Physician peer assessments for compliance with methadone maintenance treatment guidelines

INTRODUCTION: Medical associations and licensing bodies face pressure to implement quality assurance programs, but evidence-based models are lacking. To improve the quality of methadone maintenance treatment (MMT), the College of Physicians and Surgeons of Ontario, Canada, conducts an innovative quality assurance program on the basis of peer assessments. Using data from this program, we assessed physician compliance with MMT guidelines and determined whether physician factors (e.g., training, years of practice), practice type, practice location, and/or caseload is associated with MMT guideline adherence. METHODS: Secondary analysis of methadone practice assessment data collected by the College of Physicians and Surgeons of Ontario, Canada. Assessment data from methadone prescribing physicians who completed their first year of methadone practice were analyzed. We calculated the mean percentage compliance per guideline per physician and global compliance across all guidelines per physician. Linear regression was used to assess factors associated with compliance. RESULTS: Data from 149 physician practices and 1,326 patient charts were analyzed. Compliance across all charts was greater than 90% for most areas of care. Compliance was less than 90% for take-home medication procedures; urine toxicology screening; screening for hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), tuberculosis, other sexually transmitted infections, and completion of a psychosocial assessment. Mean global compliance across all charts and guidelines per physician was 94.3% (standard deviation = 7.4%) with a range of 70% to 100%. Linear regression analysis revealed that only year of medical school graduation was a significant predictor of physician compliance. DISCUSSION: This is the first report of MMT peer assessments in Canada. Compliance is high. Few countries conduct similar assessment processes; none report physician-level results. We cannot quantify the contribution of peer assessment, training, or self-selection to the compliance rates, but compared to other areas of practice these rates suggest that peer assessment may exert a significant effect on compliance. A similar assessment process may in other areas of clinical practice improve physician compliance.     

Microcomputer-generated reminders. Improving the compliance of primary care physicians with mammography screening guidelines

Recent studies have documented that physician compliance with recommended periodic health screening improves with reminders to physicians. These reminders, however, are often costly to maintain and modify. This study investigates the influence of a microcomputer tickler system on the ordering of mammograms. All women (N = 1262) aged 40 years and older who made visits to an outpatient office during a 6-month period were randomly assigned to one of two groups. For the experimental group, the date of the last mammogram ordered and recorded in the clinical database was printed on the encounter form generated for each patient visit. No information regarding previous mammograms was printed for patients in the control group. Women in the experimental group were more likely to have a mammogram ordered during the study period (19% compared with 12%, P = .001) and, as a result, were more likely to be in compliance with mammography guidelines at the study's completion (27% compared with 21%, P = .011). Microcomputerized data storage and retrieval systems may help increase physicians' attention to preventive health screening recommendations.     

Effect of continuing medical education and cost reduction on physician compliance with mammography screening guidelines

BACKGROUND. Primary care physicians perform breast cancer screening in women aged 50 years and older less frequently than recommended by national guidelines. METHODS. A multimethod continuing medical education (CME) intervention was tested in an attempt to increase breast cancer screening practices in a predominantly fee-for-service practice community in New York State. Preintervention and postintervention surveys of primary care physicians were conducted in 1988 and 1990, respectively. Project-initiated, low-cost mammography in one town and the unanticipated provision of free mammography services in another town under nonproject auspices permitted a comparison to be made between these towns and towns where mammography screening was provided at the prevailing fees to determine the impact that cost has on physicians' referral of women patients for mammography. RESULTS. Physicians practicing in the towns in which the CME intervention was provided showed a significant increase, consistent across specialty groups and greatest among family physicians, in the number of reported mammography referrals of asymptomatic women aged 50 to 75 years. Changes in the CME control town were smaller and not statistically significant for the sample size available. The increase in compliance was as large in the CME-intervention towns, one without (19%) and one with low-cost mammography (20%), as the increase in the town with free mammography alone (18%). There were no significant increases in reported performance of breast examination. CONCLUSIONS. A multimethod program of CME is a feasible approach to increasing community physician compliance with mammography screening guidelines, particularly among family physicians, and can enhance the impact of reduced cost or have at least the equivalent effect of free mammography services.     

Compliance with mammography guidelines: physician recommendation and patient adherence

BACKGROUND: Guidelines recommend that women ages 50-75 years receive screening mammography every 1-2 years. We related receipt of physician recommendations for mammography and patient adherence to such recommendations to several patient characteristics. METHODS: We retrospectively reviewed medical records of 1,111 women ages 50-75 attending three clinics in an urban university medical center. We ascertained overall compliance with mammography guidelines and two components of compliance: receipt of a physician recommendation and adherence to a recommendation. Outcome measures were the proportion of patients demonstrating each type of compliance and adjusted odds ratios, according to several patient-related characteristics. RESULTS: Overall, 66% of women received a recommendation. Of women receiving a documented recommendation, 75% adhered. Factors showing significant positive associations with receiving a recommendation included being a patient in the general internal medicine clinic, having private insurance, visiting the clinic more often, and having a recent Pap smear. Patient adherence was positively associated with private insurance and Pap smear history, negatively associated with internal medicine, and not associated with visit frequency. CONCLUSIONS: Patient factors influencing physician mammography recommendations may be different from those associated with patient adherence, except for having private health insurance, which was a predictor of both.     

Prenatal hospitalization and compliance with guidelines for prenatal care.

OBJECTIVES: This study examined the relationship between compliance with the US Public Health Service guidelines for prenatal care and the rate of prenatal hospitalization. METHODS: For all women admitted to a Boston referral center during January and February 1993 with a pregnancy of at least 18 weeks gestation (n = 1400), a proportional hazards model was used to examine factors associated with prenatal hospitalization. RESULTS: Prenatal hospitalization occurred during 248 (17.7%) pregnancies. The median length of stay for all prenatal admissions was 4 days; the medial total charge was $5667. Prior medical and obstetrical problems were strongly associated with prenatal hospitalization. After adjustment for age, race, and medical and obstetrical complications, women who received less than 70% of the prenatal care recommended were significantly more likely to be hospitalized (relative risk [RR] = 2.14, 95% confidence interval [CI] 1.50, 3.06). CONCLUSIONS: Prenatal hospitalization is a common, costly complication of pregnancy. Because of its association with compliance with the Public Health Service guidelines for the content of prenatal care, prenatal hospitalization may be a sentinel indicator of inadequate prenatal care amenable to intervention.     

Factors associated with women''s adherence to mammography screening guidelines.

OBJECTIVE: To examine individual and environmental factors associated with adherence to mammography screening guidelines. DATA SOURCES: A unique data set that combines a national probability sample (1992 National Health Interview Survey); a national probability sample of mammography facility characteristics (1992 National Survey of Mammography Facilities); county-level data on 1990 HMO market share; and county-level data on the supply of primary care providers (1991 Area Resource File). STUDY DESIGN: The design was cross-sectional. DATA EXTRACTION/ANALYSIS: Data sets were linked to create an individual-level sample of women ages 50-74 (weighted n = 2,026). We used multipart, sequential logistic regression models to examine the predictors of having ever had mammography, having had recent mammography, and adherence to guidelines. We categorized women as adherent if they reported a lifetime number of exams appropriate for their age (based on screening every two years) and they reported having had an exam in the past two years. PRINCIPAL FINDINGS: Only 27 percent of women had the age-appropriate number of screening exams (range 16 percent-37 percent), while 59 percent of women had been screened within two years. Women were significantly more likely to adhere to screening guidelines if they reported participating with their doctor in the decision to be screened; were younger; had smaller families, higher education and income, and a recent Pap smear; reported breast problems; and lived in an area with a higher percentage of mammography facilities with reminder systems, no shortage of primary care providers, higher HMO market share, and higher screening charges. CONCLUSIONS: A small percentage of women adhere to screening guidelines, suggesting that adherence needs to become a focus of clinical, programmatic, and policy efforts.     

Physician compliance with pneumococcal conjugate vaccine shortage recommendations in 2004.

OBJECTIVE: To assess pattern of pneumococcal conjugate vaccine (PCV) administration during periods of vaccine shortage and changing recommendations. METHODS: During 2004 PCV shortages, the Advisory Committee for Immunization Practices recommended delay of doses 3 and 4 (PCV3 and PCV4) to healthy children. A managed care health plan evaluated PCV doses administered to all enrolled children at ages 3, 5, 7, and 16 months in 2004; ICD9 codes were used to identify high-risk children. RESULTS: Immunization coverage for the first two PCV doses remained relatively stable throughout 2004 for both high-risk and healthy children. PCV3 coverage for healthy children dropped significantly from 63 percent preshortage (February 2004) to a low of 7 percent (June 2004), then rose to preshortage levels of 2 months after recommendations were made to resume PCV3 administration. Coverage of high-risk children followed a similar pattern as that for healthy children. PCV4 coverage showed similar declines and increases following shortage-related recommendations as PCV3. Most children whose PCV3 dose may have been delayed during the shortage did receive PCV3 after the shortage. CONCLUSIONS: Providers demonstrated rapid change in PCV administration in response to shortage-related recommendations. Little coverage difference was seen between healthy and high-risk children, possibly due to inadequate ability to determine which children truly are at high risk identified on the basis of ICD9 codes.     

Assessing compliance with power-frequency magnetic-field guidelines

Several organizations have established guidelines for occupational exposure to power-frequency magnetic fields. At 60 hertz, exposure limits are 1.0 millitesla (mT) for the American Conference of Governmental Industrial Hygienists, 0.42 mT for the International Committee on Non-ionizing Radiation Protection, and 1.6 mT for the National Radiation Protection Board guidelines. Adoption of the current guidelines as mandatory standards could dramatically affect electric-utility work practices. Two large personal-exposure monitoring projects have characterized exposures of overhead lineworkers and cable splicers while they perform various tasks near energized conductors. Personal exposure measurements indicate that these two groups are very likely the most highly exposed among utility workers and often experience fields above guideline levels. In addition, survey measurements in utility environments have identified locations where other workers may experience exposures at guideline levels. The nature of high-field exposure scenarios in the utility industry suggests a simple practical method for determining compliance with basic restrictions on internal induced current density [< 10 milliamperes per square meter (mA m(-2))] in the presence of fields that exceed limits to magnetic fields external to the body.     

Establishing a statewide mammography database in Arkansas: overcoming the barriers.

To determine patterns of mammography utilization in Arkansas, the Arkansas Mammography Data Collection Project (MDCP) was established. The project's objective was to compile into one database statewide information about mammograms performed. All mammography centers were invited to participate in the project. Many barriers were encountered that were center related, data related, or personnel related; different interventions were implemented for each barrier. At the conclusion of the project, 92 out of 112 centers (82%) participated in the project, creating a database of 157,976 mammography data sets. Identifying and overcoming many of the barriers were crucial steps in the project's success.     

Alcohol and tobacco marketing: evaluating compliance with outdoor advertising guidelines

BACKGROUND: Historically, the alcohol and tobacco industries have been the biggest users of outdoor advertising. However, the 1999 Master Settlement Agreement (MSA) outlawed tobacco billboards and transit furniture (e.g., bus, bench) ads, and the Outdoor Advertising Association of America (OAAA) has pledged to voluntarily eliminate ads for alcohol and tobacco within 500 feet of schools, playgrounds, and churches. METHODS: Outdoor advertisements were observed (2004-2005) in a sample of urban census tracts (106 in pre-Katrina southern Louisiana and 114 in Los Angeles County) to evaluate tobacco and alcohol advertisers' compliance with the MSA and the OAAA Code of Industry Principles. Data were analyzed in 2007-2008. RESULTS: More than one in four tobacco ads in Louisiana failed to comply with the MSA. In Los Angeles, 37% of alcohol ads and 25% of tobacco ads were located within 500 feet of a school, playground, or church; in Louisiana, roughly one in five ads promoting alcohol or tobacco fell within this distance. In Los Angeles, low-income status and the presence of a freeway in the tract were associated with 40% more alcohol and tobacco billboards near children. In Louisiana, each additional major roadway-mile was associated with 4% more tobacco ads-in violation of MSA-and 7% more small ads near schools, playgrounds, and churches; city jurisdiction accounted for 55% of MSA violations and more than 70% of the violations of OAAA guidelines. CONCLUSIONS: Cities must be empowered to deal locally with violations of the MSA. Legislation may be needed to force advertisers to honor their pledge to protect children from alcohol and tobacco ads.     

Spanish children's diet: compliance with nutrient and food intake guidelines

OBJECTIVE: To compare the diet of Spanish children against the nutrient and food intake guidelines. To calculate an index of overall diet quality and check its validity against nutrient intake. DESIGN AND SETTING: Cross-sectional study in four cities in Spain, where information on food and nutrient intake was obtained from schoolchildren through a food frequency questionnaire. PARTICIPANTS: The sample included 1112 children (overall response rate of 85%) attending public and private schools and aged 6-7 y. Children were selected through random cluster sampling in schools, and stratified by sex and socioeconomic level. MAIN OUTCOME MEASURES: Mean nutrient intake, number of food servings, and the percentage of children who meet recommended nutrient and food-serving intake levels. The overall dietary quality was assessed using the Healthy Eating Index (HEI). RESULTS: Mean micronutrient intake exceeded 100% of the recommended dietary allowances, except for vitamin B6, which registered a mean intake of 77.1%. For almost all children, intake of saturated fat was above, and that of carbohydrate below, the recommended level, in contrast to the relatively high compliance with the recommendations for poly- and monounsaturated fatty acid, salt and fiber intake (69.7, 43.7, 40.7, and 30.1%, respectively). Consumption of food servings for each of the five American pyramid food groups came close to or exceeded USDA guidelines, with the exception of cereals, with 5.4 servings per day. The mean score obtained in the HEI was 64.6. Children who complied with all the food guide pyramid recommendations registered a higher dietary variety and a healthier nutritional profile. CONCLUSIONS: Children aged 6-7 y show scant compliance with the macronutrient goals for healthy eating. Micronutrient intake is adequate in general, yet there are small groups of children with risk of deficient intake of vitamins B6 and D. While Spanish children's eating habits are reasonably in line with American food guide pyramid guidelines, consumptions of cereals and fruit should be improved.     

报纸报道自杀事件失范现状分析

目的分析广东地区报纸报道自杀事件的失范现况, 促进媒体对自杀事件的规范报道。方法以WHO媒体报道的原则及禁忌为标准, 以广东地区具有代表性的5份报纸在2011年全年对自杀事件的报道对象, 采用内容分析法从5个方面用27个条目进行分析。结果内容涉及自杀事件的报道总计453篇;99.1%的用词语准确地描述了自杀的结果;99.6%未使用“自杀成功”一词;1篇国外的报道将自杀理由归结为宗教原因。头版报道的新闻共51篇, 占所有自杀报道的11.3%, 版面中使用大字标题的报道共269篇, 占59.4%;当自杀者为有一定社会地位者, 置于头版和采用大字标题的比例高于普通民众(P<0.05);37.4%的报道有配图;68.7%详细描述了自杀的方法, 96.7%描述了自杀地点;有9篇报道采用渲染的词句进行报道, 有4篇报道涉嫌美化自杀行为。96.7%未提及与心理健康相关领域专家协商, 52.1%的报道将自杀的原因简单归因, 6.2%指出了自杀前有征兆, 11.9%明确指出了与自杀相关的精神疾病。结论报纸对自杀事件报道存在较为严重的失范现象, 需要编制适合我国社会文化背景的自杀事件报道规范, 采取适当的策略提高媒体对规范的依从性。     

Physician recruitment: guidelines for a safer tomorrow

As hospitals are challenged to recruit and retain qualified medical staff, they must continually consider the legal ramifications of their actions. Developing a physician-hospital alliance may conceptually be an excellent idea within a medical-service area, but rulings by the Office of the Inspector General and the Internal Revenue Service can challenge the decisions of hospital administrators and boards. Writing for the National Institute of Physician Recruitment and Retention, Roger G. Bonds and Michael R. Callahan address legal ramifications of physician-hospital alliances.     

Physician adherence to preventive cardiology guidelines for women.

Despite the publication of the American Heart Association/American College of Cardiology (AHA/ACC) "Guide to Preventive Cardiology for Women" primary care screening and treatment of women at risk for coronary heart disease risk is not optimal. The purpose of this article is to apply a framework of physician behavior to describe specific challenges in implementing clinical practice guidelines for women's cardiovascular health in the primary care setting. Specifically, we illustrate 1) underlying barriers to adherence, 2) attempts and interventions to overcome these barriers, and 3) future areas of research to improve physician adherence to guidelines for the prevention and treatment of heart disease in women.     

Assessing doctors' compliance with guidelines on diabetes management

PURPOSE: In 2002 the Singapore Ministry of Health (MOH) audited doctors' compliance with diabetes clinical practice guidelines in public healthcare institutions and attempted to postulate factors that influenced the degree of conformity. This study aims to address this issue. DESIGN/METHODOLOGY/APPROACH: A retrospective cross-sectional chart review of diabetes patient records sampled from hospital specialist outpatient clinics (SOCs) and polyclinics was performed. Childhood, gestational and secondary diabetes cases were excluded. The nine audit parameters used were process measures concerning the assessment of HbA1c, weight, blood pressure, urinary protein, serum creatinine, serum lipids, electrocardiography, retina and feet. Age-standardised prevalence rate ratios of parameter adherence were calculated. Of the SOC cases, 89 per cent were analysed. Of the polyclinic cases, 94 per cent were analysed. FINDINGS: Adherence to ECG and foot assessment parameters was poor among SOC cases, while poor adherence to weight and foot assessment parameters was seen in the polyclinics. There was poorer adherence to blood pressure and ECG parameters in the SOCs, but better adherence was seen for weight assessment. Among the SOC cases, Cluster A fared better than Cluster B in ECG monitoring. In the polyclinics, better adherence was seen in Cluster A for urinary protein, serum creatinine, lipids, ECG, retinal and foot assessment parameters. ORIGINALITY/VALUE: Based on pre-existing information on local diabetes care, certain system, physician, patient and guideline factors are postulated to explain clinical practice guideline non-compliance among doctors.     

Understanding barriers to participation in mammography by women with disabilities

PURPOSE: The study purpose was to identify barriers to mammography screening among women with different disabilities and to suggest interventions to address barriers. METHODS: Forty-two women with self-reported disabilities, ages 40 to 69 years participated. They resided in 24 Connecticut towns, and most had a prior mammogram. Data were collected through six disability-specific focus groups from women with sensory, physical, psychiatric, and cognitive/intellectual impairments. Facilitator-conducted groups used a semistructured guide. Qualitative analysis applied an iterative coding process to generate themes and categories. RESULTS: We identified four themes (i.e., access, beliefs, social support, and comfort/ accommodations) and nine subthemes that characterized barriers. In all focus groups, women mentioned physical access and physical comfort/accommodations as types of barriers. Other major subthemes were communication and professional support. Women also described mammography facilitators. CONCLUSION: Despite frequent use of health care and personal strategies to facilitate mammography screening, women with disabilities reported barriers to getting mammograms. Findings suggest a multifaceted approach to address these barriers.     

Assessing compliance with 60-hertz magnetic-field exposure guidelines

Exposure limits for magnetic fields in the extremely low frequency range (3 to 3000 hertz) have been established by a number of organizations. The limits are generally intended to prevent overstimulation of electrically sensitive tissue and are expressed as ceiling values-levels not to be exceeded even momentarily. Exposures near or above the limits occur around high-current equipment and often have large spatial and temporal variability. The combination of variable exposures and ceiling-value exposure limits means that a practical exposure assessment must be statistically based. Practical guidance for assessing compliance for these exposures is limited. To fill this gap, this work develops a statistically based sampling and analysis methodology for evaluating compliance with magnetic-field exposure guidelines, using 60-hertz exposures in the electric utility industry as a model. The resulting methodology relies on (1) defining a scenario that includes tasks with similar high-field exposures for a group of workers, (2) having appropriate protocols for performing magnetic-field personal exposure measurements or having an exposure data set corresponding to that scenario, (3) assuming that the measured peak field is consistent with the exposure limit, (4) assuming that the peak exposure values follow a lognormal distribution, and (5) collecting sufficient measurements to determine the probability of compliance with a desired degree of statistical confidence. As examples, specific compliance probabilities and their confidence intervals are estimated for electric utility scenarios from available personal exposure measurements. This specific application demonstrates the general methodology and indicates that compliance with existing exposure limits may become an issue for certain tasks.