The availability of reproductive health services from U.S. private physicians

Data on the provision of seven types of reproductive health care were collected from private physicians in four specialties: general/family practitioners (GP/FPs), general surgeons, obstetrician-gynecologists and urologists. All ob-gyns, and eight in 10 GP/FPs, provide the pill, IUD or diaphragm. Over nine in 10 ob-gyns provide infertility and obstetric care and prenatal genetic screening; but only one-third or fewer of GP/FPs do so. Ob-gyns and urologists are far more likely to perform sterilizations than are GP/FPs and surgeons (nine in 10, compared with one-fifth to one-half). Although ob-gyns are the most likely to perform abortions, only four in 10 do so. Among ob-gyns who do not perform tubal sterilizations or abortions, and among urologists who do not perform vasectomies, the primary reason is moral or religious objections (reported by 59-71 percent). For GP/FPs and surgeons who do not perform the three procedures, the leading reason is that they do not perform surgery or that type of surgery; however, 34 percent of nonproviders in these specialties report moral or religious opposition to abortion. Eight in 10 ob-gyns will provide contraceptives to minors without parental consent, but only six in 10 GP/FPs will do so. One-half of doctors who perform female sterilizations, and eight in 10 of those who do vasectomies, require spousal consent. Among those who perform abortions, half require parental consent for minors. Access to private reproductive health care is quite limited for the poor, because many physicians will not accept Medicaid reimbursements or reduce their fees for low-income patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Symptomatology of chronic brucellosis

McDevitt, D. G. (1973).British Journal of Industrial Medicine,30, 385-389. Symptomatology of chronic brucellosis. A survey of the occurrence of symptoms commonly attributed to chronic brucellosis was carried out by questionnaire in four different occupational groups in Northern Ireland—veterinary surgeons working in private practice, veterinary surgeons employed by the Ministry of Agriculture, general medical practitioners, and a group of forestry workers. The veterinary surgeons generally had a higher incidence of symptoms than the other two groups. This could not be accounted for by age, heavy physical exertion or professional familiarity with disease but could be related to contact with cattle and hence to possible brucella infection. Of the symptoms investigated, sweating, weakness, malaise, irritability, depression, rheumatism, arthritis, and backache occurred significantly more often in the veterinary surgeons than in the others, with selective differences between the types of veterinary practice: the alimentary system symptoms, headache, and insomnia were more evenly distributed between all groups and their inclusion as part of the chronic brucellosis symptom complex must be seriously questioned. The lack of specificity of the symptoms, their occurrence in normal persons, and the finding of high serological brucella antibody titres in asymptomatic persons who are exposed to brucella infection emphasize the need for caution against overdiagnosis. This need is illustrated by the fact that a higher proportion of Ministry veterinary surgeons unexpectedly complain of symptoms now than five years ago. The incidence of symptoms in this group is now approximately equal to that of the veterinary surgeons in private practice, although the latter continue to have much greater exposure to brucella infection. Alternative explanations for this increase are discussed.     

Comparison of NHS and private patients undergoing elective transurethral resection of the prostate for benign prostatic hypertrophy.

OBJECTIVES--To compare the operative thresholds and clinical management of men undergoing elective transurethral resection of the prostate for benign prostatic hypertrophy in the NHS and privately. DESIGN--Cohort study of patients recruited by 25 surgeons during 1988. SETTING--Hospitals in Oxford and North West Thames regions. PATIENTS--Of 400 consecutive patients, 129 were excluded because of open surgery (nine), lack of surgeons' information (three), and emergency admission (117) and three failed to give information, leaving 268 patients, 214 NHS patients and 54 private patients. MAIN MEASURES--Sociodemographic factors, prevalence and severity of symptoms, comorbidity, general health (Nottingham health profile) obtained from patient questionnaire preoperatively and reasons for operating, and operative management obtained from surgeons perioperatively. RESULTS--NHS and private patients were similar in severity of symptoms and prevalence of urinary tract abnormalities. They differed in four respects: NHS patients' general health was poorer as a consequence of more comorbid conditions (49, 23% v 7, 13% in severe category); the condition had a greater detrimental effect on their lives (36, 17% v 2, 4% severely affected; p < 0.01); private patients received more personalised care more quickly and were investigated more before surgery, (29, 54% v 60, 20% receiving ultrasonography of the urinary tract); and NHS patients stayed in hospital longer (57, 27% v 3, 6% more than seven days; p < 0.001). CONCLUSIONS--Private patients' need for surgery, judged by symptom severity, was as great as that of NHS patients, and there was no evidence of different operative thresholds in the two sectors, but, judged by impact on lifestyle, NHS patients' need was greater.     

Calculating dental fees--a 1988-1999 trend analysis

German GOZ (Gebührenordnung für Zahn?rzte, catalogue of dental services) allows multipliers within a range from 1.0 to 3.5 for each fee, and it also prescribes medical arguments if dentists want to justify multipliers beyond 2.3. The authors analyze formal and material developments in these medical arguments of more than 3500 invoices from 1988 to 1999. Since 1988--amendment of GOZ--a development can be seen away from more general and patient-focussed towards arguments dealing with new dental materials and new forms of dental treatment. The authors analyse the way dentists (private ones and dentists of health insurance system), orthodontists, maxillo-facial- and oral surgeons charge their fees.     

A survey of glove preferences of general and orthopaedic surgeons in North West Thames Regional Health Authority

The glove preferences of all the consultant surgeons and consultant orthopaedic surgeons in North West Thames were surveyed by questionnaire. Responses were received from 59 of 78 general surgeons and 47 of 55 orthopaedic surgeons. Twenty-two percent of general surgeons never double gloved compared with 4% of orthopaedic surgeons (P < 0·01). Seventy-three percent of general surgeons double gloved for ‘high risk’ patients compared with 17% of orthopaedic surgeons (P < 0·001). When double gloving the majority of surgeons (67%) used their normal sized glove inside and half a size larger on the outside.     

2018年我国整形美容专业质控分析

目的分析2018年我国公立及民营医院整形美容专业相关指标数据,了解整形美容专业分布情况。方法通过国家卫生健康委员会医疗质量控制数据收集系统,收集2018年全年公立及民营医院整形美容专业病房相关数据。结果截至2018年12月31日,全国共954家医院设立整形美容专业病房,其中公立医院868家、民营医院86家。公立医院和民营医院均以西医医院、综合医院、三级医院为主。民营医院医师学士以下学历占比较公立医院多,职称分布与公立医院基本一致,整形专业医师比例和先天性患者比例少于公立医院,治疗相关并发症发生率较公立医院低。结论我国整形美容专业质量控制工作尚处于起步阶段,对专业相关指标数据进行整理分析具有重要作用。但本次收集民营医院数量较少,后续需纳入更多样本量进行研究。     

The practice of prophylactic mastectomy: a survey of Maryland surgeons.

OBJECTIVES. Bilateral prophylactic mastectomy is a drastic breast cancer preventive option for which indications are not standardized and efficacy has not been proven. To estimate the magnitude of this controversial practice, surgeons were surveyed on their recommendations about and performance of prophylactic mastectomy. METHODS. A cross-sectional survey was sent to general surgeons (n = 522), plastic surgeons (n = 80), and gynecologists (n = 801) licensed to practice in Maryland in 1992. Proportions responding were 41.9%, 66.3%, and 54.9%, respectively. In addition, there were 30 respondents who identified "other" as their specialty. The respondents were asked about the role of bilateral prophylactic mastectomy and the number of times they had recommended and performed it in a year. RESULTS. Seven hundred forty-two surgeons responded (51.8%). More plastic surgeons (84.6%) than general surgeons (47.0%) and gynecologists (38.3%) agreed that bilateral prophylactic mastectomy has a role in the care of high-risk women. Eighty-one percent of plastic surgeons had recommended the procedure, compared with 38.8% of general surgeons and 17.7% of gynecologists. CONCLUSIONS. Indications and practice patterns reveal heterogeneity of medical opinion and practice of prophylactic mastectomy. This study raises the need for better evaluation of the efficacy and appropriateness of prophylactic mastectomy.     

Influencing physician performance

For physicians to change their behavior, they must internalize the need for change. One way to do this is to get the physicians to agree to the improvement. In this study, surgeons were asked to agree that documentation is important. When surgeons who agreed that documentation is important were compared with those who did not express agreement, those who agreed were more likely to provide the required clinical documentation. Furthermore, they showed improvement in their percentage of cases with the required documentation when compared to themselves over time. Simple strategies such as asking for a private commitment to change can enhance competency with documentation requirements.     

基于DRGs的医疗服务绩效差异分析:以二级综合医院为例

目的对成都市二级民营综合医院与公立综合医院住院医疗服务绩效进行DRGs分析和比较,找出差异,提出建议。方法收集2019年成都市二级民营综合医院和二级公立综合医院住院病案首页数据,利用四川省DRGs应用平台进行分组计算,使用SPSS 20.0软件进行指标分析。结果成都市二级民营综合医院与二级公立综合医院2019年住院医疗服务绩效在医疗服务（总权重、覆盖DRGs组数和CMI值）、医疗效率（时间消耗指数、费用消耗指数）上并无显著差异,但在医疗质量与安全（中低风险及以下组病死率、标化病死率）上差异明显。结论二级民营综合医院与二级公立综合医院整体医疗服务差距逐渐缩小;二级民营综合医院内部发展不均衡,医疗质量与安全水平低于二级公立综合医院。建议持续提升民营综合医院服务能力,加强民营综合医院医疗质量与安全管理,同时政府须对民营医院强化监管。     

The performance of different models of primary care provision in Southern Africa

Despite the emphasis placed during the last two decades on public delivery of comprehensive and equitable primary care (PC) to developing country populations, coverage remains far from universal and the quality often poor. Users frequently patronise private providers, ranging from informal drug sellers to trained professionals. Interest is increasing internationally in the potential for making better use of private providers, including contractual approaches. The research aim was to examine the performance of different models of PC provision, in order to identify their strengths and weaknesses from the perspective of a government wishing to develop an overall strategy for improving PC provision. Models evaluated were: (a) South African general practitioners (district surgeons) providing services under public contracts; (b) clinics provided in Lesotho under a sub-contract between a construction company and a South African health care company; (c) GP services provided through an Independent Practitioner Association to low income insured workers and families; (d) a private clinic chain serving low income insured and uninsured workers and their families; and (e) for comparative purposes, South African public clinics. Performance was analysed in terms of provider cost and quality (of infrastructure, treatment practices, acceptability to patients and communities), allowing for differences in services and case-mix. The diversity of the arrangements made direct comparisons difficult, however, clear differences were identified between the models and conclusions drawn on their relative performance and the influences upon performance. The study findings demonstrate that contextual features strongly influence provider performance, and that a crude public/private comparison is not helpful. Key issues in contract design likely to influence performance are highlighted. Finally, the study argues that there is a need before contracting out service provision to consider how the performance of private providers might change when the context within which they are working changes with the introduction of a contract.     

Identification of criteria for the prioritisation of patients for elective general surgery

OBJECTIVE: A single visual analogue scale is used in New Zealand to prioritise patients for elective general surgery. Although it reflects clinical judgement, it has been criticised for its lack of transparency. We wished to elicit generic criteria used by surgeons for prioritisation of patients for elective general surgery in order to improve the transparency of the visual analogue scale. METHODS: Semi-structured interviews were undertaken with 15 general surgeons. Using the repertory grid method, surgeons were asked to explain their rationale for distinguishing between patients they considered a high, medium or low priority for treatment. Interviews were audiotaped, transcribed and analysed for themes. The accuracy of the thematic analysis was checked using a five-point Likert scale to assess surgeons' agreement with the identified themes. Further testing to check for face, content and construct validity was undertaken with a purposive sample of six surgeons prioritising patient vignettes. RESULTS: Eight major themes were deduced: diagnosis; treatment; patient characteristics; symptomatology and sequelae to date; future complications; quality of life; psychological/emotional impact; and socio-political/logistic factors. The utilisation of these themes by surgeons was confirmed. Tests of collinearity indicated good content validity. Factor analysis confirmed the hypothesis of one underlying construct, namely priority. CONCLUSION: Seven of the themes became the basis for a new clinical priority assessment criteria tool using visual analogue scales to determine priority of patients for elective general surgery. Further testing of reliability and validity is needed.     

普外科医师抗菌药物合理应用认知行为干预效果评价

目的为不断提高临床医师合理应用抗菌药物知识水平探索有效干预路径。方法采取整群抽样方法 ,对医院普外科医师的抗菌药物认知状况进行调查与干预。结果医师用通用名开具药品的比例由干预前57.7%上升为干预后94.0%(P0.05);医师对手术患者预防用抗菌药物30.0%的由干预前4人增加为干预后10人,使用比例30.0%～50.0%由干预前6人增加为干预后14人;用药天数选择3d的医师明显增多,由干预前12.5%上升为干预后40.6%(P0.05);干预前后医师选择抗菌药物所考虑的前3位因素均为疗效、感染病原菌、安全性,但干预后有更多医师开始关注细菌耐药状况,由干预前3人增加到干预后12人;干预前后医师对抗菌药物知识掌握主观自我评价均较好;通过定量评价医师专业知识认知情况,干预前人均得分仅为(3.91±1.12)分,干预后上升为(6.06±1.27)分,有所改善(P0.05)。结论干预后医师抗菌药物认知水平虽有所提高,但总体变化幅度不大,仍有待进一步加强综合管理、交流和培训。     

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.     

A Survey of General Surgeons in Rural Missouri: Potential for Rapid Decrease in Work Force

General surgeons have an essential role in the rural health care system. This telephone survey of 39 rural general surgeons in Missouri found that more than half were 55 or older. Most reported they practiced a broader scope of surgery than colleagues in urban areas, and half believed that current residency graduates are not prepared for surgical practice in rural areas. One-fifth had sought special training experiences to prepare them for rural practice. On balance, 70 percent of the respondents' practices was general surgery, 13 percent "specialty surgery" and 17 percent primary care. Many reported feeling professionally isolated. One-fourth had literally "returned home" to practice. The results suggest that if present trends continue, the next 10 years will see a substantial reduction in the number of general surgeons in rural Missouri.     

Judgment analysis of surgeons' prioritization of patients for elective general surgery.

BACKGROUND: Access to elective general surgery in New Zealand is governed by clinicians' judgment of priority using a visual analog scale (VAS). This has been criticized as lacking reliability and transparency. Our objective was to describe this judgment in terms of previously elicited cues. METHODS: We asked 60 general surgeons in New Zealand to assess patient vignettes using 8 VAS scales to determine priority. They then conducted judgment analysis to determine agreement between surgeons. Cluster analysis was performed to identify groups of surgeons who used different cues. Multiple regression for the combined surgeons was undertaken to determine the predictability of the 8-scale VAS. RESULTS: Agreement between surgeons was poor (ra=0.48). The cause of poor agreement was mostly due to poor consensus (G) between surgeons in how they weighted criteria. Using cluster analysis, we classified the surgeons into 2 groups: 1 took more account of quality of life and diagnosis, whereas the other group placed more weight on the influence of treatment. The 8-scale VAS showed good predictability in assigning a priority score (R2=0.66). DISCUSSION: The level of agreement reflects surgeons' practice variation. This is exemplified by 2 distinct surgeon groups that differ in how criteria were weighted.     

Two-MILP models for scheduling elective surgeries within a private healthcare facility

This paper deals with an Integrated Elective Surgery-Scheduling Problem (IESSP) that arises in a privately operated healthcare facility. It aims to optimize the resource utilization of the entire surgery process including pre-operative, per-operative and post-operative activities. Moreover, it addresses a specific feature of private facilities where surgeons are independent service providers and may conduct their surgeries in different private healthcare facilities. Thus, the problem requires the assignment of surgery patients to hospital beds, operating rooms and recovery beds as well as their sequencing over a 1-day period while taking into account surgeons’ availability constraints. We present two Mixed Integer Linear Programs (MILP) that model the IESSP as a three-stage hybrid flow-shop scheduling problem with recirculation, resource synchronization, dedicated machines, and blocking constraints. To assess the empirical performance of the proposed models, we conducted experiments on real-world data of a Tunisian private clinic: Clinique Ennasr and on randomly generated instances. Two criteria were minimised: the patients’ average length of stay and the number of patients’ overnight stays. The computational results show that the proposed models can solve instances with up to 44 surgical cases in a reasonable CPU time using a general-purpose MILP solver.     

Comparison between surgeons and general practitioners with respect to cardiovascular and psychosocial risk factors among physicians

The incidence of mortality from ischemic heart disease in Sweden has been reported to be elevated for surgeons in comparisons with most other groups of physicians. The objective of the present investigation was to compare cardiovascular risk factors and psychosocial work characteristics of surgeons and general practitioners, the latter having a substantially lower rate of ischemic heart disease. A random sample of 36 male surgeons and 30 male general practitioners was selected. The results showed no clear-cut differences in physiological risk factors. Overall mental strain was greater among the surgeons, as was the inability to relax after work, perceived work tempo, and total number of workhours. There were significant associations between psychosocial work characteristics and traditional cardiovascular risk factors, and the study gives further support to the validity of using long-term glucose markers, such as fructosamine, as indicators of metabolic stress.     

One hundred years of the Association of Surgeons in the Netherlands. IV. Thoracic surgery

In the Netherlands, two disciplines are involved, in thoracic surgery. Firstly, general surgeons, since thoracic surgery initially consisted of surgical treatment for pulmonary tuberculosis, bronchiectasis and empyema. Once tuberculostatics became available, surgical treatment of pulmonary tuberculosis became less important and lung/thoracic operations were carried out primarily for lung cancer. Secondly, cardio-pulmonary surgeons (now known as 'cardiothoracic surgeons') also play a role in thoracic surgery. This discipline is also allowed to carry out heart surgery. Surgery for stage-I and -II lung cancer is the mainstay of the practice of general thoracic surgeons. Surgery after induction chemotherapy for stage-III tumours is under investigation to find out whether this will improve treatment results. Video-assisted thoracic surgery (VATS) is a most interesting development, and has led to the revival of volume-reduction surgery for lung emphysema. Education is of paramount importance in ensuring the quality of surgery. In the near future there will be a need for qualified thoracic surgeons in the Netherlands and organisational and financial measures should be taken to prevent a shortage.     

Mortality among Finnish doctors, 1953-1972.

The mortality with respect to the total population of Finnish physicians during the period 1953 to 1972 has been analysed and compared with the corresponding statistics for the general Finnish population, for Finnish foundry workers, and for American physicians. It was found that the overall mortality was lower for male physicians than that for the general population or for foundry workers, but was clearly higher than that for American physicians. Male physicians did not exhibit any major differences from the general population with regard to cardiovascular diseases and suicide, but had a lower mortality from malignant neoplasms, accidents and "other diseases" (including infectious diseases). The explanation of cancer mortality being lower than expected among male physicians was mainly to be found in a deficit in lung cancer. Although female physicians had higher life expectancy than male physicians and the female general Finnish population, they did not show any clear deficit for cancer. In respect of all specialists, surgical specialists had the lowest mortality; general practitioners had the highest mortality. Most of these variations were attributable to differences in coronary mortality, but mortality from lung cancer was also remarkably low among surgeons. Differences of a similar type were also found between occupational sub-categories; private practitioners had the highest, and research workers and central hospital physicians the lowest mortality figures. The lower cancer mortality among male physicians, as contrasted with the general population, is probably attributable to differences in smoking habits; about 22% of male physicians smoked in 1973, whereas earlier studies by others have indicated that the corresponding proportion was about 50% in the general population. In contrast, the differences in mortality between different specialist categories probably arises from other factors, since Finnish physicians reportedly display a relatively homogeneous smoking pattern.     

Public and private funding of general practice services for children and adolescents in New Zealand

Objective

To measure public and private funding of general practice services for New Zealand children.

Methods

Computerized records from 111 general practices provided private payments for 118,905 general practice services to children aged 6-17 years. Government subsidies and public insurance payments provided public funding amounts for seven services. Overall and for each service we estimated the ratio of public:private payments (RPPP).

Results

64.0% of annual expenditure was public, 36.0% private, (RPPP = 1:0.56). General medical consultations were 67.2% of services (RPPP = 1:0.57); 15.3% were injury-related (RPPP = 1:0.36); 5.2% were prescribing services (all private); 4.9% were immunizations (RPPP = 1:0.12); 2.9% were nursing (RPPP = 1:1.33); 4.4% were administration (all private); and 0.1% were for maternity care (RPPP = 1:0.007). Before capitation funding, public and private funding levels for general medical consultations were similar (RPPP = 1:0.93) but after capitation public payments more than doubled (RPPP = 1:0.40).

Conclusion

There is a complex of pattern of public and private payments for general practice services for children and adolescents in New Zealand. Both funding sources are critical. Capitation funding changed the balance substantially but did not remove ongoing reliance on private funding to support general practice care for children.