practicing in a solo practice.

RESULTS

More than one-half of respondents worked in solo or small practices. Small practices were the largest group (36%) and were the most likely to be located in a rural setting (20%). The likelihood of having a care coordinator and medical home certification increased with practice size. Physicians were more likely to be practicing in small or solo practices (vs medium-sized or large ones) if they were African American or Hispanic, had been working for more than 30 years, and worked in rural areas. Physicians were more likely to be practicing in small practices (vs solo ones) if they worked in highly rural areas.

CONCLUSIONS

Family physicians in solo and small practices comprised the majority among all family physicians seeking board certification and were more likely to work in rural geographies. Extension programs and community health teams have the potential to support transformation within these practices.     

Prognostic value of the presence of the mutation of the codons 12, 13 and 61 in K-ras oncogene in colorectal cancer]

Despite of extensive and intensive investigations, the predictive and prognostic value of c-K-ras mutation is not unequivocal. There has been reported about investigation the occurrence of mutations in the 88 colorectal cancer patient's specimen using polymerase chain reaction. Age: 61.9 years (27-80), gender 8 male, 42 female. Dukes' stages: 43 at the B, 35 at C, 10 at D. Primary of tumour: 52 colon, 36 rectal adenocarcinoma. Mutation out of one of the three ras-codons was detectable in the 54 cases, more frequently at the stage Dukes' C (p < 0.05). The ras-mutation concerned to more elevated death-rate in the stages Dukes' B and C (p < 0.01). Mean survival time to progression was significantly longer at the stage Dukes' B if mutation had not been detected (p < 0.01). The occurrence of the rate of genetic alteration was significantly more frequent at tumours of right-side colon, than left side (p < 0.02) or rectum (p < 0.05) one's. However, at the age of 41-50 years it was significantly more presented at the cases of rectal cancer (p < 0.01). At the age of 51-60 years mutations were detected among men at higher rate (p < 0.05). The cases of local recurrences concerned by mutation at the codon of 13 (p < 0.05). Occurrence of ras-oncogene is the sign of extremely malignant potential of tumour. This fact manifested itself in the time to progression and mean survival time of patients at same clinical or pathological stage. The higher frequency of genetic alterations at the proximal colon may be the reason of more unfavourable prognosis of the disease localised to this site. Reconstructing the molecular events, the presence of ras mutation can serve as a basis for prognosis of the disease and permit of potentially individualised therapeutic intervention.     

Making it work: characteristics of high-performing hospital-physician networks

Physician practice is in the midst of another historic change--from solo and small groups to large, hospital-sponsored employed-physician networks. The question remains as to whether these large, hospital-centric physician organizations are sustainable. This article examines the stress points that physicians and practice managers face as they find themselves thrust into new but often ill-defined business models. It offers insights and pathways to help them navigate the changes that will be necessary for these business models to survive, evolve, and thrive.     

Evaluating the physician office visit: in pursuit of a valid and reliable measure of quality improvement efforts

In an effort to develop a patient questionnaire with sufficient validity and reliability to be used to measure patient perceptions of quality, over 30,000 patients from 178 solo and group practices completed the Physician Office Quality of Care Monitor (QCM). The study found strong evidence of construct validity, predictive validity, and internal consistency for the questionnaire. Physician interactions were the most important aspect of office care while coordination of care over time was found to be the best issue to differentiate patients likely to recommend a practice from those less likely to recommend. An inverse relationship was found between practice size and patient satisfaction. Health maintenance organization (HMO) patients reported lower satisfaction, as did younger patients.